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How choline increases the risk of thrombotic events
Past research indicated that choline, a nutrient found in animal products, is associated with a heightened risk of thrombosis.
Now, researchers have found evidence to suggest that consuming excess choline increases levels of the gut microbial metabolite trimethylamine N-oxide (TMAO), which increases platelet responsiveness, and this raises the risk of thrombotic events.
However, taking low-dose aspirin may reduce that risk.
“This is the first study in humans to directly demonstrate that dietary choline substantially elevates TMAO production by gut bacteria, impacting platelet function,” said Stanley Hazen, MD, PhD, of the Cleveland Clinic in Ohio.
“It provides direct evidence of a mechanistic link between TMAO levels and risk for blood clotting events like heart attack and stroke, the major culprit for the development of cardiovascular events.”
Dr Hazen and his colleagues reported these findings in Circulation.
For this study, the team tested the effects of oral choline supplements in healthy vegans/vegetarians (n=8) and omnivores (n=10). The subjects received choline bitartrate at 500 mg twice daily (about 450 mg total choline per day) for 2 months.
Both omnivores and vegans/vegetarians had at least a 10-fold increase in plasma levels of TMAO at 1 month and 2 months after starting choline supplementation, as well as an increase in platelet responsiveness.
In fact, the researchers observed a dose-dependent association between plasma TMAO levels and platelet function.
The team then set out to determine whether platelet hyper-responsiveness associated with choline supplementation and elevated TMAO would occur in the presence of aspirin.
For this, the researchers evaluated the 10 omnivores after a choline-free washout period of at least 1 month.
The subjects had their platelet function tested at baseline and after taking low-dose aspirin daily (81 mg each evening) for at least a month.
The subjects were then followed for another 2 months while continuing to take aspirin and a daily supplement of choline.
The researchers found that elevated TMAO levels and enhanced susceptibility for platelet activation still occurred, but the TMAO levels were attenuated by aspirin.
These findings suggest that a low dose of aspirin may partially counter the pro-thrombotic effects of a high TMAO plasma level associated with a diet rich in choline, and a high TMAO level can partially overcome the beneficial antiplatelet effects of taking low-dose aspirin.
“Further research is necessary to confirm these findings, but these studies suggest patients without known cardiovascular disease but with elevated TMAO levels may benefit from aspirin and diet modification in preventing blood clotting, which can lead to heart attack and stroke,” Dr Hazen said.
“They also suggest that a high TMAO level in a patient with known cardiovascular disease should be considered for more aggressive antiplatelet therapy.” 
Past research indicated that choline, a nutrient found in animal products, is associated with a heightened risk of thrombosis.
Now, researchers have found evidence to suggest that consuming excess choline increases levels of the gut microbial metabolite trimethylamine N-oxide (TMAO), which increases platelet responsiveness, and this raises the risk of thrombotic events.
However, taking low-dose aspirin may reduce that risk.
“This is the first study in humans to directly demonstrate that dietary choline substantially elevates TMAO production by gut bacteria, impacting platelet function,” said Stanley Hazen, MD, PhD, of the Cleveland Clinic in Ohio.
“It provides direct evidence of a mechanistic link between TMAO levels and risk for blood clotting events like heart attack and stroke, the major culprit for the development of cardiovascular events.”
Dr Hazen and his colleagues reported these findings in Circulation.
For this study, the team tested the effects of oral choline supplements in healthy vegans/vegetarians (n=8) and omnivores (n=10). The subjects received choline bitartrate at 500 mg twice daily (about 450 mg total choline per day) for 2 months.
Both omnivores and vegans/vegetarians had at least a 10-fold increase in plasma levels of TMAO at 1 month and 2 months after starting choline supplementation, as well as an increase in platelet responsiveness.
In fact, the researchers observed a dose-dependent association between plasma TMAO levels and platelet function.
The team then set out to determine whether platelet hyper-responsiveness associated with choline supplementation and elevated TMAO would occur in the presence of aspirin.
For this, the researchers evaluated the 10 omnivores after a choline-free washout period of at least 1 month.
The subjects had their platelet function tested at baseline and after taking low-dose aspirin daily (81 mg each evening) for at least a month.
The subjects were then followed for another 2 months while continuing to take aspirin and a daily supplement of choline.
The researchers found that elevated TMAO levels and enhanced susceptibility for platelet activation still occurred, but the TMAO levels were attenuated by aspirin.
These findings suggest that a low dose of aspirin may partially counter the pro-thrombotic effects of a high TMAO plasma level associated with a diet rich in choline, and a high TMAO level can partially overcome the beneficial antiplatelet effects of taking low-dose aspirin.
“Further research is necessary to confirm these findings, but these studies suggest patients without known cardiovascular disease but with elevated TMAO levels may benefit from aspirin and diet modification in preventing blood clotting, which can lead to heart attack and stroke,” Dr Hazen said.
“They also suggest that a high TMAO level in a patient with known cardiovascular disease should be considered for more aggressive antiplatelet therapy.”
Past research indicated that choline, a nutrient found in animal products, is associated with a heightened risk of thrombosis.
Now, researchers have found evidence to suggest that consuming excess choline increases levels of the gut microbial metabolite trimethylamine N-oxide (TMAO), which increases platelet responsiveness, and this raises the risk of thrombotic events.
However, taking low-dose aspirin may reduce that risk.
“This is the first study in humans to directly demonstrate that dietary choline substantially elevates TMAO production by gut bacteria, impacting platelet function,” said Stanley Hazen, MD, PhD, of the Cleveland Clinic in Ohio.
“It provides direct evidence of a mechanistic link between TMAO levels and risk for blood clotting events like heart attack and stroke, the major culprit for the development of cardiovascular events.”
Dr Hazen and his colleagues reported these findings in Circulation.
For this study, the team tested the effects of oral choline supplements in healthy vegans/vegetarians (n=8) and omnivores (n=10). The subjects received choline bitartrate at 500 mg twice daily (about 450 mg total choline per day) for 2 months.
Both omnivores and vegans/vegetarians had at least a 10-fold increase in plasma levels of TMAO at 1 month and 2 months after starting choline supplementation, as well as an increase in platelet responsiveness.
In fact, the researchers observed a dose-dependent association between plasma TMAO levels and platelet function.
The team then set out to determine whether platelet hyper-responsiveness associated with choline supplementation and elevated TMAO would occur in the presence of aspirin.
For this, the researchers evaluated the 10 omnivores after a choline-free washout period of at least 1 month.
The subjects had their platelet function tested at baseline and after taking low-dose aspirin daily (81 mg each evening) for at least a month.
The subjects were then followed for another 2 months while continuing to take aspirin and a daily supplement of choline.
The researchers found that elevated TMAO levels and enhanced susceptibility for platelet activation still occurred, but the TMAO levels were attenuated by aspirin.
These findings suggest that a low dose of aspirin may partially counter the pro-thrombotic effects of a high TMAO plasma level associated with a diet rich in choline, and a high TMAO level can partially overcome the beneficial antiplatelet effects of taking low-dose aspirin.
“Further research is necessary to confirm these findings, but these studies suggest patients without known cardiovascular disease but with elevated TMAO levels may benefit from aspirin and diet modification in preventing blood clotting, which can lead to heart attack and stroke,” Dr Hazen said.
“They also suggest that a high TMAO level in a patient with known cardiovascular disease should be considered for more aggressive antiplatelet therapy.”
Decision pathway for periprocedural management of anticoagulation in patients with nonvalvular atrial fibrillation
Clinical question: This work group synthesized available data to address whether and when anticoagulant therapy should be interrupted, whether and how anticoagulant bridging with a parenteral agent should be performed, and when and how anticoagulant therapy should be restarted for those who require temporary interruption.
Background: Atrial fibrillation is the most common sustained arrhythmia worldwide. Antithrombotic therapy, with a strong preference to oral anticoagulant (vitamin K antagonists [VKA] or Direct oral anticoagulant [DOAC]) over antiplatelet, is recommended for patients with high thrombotic risk. Temporary interruption is frequently necessary to mitigate bleed risk with surgical or invasive procedures. Although several factors go into the decision to interrupt anticoagulation, practice varies widely.
Study design: Data review and commentary.
Setting: Veterans’ Affairs Hospitals.
For the assessment of patient-related bleed risk, consider the HAS-BLED (Hypertension, Abnormal Renal and Liver Function, Stroke–Bleeding, Labile INRs, Elderly, Drugs or Alcohol) score: bleeding in the preceding 3 months, bleeding with a similar procedure or prior bridging, abnormalities of platelet function, concomitant use of antiplatelet therapy, and/or supratherapeutic international normalized ratio.
Vitamin K Antagonists:
- Do not interrupt for no clinically important or low bleed risk AND absence of patient-related bleed risk factor(s).
- Interrupt for procedures with intermediate or high bleed risk OR procedures with uncertain bleed risk and the presence of patient-related bleed risk factor(s).
- Consider interruption for procedure with no clinically important or low bleed risk AND the presence of patient-related bleed risk factor(s) OR procedures with uncertain bleed risk AND the absence of patient-related bleed risk factor(s).
Direct Oral Anticoagulants:
Can interrupt therapy for all bleed risks; duration based on creatinine clearance.
A procedure performed at the trough level may allow reinitiation the evening of or the day after the procedure with 1 or fewer dose(s) missed.
Bottom line: VKAs should be held based on surgical and patient bleed risk factors. Guidelines provide tools to calculate and consider. DOACs can always be held, preferably at trough times to minimize interruptions and for durations based on creatinine clearance.
Citation: Doherty JU, Gluckman TJ, Hucker WJ, et al. “2017 ACC Expert consensus decision pathway for periprocedural management of anticoagulation in patients with nonvalvular atrial fibrillation.” J Am Coll Cardiol. 2017 Feb 21;69(7):871-98.
Dr. White is an instructor in the Division of Hospital Medicine, Loyola University Chicago.
Clinical question: This work group synthesized available data to address whether and when anticoagulant therapy should be interrupted, whether and how anticoagulant bridging with a parenteral agent should be performed, and when and how anticoagulant therapy should be restarted for those who require temporary interruption.
Background: Atrial fibrillation is the most common sustained arrhythmia worldwide. Antithrombotic therapy, with a strong preference to oral anticoagulant (vitamin K antagonists [VKA] or Direct oral anticoagulant [DOAC]) over antiplatelet, is recommended for patients with high thrombotic risk. Temporary interruption is frequently necessary to mitigate bleed risk with surgical or invasive procedures. Although several factors go into the decision to interrupt anticoagulation, practice varies widely.
Study design: Data review and commentary.
Setting: Veterans’ Affairs Hospitals.
For the assessment of patient-related bleed risk, consider the HAS-BLED (Hypertension, Abnormal Renal and Liver Function, Stroke–Bleeding, Labile INRs, Elderly, Drugs or Alcohol) score: bleeding in the preceding 3 months, bleeding with a similar procedure or prior bridging, abnormalities of platelet function, concomitant use of antiplatelet therapy, and/or supratherapeutic international normalized ratio.
Vitamin K Antagonists:
- Do not interrupt for no clinically important or low bleed risk AND absence of patient-related bleed risk factor(s).
- Interrupt for procedures with intermediate or high bleed risk OR procedures with uncertain bleed risk and the presence of patient-related bleed risk factor(s).
- Consider interruption for procedure with no clinically important or low bleed risk AND the presence of patient-related bleed risk factor(s) OR procedures with uncertain bleed risk AND the absence of patient-related bleed risk factor(s).
Direct Oral Anticoagulants:
Can interrupt therapy for all bleed risks; duration based on creatinine clearance.
A procedure performed at the trough level may allow reinitiation the evening of or the day after the procedure with 1 or fewer dose(s) missed.
Bottom line: VKAs should be held based on surgical and patient bleed risk factors. Guidelines provide tools to calculate and consider. DOACs can always be held, preferably at trough times to minimize interruptions and for durations based on creatinine clearance.
Citation: Doherty JU, Gluckman TJ, Hucker WJ, et al. “2017 ACC Expert consensus decision pathway for periprocedural management of anticoagulation in patients with nonvalvular atrial fibrillation.” J Am Coll Cardiol. 2017 Feb 21;69(7):871-98.
Dr. White is an instructor in the Division of Hospital Medicine, Loyola University Chicago.
Clinical question: This work group synthesized available data to address whether and when anticoagulant therapy should be interrupted, whether and how anticoagulant bridging with a parenteral agent should be performed, and when and how anticoagulant therapy should be restarted for those who require temporary interruption.
Background: Atrial fibrillation is the most common sustained arrhythmia worldwide. Antithrombotic therapy, with a strong preference to oral anticoagulant (vitamin K antagonists [VKA] or Direct oral anticoagulant [DOAC]) over antiplatelet, is recommended for patients with high thrombotic risk. Temporary interruption is frequently necessary to mitigate bleed risk with surgical or invasive procedures. Although several factors go into the decision to interrupt anticoagulation, practice varies widely.
Study design: Data review and commentary.
Setting: Veterans’ Affairs Hospitals.
For the assessment of patient-related bleed risk, consider the HAS-BLED (Hypertension, Abnormal Renal and Liver Function, Stroke–Bleeding, Labile INRs, Elderly, Drugs or Alcohol) score: bleeding in the preceding 3 months, bleeding with a similar procedure or prior bridging, abnormalities of platelet function, concomitant use of antiplatelet therapy, and/or supratherapeutic international normalized ratio.
Vitamin K Antagonists:
- Do not interrupt for no clinically important or low bleed risk AND absence of patient-related bleed risk factor(s).
- Interrupt for procedures with intermediate or high bleed risk OR procedures with uncertain bleed risk and the presence of patient-related bleed risk factor(s).
- Consider interruption for procedure with no clinically important or low bleed risk AND the presence of patient-related bleed risk factor(s) OR procedures with uncertain bleed risk AND the absence of patient-related bleed risk factor(s).
Direct Oral Anticoagulants:
Can interrupt therapy for all bleed risks; duration based on creatinine clearance.
A procedure performed at the trough level may allow reinitiation the evening of or the day after the procedure with 1 or fewer dose(s) missed.
Bottom line: VKAs should be held based on surgical and patient bleed risk factors. Guidelines provide tools to calculate and consider. DOACs can always be held, preferably at trough times to minimize interruptions and for durations based on creatinine clearance.
Citation: Doherty JU, Gluckman TJ, Hucker WJ, et al. “2017 ACC Expert consensus decision pathway for periprocedural management of anticoagulation in patients with nonvalvular atrial fibrillation.” J Am Coll Cardiol. 2017 Feb 21;69(7):871-98.
Dr. White is an instructor in the Division of Hospital Medicine, Loyola University Chicago.
HM17 satellite symposia schedule, information
Patient Care Transitions in COPD: Improving Collaboration Between Inpatient and Outpatient Providers to Reduce Readmissions
Monday, May 1
5–7 p.m., Mandalay Bay J
Dinner at 5 p.m.
Overview: The faculty panel will be composed of leading experts representing hospital medicine and pulmonary specialties. For detailed faculty information please visit www.practitionersedge.com/shmcopd.
Integrity Continuing Education Inc. is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. Integrity Continuing Education designates this live activity for a maximum of 1.5 AMA PRA Category 1 Credits™. Register: www.practitionersedge.com/shmcopd.
Alcoholic Hepatitis: Advances in Therapeutic Management
Monday, May 1
5:30–7:30 p.m., Jasmine CDGH
Dinner at 5:30 p.m.
Overview: Because alcohol potentiates the fibrosis- and cancer-inducing actions of the hepatitis virus, people with heavy alcohol intake are particularly vulnerable to hepatitis infection and are most in need of treatment. In this activity, we will discuss advances in acute and long-term management of alcoholic hepatitis and liver function. Specifically, we will aim to review guideline-based screening and diagnostic considerations for alcoholic hepatitis; assess standards of care for management of acute alcoholic hepatitis, including lifestyle-, pharmacologic-, and device-related methods; and evaluate investigational methods of treatment with respect to efficacy, safety, and long-term management.
Presenters: Ram Mohan Subramanian, MD, associate professor of medicine and surgery, medical director of liver transplant, Emory University, Atlanta; Julie Thompson, MD, MPH, assistant professor of medicine, division of gastroenterology, hepatology, and nutrition, University of Minnesota, Minneapolis.
This activity has been approved for AMA PRA Category 1 Credit(s)™. Full accreditation information available: www.akhcme.com/SHM. This activity is supported by an educational grant from Vital Therapies, Inc. Register: https://akhinc.formstack.com/forms/shm.
A Physician’s Keys to Locking Out Lawsuits and Reducing Taxes
Tuesday, May 2
Noon–1 p.m., Oceanside G
Overview: This course educates on the dangers of lawsuits in the healthcare community. Focused primarily toward physicians and how they should be structured to protect themselves.
Presenter: Art McOmber business owner, retired FBI Agent.
Sponsored by Legally Mine.
A Master Class in Understanding & Applying Updated Treatment Guidelines and Scientific Advances to Reduce Mortality and Hospitalizations in Chronic Heart Failure Patients
Tuesday, May 2
7:30–9:30 p.m., Breakers ABGH
Dinner at 7 p.m.
Presenters: Alpesh Amin, MD, MBA, MACP, SFHM, University of California Irvine, California; Mark H. Drazner, MD, MSc, University of Texas Southwestern Medical Center, Dallas.
This CME activity is jointly provided by Medical Learning Institute and PVI, PeerView Institute for Medical Education. This activity is accredited by the ACCME to provide continuing medical education for physicians.
The Medical Learning Institute designates this live activity for a maximum of 2.0 AMA PRA Category 1 Credits™. This activity is supported by educational grants from Novartis Pharmaceuticals Corporation and ZS Pharma, a member of the AstraZeneca Group. Register: www.peerviewpress.com/CHF2017.
Assessing VTE Risk in Medically Ill Patients: The Critical Role of the Hospitalist
Tuesday, May 2
7:30–9:30 p.m., Jasmine CDGH
Dinner at 7 p.m.
Presenters: Ebrahim Barkoudah, MD, MPH, instructor in medicine, associate director, global clinical scholars research training program, office of global education, Harvard Medical School, associate director, hospital medicine unit, department of medicine, Brigham and Women’s Hospital (BWH), Boston; Elaine M. Hylek, MD, MPH, professor of medicine, Boston University School of Medicine, director, thrombosis and anticoagulation service, Boston Medical Center; Aaron P. Kithcart, MD, PhD, vascular medicine fellow, BWH; John Fanikos, RPh, MBA, assistant professor of clinical pharmacy practice at Northeastern University, Massachusetts College of Pharmacy, director of pharmacy business and financial services, BWH; Arman Qamar, MD, vascular medicine and cardiology fellow, BWH.
This activity is held in conjunction with the North American Thrombosis Forum and with HM17.
Medscape LLC is accredited by the American Nurses Credentialing Center (ANCC), the Accreditation Council for Pharmacy Education (ACPE), and the Accreditation Council for Continuing Medical Education (ACCME), to provide continuing education for the health care team. Medscape LLC designates this live activity for a maximum of 2.0 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity. This activity is supported by an independent educational grant from Portola Pharmaceuticals. Register: www.medscape.org/townhall/vte-risk.
Understanding and Managing Hyponatremia: Key Information for Today’s Hospitalist
Wednesday, May 3
7:30 - 9:30 p.m., Jasmine CDGH
Dinner at 7:30 p.m.
Presenters: Jeffrey S. Shapiro, MD, regional medical director and hospitalist, Southern California Hospitalist Network, Anaheim; Alpesh N. Amin, MD, MBA, MACP, SFHM, FACC, Thomas and Mary Cesario chair, Department of Medicine, professor of medicine, business, public health, nursing science, and biomedical engineering, executive director, hospitalist program, University of California, Irvine; Mohammed S. Ahmed, DO, CSH, FASN, associate professor, Department of Internal Medicine, Midwestern University, Chicago College of Osteopathic Medicine
Sponsored by Otsuka Pharmaceuticals.
Patient Care Transitions in COPD: Improving Collaboration Between Inpatient and Outpatient Providers to Reduce Readmissions
Monday, May 1
5–7 p.m., Mandalay Bay J
Dinner at 5 p.m.
Overview: The faculty panel will be composed of leading experts representing hospital medicine and pulmonary specialties. For detailed faculty information please visit www.practitionersedge.com/shmcopd.
Integrity Continuing Education Inc. is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. Integrity Continuing Education designates this live activity for a maximum of 1.5 AMA PRA Category 1 Credits™. Register: www.practitionersedge.com/shmcopd.
Alcoholic Hepatitis: Advances in Therapeutic Management
Monday, May 1
5:30–7:30 p.m., Jasmine CDGH
Dinner at 5:30 p.m.
Overview: Because alcohol potentiates the fibrosis- and cancer-inducing actions of the hepatitis virus, people with heavy alcohol intake are particularly vulnerable to hepatitis infection and are most in need of treatment. In this activity, we will discuss advances in acute and long-term management of alcoholic hepatitis and liver function. Specifically, we will aim to review guideline-based screening and diagnostic considerations for alcoholic hepatitis; assess standards of care for management of acute alcoholic hepatitis, including lifestyle-, pharmacologic-, and device-related methods; and evaluate investigational methods of treatment with respect to efficacy, safety, and long-term management.
Presenters: Ram Mohan Subramanian, MD, associate professor of medicine and surgery, medical director of liver transplant, Emory University, Atlanta; Julie Thompson, MD, MPH, assistant professor of medicine, division of gastroenterology, hepatology, and nutrition, University of Minnesota, Minneapolis.
This activity has been approved for AMA PRA Category 1 Credit(s)™. Full accreditation information available: www.akhcme.com/SHM. This activity is supported by an educational grant from Vital Therapies, Inc. Register: https://akhinc.formstack.com/forms/shm.
A Physician’s Keys to Locking Out Lawsuits and Reducing Taxes
Tuesday, May 2
Noon–1 p.m., Oceanside G
Overview: This course educates on the dangers of lawsuits in the healthcare community. Focused primarily toward physicians and how they should be structured to protect themselves.
Presenter: Art McOmber business owner, retired FBI Agent.
Sponsored by Legally Mine.
A Master Class in Understanding & Applying Updated Treatment Guidelines and Scientific Advances to Reduce Mortality and Hospitalizations in Chronic Heart Failure Patients
Tuesday, May 2
7:30–9:30 p.m., Breakers ABGH
Dinner at 7 p.m.
Presenters: Alpesh Amin, MD, MBA, MACP, SFHM, University of California Irvine, California; Mark H. Drazner, MD, MSc, University of Texas Southwestern Medical Center, Dallas.
This CME activity is jointly provided by Medical Learning Institute and PVI, PeerView Institute for Medical Education. This activity is accredited by the ACCME to provide continuing medical education for physicians.
The Medical Learning Institute designates this live activity for a maximum of 2.0 AMA PRA Category 1 Credits™. This activity is supported by educational grants from Novartis Pharmaceuticals Corporation and ZS Pharma, a member of the AstraZeneca Group. Register: www.peerviewpress.com/CHF2017.
Assessing VTE Risk in Medically Ill Patients: The Critical Role of the Hospitalist
Tuesday, May 2
7:30–9:30 p.m., Jasmine CDGH
Dinner at 7 p.m.
Presenters: Ebrahim Barkoudah, MD, MPH, instructor in medicine, associate director, global clinical scholars research training program, office of global education, Harvard Medical School, associate director, hospital medicine unit, department of medicine, Brigham and Women’s Hospital (BWH), Boston; Elaine M. Hylek, MD, MPH, professor of medicine, Boston University School of Medicine, director, thrombosis and anticoagulation service, Boston Medical Center; Aaron P. Kithcart, MD, PhD, vascular medicine fellow, BWH; John Fanikos, RPh, MBA, assistant professor of clinical pharmacy practice at Northeastern University, Massachusetts College of Pharmacy, director of pharmacy business and financial services, BWH; Arman Qamar, MD, vascular medicine and cardiology fellow, BWH.
This activity is held in conjunction with the North American Thrombosis Forum and with HM17.
Medscape LLC is accredited by the American Nurses Credentialing Center (ANCC), the Accreditation Council for Pharmacy Education (ACPE), and the Accreditation Council for Continuing Medical Education (ACCME), to provide continuing education for the health care team. Medscape LLC designates this live activity for a maximum of 2.0 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity. This activity is supported by an independent educational grant from Portola Pharmaceuticals. Register: www.medscape.org/townhall/vte-risk.
Understanding and Managing Hyponatremia: Key Information for Today’s Hospitalist
Wednesday, May 3
7:30 - 9:30 p.m., Jasmine CDGH
Dinner at 7:30 p.m.
Presenters: Jeffrey S. Shapiro, MD, regional medical director and hospitalist, Southern California Hospitalist Network, Anaheim; Alpesh N. Amin, MD, MBA, MACP, SFHM, FACC, Thomas and Mary Cesario chair, Department of Medicine, professor of medicine, business, public health, nursing science, and biomedical engineering, executive director, hospitalist program, University of California, Irvine; Mohammed S. Ahmed, DO, CSH, FASN, associate professor, Department of Internal Medicine, Midwestern University, Chicago College of Osteopathic Medicine
Sponsored by Otsuka Pharmaceuticals.
Patient Care Transitions in COPD: Improving Collaboration Between Inpatient and Outpatient Providers to Reduce Readmissions
Monday, May 1
5–7 p.m., Mandalay Bay J
Dinner at 5 p.m.
Overview: The faculty panel will be composed of leading experts representing hospital medicine and pulmonary specialties. For detailed faculty information please visit www.practitionersedge.com/shmcopd.
Integrity Continuing Education Inc. is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. Integrity Continuing Education designates this live activity for a maximum of 1.5 AMA PRA Category 1 Credits™. Register: www.practitionersedge.com/shmcopd.
Alcoholic Hepatitis: Advances in Therapeutic Management
Monday, May 1
5:30–7:30 p.m., Jasmine CDGH
Dinner at 5:30 p.m.
Overview: Because alcohol potentiates the fibrosis- and cancer-inducing actions of the hepatitis virus, people with heavy alcohol intake are particularly vulnerable to hepatitis infection and are most in need of treatment. In this activity, we will discuss advances in acute and long-term management of alcoholic hepatitis and liver function. Specifically, we will aim to review guideline-based screening and diagnostic considerations for alcoholic hepatitis; assess standards of care for management of acute alcoholic hepatitis, including lifestyle-, pharmacologic-, and device-related methods; and evaluate investigational methods of treatment with respect to efficacy, safety, and long-term management.
Presenters: Ram Mohan Subramanian, MD, associate professor of medicine and surgery, medical director of liver transplant, Emory University, Atlanta; Julie Thompson, MD, MPH, assistant professor of medicine, division of gastroenterology, hepatology, and nutrition, University of Minnesota, Minneapolis.
This activity has been approved for AMA PRA Category 1 Credit(s)™. Full accreditation information available: www.akhcme.com/SHM. This activity is supported by an educational grant from Vital Therapies, Inc. Register: https://akhinc.formstack.com/forms/shm.
A Physician’s Keys to Locking Out Lawsuits and Reducing Taxes
Tuesday, May 2
Noon–1 p.m., Oceanside G
Overview: This course educates on the dangers of lawsuits in the healthcare community. Focused primarily toward physicians and how they should be structured to protect themselves.
Presenter: Art McOmber business owner, retired FBI Agent.
Sponsored by Legally Mine.
A Master Class in Understanding & Applying Updated Treatment Guidelines and Scientific Advances to Reduce Mortality and Hospitalizations in Chronic Heart Failure Patients
Tuesday, May 2
7:30–9:30 p.m., Breakers ABGH
Dinner at 7 p.m.
Presenters: Alpesh Amin, MD, MBA, MACP, SFHM, University of California Irvine, California; Mark H. Drazner, MD, MSc, University of Texas Southwestern Medical Center, Dallas.
This CME activity is jointly provided by Medical Learning Institute and PVI, PeerView Institute for Medical Education. This activity is accredited by the ACCME to provide continuing medical education for physicians.
The Medical Learning Institute designates this live activity for a maximum of 2.0 AMA PRA Category 1 Credits™. This activity is supported by educational grants from Novartis Pharmaceuticals Corporation and ZS Pharma, a member of the AstraZeneca Group. Register: www.peerviewpress.com/CHF2017.
Assessing VTE Risk in Medically Ill Patients: The Critical Role of the Hospitalist
Tuesday, May 2
7:30–9:30 p.m., Jasmine CDGH
Dinner at 7 p.m.
Presenters: Ebrahim Barkoudah, MD, MPH, instructor in medicine, associate director, global clinical scholars research training program, office of global education, Harvard Medical School, associate director, hospital medicine unit, department of medicine, Brigham and Women’s Hospital (BWH), Boston; Elaine M. Hylek, MD, MPH, professor of medicine, Boston University School of Medicine, director, thrombosis and anticoagulation service, Boston Medical Center; Aaron P. Kithcart, MD, PhD, vascular medicine fellow, BWH; John Fanikos, RPh, MBA, assistant professor of clinical pharmacy practice at Northeastern University, Massachusetts College of Pharmacy, director of pharmacy business and financial services, BWH; Arman Qamar, MD, vascular medicine and cardiology fellow, BWH.
This activity is held in conjunction with the North American Thrombosis Forum and with HM17.
Medscape LLC is accredited by the American Nurses Credentialing Center (ANCC), the Accreditation Council for Pharmacy Education (ACPE), and the Accreditation Council for Continuing Medical Education (ACCME), to provide continuing education for the health care team. Medscape LLC designates this live activity for a maximum of 2.0 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity. This activity is supported by an independent educational grant from Portola Pharmaceuticals. Register: www.medscape.org/townhall/vte-risk.
Understanding and Managing Hyponatremia: Key Information for Today’s Hospitalist
Wednesday, May 3
7:30 - 9:30 p.m., Jasmine CDGH
Dinner at 7:30 p.m.
Presenters: Jeffrey S. Shapiro, MD, regional medical director and hospitalist, Southern California Hospitalist Network, Anaheim; Alpesh N. Amin, MD, MBA, MACP, SFHM, FACC, Thomas and Mary Cesario chair, Department of Medicine, professor of medicine, business, public health, nursing science, and biomedical engineering, executive director, hospitalist program, University of California, Irvine; Mohammed S. Ahmed, DO, CSH, FASN, associate professor, Department of Internal Medicine, Midwestern University, Chicago College of Osteopathic Medicine
Sponsored by Otsuka Pharmaceuticals.
Multimodal breast cancer treatment linked with greater risk of lymphedema
Chemotherapy, radiation, and higher body mass index are strongly associated with increased risk of lymphedema in breast cancer patients who have undergone sentinel node biopsy or axillary lymph node dissection, according to analysis of data from the Rochester Epidemiology Project.
Judy C. Boughey, MD, professor of surgery and vice chair of research at the Mayo Clinic, Rochester, Minn., and her associates performed a chart review of 1,794 patients diagnosed with a first breast cancer in Olmsted County, Minn., between 1990 and 2010. Patients’ median age at diagnosis was 60 years. About half (48%) were diagnosed at stage I, while 17% were diagnosed at Stage 0, 29% at Stage II, and 6% at Stage III.
At a median of 10 years of follow-up, 209 patients had been diagnosed with breast cancer–related lymphedema, with most diagnoses occurring within 5 years of surgery. No cases of lymphedema were found in patients who did not have axillary surgery.
There was no significant difference in the rate of lymphedema based on type of breast cancer surgery (mastectomy vs. lumpectomy with breast-conserving surgery); however, lymphedema occurred significantly more frequently in patients who received ALND as compared to those who received SLN (15.9% vs. 5.3%). Lymphedema rates did not differ based on type of axillary surgery (3.5% for ALND and 4.1% for SLN) in a subset of 453 patients who did not receive radiation or chemotherapy.
Almost a third (31.3%) of patients who had nodal radiation, with or without breast or chest wall radiation, developed lymphedema by 5 years, as compared with 5.9% of patients who did not receive radiation (P less than .001). Similarly, patients who received chemotherapy were significantly more likely to develop lymphedema. At 5 years, lymphedema was present in 27.2% of patients who received anthracylcline/cyclophosphamide (AC) with a taxane agent, 29.7% of those who received a taxane agent without AC , and 6.0% of those who did not get chemotherapy (P less than .001).
Five-year incidence of lymphedema also increased significantly with body mass index, occurring in 17.1% of patients with a BMI greater than 35 kg/m2, 13% of those with a BMI between 30-34.99, and 14.4% of those with a BMI between 25-29.99, as compared with 8% of those with a BMI below 25.
On univariate analysis, increased stage was associated with risk of lymphedema, Dr. Boughey said. However, on multivariate analysis, stage was no longer associated with risk of lymphedema and “the dominate factors were BMI, type of axillary surgery, use of radiation therapy and particularly nodal radiation, and the use of chemotherapy.”
The highest rate of lymphedema was seen in a patients with the most advanced disease who had ALND with nodal radiation and AC with a taxane agent, she said.
“We think this is primarily due to the modalities of treatment rather that the pure phenomenon of stage,” Dr. Boughey added. “This study can help identify patients at a higher risk of lymphedema so that we can individualize the surveillance of these patients to allow them to have earlier identification and earlier treatment of lymphedema.”
[email protected]
On Twitter @denisefulton
Chemotherapy, radiation, and higher body mass index are strongly associated with increased risk of lymphedema in breast cancer patients who have undergone sentinel node biopsy or axillary lymph node dissection, according to analysis of data from the Rochester Epidemiology Project.
Judy C. Boughey, MD, professor of surgery and vice chair of research at the Mayo Clinic, Rochester, Minn., and her associates performed a chart review of 1,794 patients diagnosed with a first breast cancer in Olmsted County, Minn., between 1990 and 2010. Patients’ median age at diagnosis was 60 years. About half (48%) were diagnosed at stage I, while 17% were diagnosed at Stage 0, 29% at Stage II, and 6% at Stage III.
At a median of 10 years of follow-up, 209 patients had been diagnosed with breast cancer–related lymphedema, with most diagnoses occurring within 5 years of surgery. No cases of lymphedema were found in patients who did not have axillary surgery.
There was no significant difference in the rate of lymphedema based on type of breast cancer surgery (mastectomy vs. lumpectomy with breast-conserving surgery); however, lymphedema occurred significantly more frequently in patients who received ALND as compared to those who received SLN (15.9% vs. 5.3%). Lymphedema rates did not differ based on type of axillary surgery (3.5% for ALND and 4.1% for SLN) in a subset of 453 patients who did not receive radiation or chemotherapy.
Almost a third (31.3%) of patients who had nodal radiation, with or without breast or chest wall radiation, developed lymphedema by 5 years, as compared with 5.9% of patients who did not receive radiation (P less than .001). Similarly, patients who received chemotherapy were significantly more likely to develop lymphedema. At 5 years, lymphedema was present in 27.2% of patients who received anthracylcline/cyclophosphamide (AC) with a taxane agent, 29.7% of those who received a taxane agent without AC , and 6.0% of those who did not get chemotherapy (P less than .001).
Five-year incidence of lymphedema also increased significantly with body mass index, occurring in 17.1% of patients with a BMI greater than 35 kg/m2, 13% of those with a BMI between 30-34.99, and 14.4% of those with a BMI between 25-29.99, as compared with 8% of those with a BMI below 25.
On univariate analysis, increased stage was associated with risk of lymphedema, Dr. Boughey said. However, on multivariate analysis, stage was no longer associated with risk of lymphedema and “the dominate factors were BMI, type of axillary surgery, use of radiation therapy and particularly nodal radiation, and the use of chemotherapy.”
The highest rate of lymphedema was seen in a patients with the most advanced disease who had ALND with nodal radiation and AC with a taxane agent, she said.
“We think this is primarily due to the modalities of treatment rather that the pure phenomenon of stage,” Dr. Boughey added. “This study can help identify patients at a higher risk of lymphedema so that we can individualize the surveillance of these patients to allow them to have earlier identification and earlier treatment of lymphedema.”
[email protected]
On Twitter @denisefulton
Chemotherapy, radiation, and higher body mass index are strongly associated with increased risk of lymphedema in breast cancer patients who have undergone sentinel node biopsy or axillary lymph node dissection, according to analysis of data from the Rochester Epidemiology Project.
Judy C. Boughey, MD, professor of surgery and vice chair of research at the Mayo Clinic, Rochester, Minn., and her associates performed a chart review of 1,794 patients diagnosed with a first breast cancer in Olmsted County, Minn., between 1990 and 2010. Patients’ median age at diagnosis was 60 years. About half (48%) were diagnosed at stage I, while 17% were diagnosed at Stage 0, 29% at Stage II, and 6% at Stage III.
At a median of 10 years of follow-up, 209 patients had been diagnosed with breast cancer–related lymphedema, with most diagnoses occurring within 5 years of surgery. No cases of lymphedema were found in patients who did not have axillary surgery.
There was no significant difference in the rate of lymphedema based on type of breast cancer surgery (mastectomy vs. lumpectomy with breast-conserving surgery); however, lymphedema occurred significantly more frequently in patients who received ALND as compared to those who received SLN (15.9% vs. 5.3%). Lymphedema rates did not differ based on type of axillary surgery (3.5% for ALND and 4.1% for SLN) in a subset of 453 patients who did not receive radiation or chemotherapy.
Almost a third (31.3%) of patients who had nodal radiation, with or without breast or chest wall radiation, developed lymphedema by 5 years, as compared with 5.9% of patients who did not receive radiation (P less than .001). Similarly, patients who received chemotherapy were significantly more likely to develop lymphedema. At 5 years, lymphedema was present in 27.2% of patients who received anthracylcline/cyclophosphamide (AC) with a taxane agent, 29.7% of those who received a taxane agent without AC , and 6.0% of those who did not get chemotherapy (P less than .001).
Five-year incidence of lymphedema also increased significantly with body mass index, occurring in 17.1% of patients with a BMI greater than 35 kg/m2, 13% of those with a BMI between 30-34.99, and 14.4% of those with a BMI between 25-29.99, as compared with 8% of those with a BMI below 25.
On univariate analysis, increased stage was associated with risk of lymphedema, Dr. Boughey said. However, on multivariate analysis, stage was no longer associated with risk of lymphedema and “the dominate factors were BMI, type of axillary surgery, use of radiation therapy and particularly nodal radiation, and the use of chemotherapy.”
The highest rate of lymphedema was seen in a patients with the most advanced disease who had ALND with nodal radiation and AC with a taxane agent, she said.
“We think this is primarily due to the modalities of treatment rather that the pure phenomenon of stage,” Dr. Boughey added. “This study can help identify patients at a higher risk of lymphedema so that we can individualize the surveillance of these patients to allow them to have earlier identification and earlier treatment of lymphedema.”
[email protected]
On Twitter @denisefulton
FROM ASBS 2017
Key clinical point:
Major finding: More than 30% of patients receiving nodal radiation developed lymphedema vs. 5.9% of those who did not. Similarly, lymphedema developed in just under 30% of patients who received a taxane vs. 6.9% of those who did not.
Data source: Analysis of all 1,794 cases of first breast cancers diagnosed in Olmsted County, Minn., 1990-2010.
Disclosures: The Rochester Epidemiology Project receives federal funding from agencies of the Health & Human Services Department. Dr. Boughey reported no relevant financial conflicts of interest.
Risk of recurrence outweighs risk of contralateral breast cancer for DCIS patients
LAS VEGAS – The risk of ipsilateral breast tumor recurrence was greater than the risk of contralateral breast cancer at both 5 and 10 years following diagnosis of ductal carcinoma in situ (DCIS), investigators report at a press conference in advance of the annual meeting of the American Society of Breast Surgeons.
“A rapidly growing number of women are choosing double mastectomies for DCIS, perhaps because they misperceive their risk of future cancer. Our research provides important data for treatment decision-making,” said Megan Miller, MD, of Memorial Sloan Kettering Cancer Center. “It suggests patients and their doctors should focus on risk factors and appropriate therapy for the diseased breast, not the opposite breast, and that ipsilateral DCIS should not prompt a bilateral mastectomy.”
The investigators also found that CBC did not correlate with age, family history, and initial DCIS characteristics, though these factors did correlate with the risk of IBTR.
Dr. Miller and her colleagues found radiation had no impact on risk of CBC (4.9% vs. 6.3%; P = .1), though it significantly reduced the risk for IBTR (10.3% vs. 19.3%; P less than .0001).
More research is needed on risk factors for patients with a preinvasive condition, Dr. Miller said.
“Most studies examining the benefits of bilateral mastectomy focus on invasive cancer,” she said. “This study is unique in providing hard data for women with preinvasive disease. For these patients, examining risk factors for recurrence and the benefits of radiation and endocrine therapy to treat the existing cancer are important.”
[email protected]
On Twitter @eaztweets
LAS VEGAS – The risk of ipsilateral breast tumor recurrence was greater than the risk of contralateral breast cancer at both 5 and 10 years following diagnosis of ductal carcinoma in situ (DCIS), investigators report at a press conference in advance of the annual meeting of the American Society of Breast Surgeons.
“A rapidly growing number of women are choosing double mastectomies for DCIS, perhaps because they misperceive their risk of future cancer. Our research provides important data for treatment decision-making,” said Megan Miller, MD, of Memorial Sloan Kettering Cancer Center. “It suggests patients and their doctors should focus on risk factors and appropriate therapy for the diseased breast, not the opposite breast, and that ipsilateral DCIS should not prompt a bilateral mastectomy.”
The investigators also found that CBC did not correlate with age, family history, and initial DCIS characteristics, though these factors did correlate with the risk of IBTR.
Dr. Miller and her colleagues found radiation had no impact on risk of CBC (4.9% vs. 6.3%; P = .1), though it significantly reduced the risk for IBTR (10.3% vs. 19.3%; P less than .0001).
More research is needed on risk factors for patients with a preinvasive condition, Dr. Miller said.
“Most studies examining the benefits of bilateral mastectomy focus on invasive cancer,” she said. “This study is unique in providing hard data for women with preinvasive disease. For these patients, examining risk factors for recurrence and the benefits of radiation and endocrine therapy to treat the existing cancer are important.”
[email protected]
On Twitter @eaztweets
LAS VEGAS – The risk of ipsilateral breast tumor recurrence was greater than the risk of contralateral breast cancer at both 5 and 10 years following diagnosis of ductal carcinoma in situ (DCIS), investigators report at a press conference in advance of the annual meeting of the American Society of Breast Surgeons.
“A rapidly growing number of women are choosing double mastectomies for DCIS, perhaps because they misperceive their risk of future cancer. Our research provides important data for treatment decision-making,” said Megan Miller, MD, of Memorial Sloan Kettering Cancer Center. “It suggests patients and their doctors should focus on risk factors and appropriate therapy for the diseased breast, not the opposite breast, and that ipsilateral DCIS should not prompt a bilateral mastectomy.”
The investigators also found that CBC did not correlate with age, family history, and initial DCIS characteristics, though these factors did correlate with the risk of IBTR.
Dr. Miller and her colleagues found radiation had no impact on risk of CBC (4.9% vs. 6.3%; P = .1), though it significantly reduced the risk for IBTR (10.3% vs. 19.3%; P less than .0001).
More research is needed on risk factors for patients with a preinvasive condition, Dr. Miller said.
“Most studies examining the benefits of bilateral mastectomy focus on invasive cancer,” she said. “This study is unique in providing hard data for women with preinvasive disease. For these patients, examining risk factors for recurrence and the benefits of radiation and endocrine therapy to treat the existing cancer are important.”
[email protected]
On Twitter @eaztweets
FROM ASBS 2017
Key clinical point:
Major finding: Among 2,759 patients, incidence rate of contralateral breast cancer was 2.8% and 5.6% over 5 and 10 years, respectively, while risk of ipsilateral breast tumor recurrence was 7.8% and 14.3% over 5 and 10 years, respectively.
Data source: Study of 2,759 DCIS patients who underwent breast conserving surgery between 1978-2011, who were followed for a median of 6.8 years.
Disclosures: The investigators reported no relevant disclosures.
The EHR Report: Communication, social media, and legal vulnerability
Social media is now a part of everyday life. From Twitter, with its 140 character limit, to Facebook to Linkedin, there is a world of possibilities for communicating with friends, family, colleagues, and others online. Communication is good, but electronic media is a minefield for medical professionals who do not think carefully before they post.
The stories in the news about health care professionals who have posted obviously inflammatory material online, perhaps in a fit of rage, and have had their careers impacted or ended are just the tip of the iceberg. HIPAA violations have received a good deal of attention, with a well-known example being the doctor who was accused of posting a selfie with Joan Rivers, who was unconscious on the operating table. These examples, however, represent obvious violations of HIPAA and are infractions that most physicians would readily identify. Other examples may not be as obvious.
We know of one case where a nurse on the staff of a physicians’ office posted on Facebook that work was grueling that day because he felt under the weather with suspected flu. This may seem, at first, to be an innocuous communication. And that’s all it was, until, the son of an immunosuppressed man who had an appointment at that doctor’s office was flabbergasted to hear from a mutual friend that one of the nurses in the office was at work despite having the flu. He demanded to speak with the office manager and made sure that his father was not seen by that nurse. It may seem like an unlikely coincidence, but, in medical-legal circles, unlikely events occur all the time.
Many people who use social media will check in or post when they are out with friends or colleagues blowing off steam. For example, you might post something on social media about a holiday party you are attending. But, consider what happens if, at work the next day, something goes wrong, your care is called into question, and a lawsuit ensues. Your post may be innocent, but it now falls into the hands of the patient’s attorney. When you are having your deposition taken, the lawyer pulls your social media post out of a stack of papers and grills you about where you were, what you were doing, how late you stayed out, whether you were drinking, how much, and so on. Maybe you explain to him that you were only at the holiday party for an hour and did not have a single drink. That attorney, however, is not required to take your word for it and can ask you who you were with. All of a sudden, your friends and colleagues are being served with subpoenas for their depositions and being examined about what you did that night. Possibly, the lawyer is sending a subpoena for your credit card receipt and the restaurant’s billing records to determine what you ordered that night.
You should never rely on the false assumption that even “private” messages sent directly to other people will truly remain private. One of us was recently involved in a case where this worked to our advantage. A 30-year-old woman claimed that her family doctor never recommended that she see a gastroenterologist. A friend of the patient testified in a deposition that the two of them had discussed her medical care in private messages on Facebook. After the court ordered that the patient turn over her private Facebook messages, we learned that she told her friend that the doctor had indeed made the recommendation for her to see that specialist.
This cautionary tale doesn’t just apply to social media. Keep in mind that, if you are involved in litigation, attorneys can subpoena the records from your cellular phone provider. All cell phone text message are archived by the cellular provider and can be retrieved under subpoena. You may innocently be blowing off steam to a spouse or friend about a difficult patient or bad outcome but later have those text messages used against you in litigation.
The various social media platforms can be great tools for all kinds of professionals to share interesting information and further their professional development. However, everybody, especially the medical professional, needs to think before they post or send a message. We must also remember that, once information is out in cyberspace, it remains there and can never be truly erased. In other words, you can never unring the proverbial bell. It is important to think about the potential impact of that communication before posting and electronically communicating. Only communicate something that you would be comfortable defending in court.
Dr. Skolnik is professor of family and community medicine at Jefferson Medical College, Philadelphia, and associate director of the family medicine residency program at Abington (Pa.) Jefferson Health. Mr. Shear is an associate attorney in the health care department at Marshall Dennehey Warner Coleman & Goggin in Pittsburgh. He represents physicians, medical professionals, and hospitals in medical malpractice actions.
Social media is now a part of everyday life. From Twitter, with its 140 character limit, to Facebook to Linkedin, there is a world of possibilities for communicating with friends, family, colleagues, and others online. Communication is good, but electronic media is a minefield for medical professionals who do not think carefully before they post.
The stories in the news about health care professionals who have posted obviously inflammatory material online, perhaps in a fit of rage, and have had their careers impacted or ended are just the tip of the iceberg. HIPAA violations have received a good deal of attention, with a well-known example being the doctor who was accused of posting a selfie with Joan Rivers, who was unconscious on the operating table. These examples, however, represent obvious violations of HIPAA and are infractions that most physicians would readily identify. Other examples may not be as obvious.
We know of one case where a nurse on the staff of a physicians’ office posted on Facebook that work was grueling that day because he felt under the weather with suspected flu. This may seem, at first, to be an innocuous communication. And that’s all it was, until, the son of an immunosuppressed man who had an appointment at that doctor’s office was flabbergasted to hear from a mutual friend that one of the nurses in the office was at work despite having the flu. He demanded to speak with the office manager and made sure that his father was not seen by that nurse. It may seem like an unlikely coincidence, but, in medical-legal circles, unlikely events occur all the time.
Many people who use social media will check in or post when they are out with friends or colleagues blowing off steam. For example, you might post something on social media about a holiday party you are attending. But, consider what happens if, at work the next day, something goes wrong, your care is called into question, and a lawsuit ensues. Your post may be innocent, but it now falls into the hands of the patient’s attorney. When you are having your deposition taken, the lawyer pulls your social media post out of a stack of papers and grills you about where you were, what you were doing, how late you stayed out, whether you were drinking, how much, and so on. Maybe you explain to him that you were only at the holiday party for an hour and did not have a single drink. That attorney, however, is not required to take your word for it and can ask you who you were with. All of a sudden, your friends and colleagues are being served with subpoenas for their depositions and being examined about what you did that night. Possibly, the lawyer is sending a subpoena for your credit card receipt and the restaurant’s billing records to determine what you ordered that night.
You should never rely on the false assumption that even “private” messages sent directly to other people will truly remain private. One of us was recently involved in a case where this worked to our advantage. A 30-year-old woman claimed that her family doctor never recommended that she see a gastroenterologist. A friend of the patient testified in a deposition that the two of them had discussed her medical care in private messages on Facebook. After the court ordered that the patient turn over her private Facebook messages, we learned that she told her friend that the doctor had indeed made the recommendation for her to see that specialist.
This cautionary tale doesn’t just apply to social media. Keep in mind that, if you are involved in litigation, attorneys can subpoena the records from your cellular phone provider. All cell phone text message are archived by the cellular provider and can be retrieved under subpoena. You may innocently be blowing off steam to a spouse or friend about a difficult patient or bad outcome but later have those text messages used against you in litigation.
The various social media platforms can be great tools for all kinds of professionals to share interesting information and further their professional development. However, everybody, especially the medical professional, needs to think before they post or send a message. We must also remember that, once information is out in cyberspace, it remains there and can never be truly erased. In other words, you can never unring the proverbial bell. It is important to think about the potential impact of that communication before posting and electronically communicating. Only communicate something that you would be comfortable defending in court.
Dr. Skolnik is professor of family and community medicine at Jefferson Medical College, Philadelphia, and associate director of the family medicine residency program at Abington (Pa.) Jefferson Health. Mr. Shear is an associate attorney in the health care department at Marshall Dennehey Warner Coleman & Goggin in Pittsburgh. He represents physicians, medical professionals, and hospitals in medical malpractice actions.
Social media is now a part of everyday life. From Twitter, with its 140 character limit, to Facebook to Linkedin, there is a world of possibilities for communicating with friends, family, colleagues, and others online. Communication is good, but electronic media is a minefield for medical professionals who do not think carefully before they post.
The stories in the news about health care professionals who have posted obviously inflammatory material online, perhaps in a fit of rage, and have had their careers impacted or ended are just the tip of the iceberg. HIPAA violations have received a good deal of attention, with a well-known example being the doctor who was accused of posting a selfie with Joan Rivers, who was unconscious on the operating table. These examples, however, represent obvious violations of HIPAA and are infractions that most physicians would readily identify. Other examples may not be as obvious.
We know of one case where a nurse on the staff of a physicians’ office posted on Facebook that work was grueling that day because he felt under the weather with suspected flu. This may seem, at first, to be an innocuous communication. And that’s all it was, until, the son of an immunosuppressed man who had an appointment at that doctor’s office was flabbergasted to hear from a mutual friend that one of the nurses in the office was at work despite having the flu. He demanded to speak with the office manager and made sure that his father was not seen by that nurse. It may seem like an unlikely coincidence, but, in medical-legal circles, unlikely events occur all the time.
Many people who use social media will check in or post when they are out with friends or colleagues blowing off steam. For example, you might post something on social media about a holiday party you are attending. But, consider what happens if, at work the next day, something goes wrong, your care is called into question, and a lawsuit ensues. Your post may be innocent, but it now falls into the hands of the patient’s attorney. When you are having your deposition taken, the lawyer pulls your social media post out of a stack of papers and grills you about where you were, what you were doing, how late you stayed out, whether you were drinking, how much, and so on. Maybe you explain to him that you were only at the holiday party for an hour and did not have a single drink. That attorney, however, is not required to take your word for it and can ask you who you were with. All of a sudden, your friends and colleagues are being served with subpoenas for their depositions and being examined about what you did that night. Possibly, the lawyer is sending a subpoena for your credit card receipt and the restaurant’s billing records to determine what you ordered that night.
You should never rely on the false assumption that even “private” messages sent directly to other people will truly remain private. One of us was recently involved in a case where this worked to our advantage. A 30-year-old woman claimed that her family doctor never recommended that she see a gastroenterologist. A friend of the patient testified in a deposition that the two of them had discussed her medical care in private messages on Facebook. After the court ordered that the patient turn over her private Facebook messages, we learned that she told her friend that the doctor had indeed made the recommendation for her to see that specialist.
This cautionary tale doesn’t just apply to social media. Keep in mind that, if you are involved in litigation, attorneys can subpoena the records from your cellular phone provider. All cell phone text message are archived by the cellular provider and can be retrieved under subpoena. You may innocently be blowing off steam to a spouse or friend about a difficult patient or bad outcome but later have those text messages used against you in litigation.
The various social media platforms can be great tools for all kinds of professionals to share interesting information and further their professional development. However, everybody, especially the medical professional, needs to think before they post or send a message. We must also remember that, once information is out in cyberspace, it remains there and can never be truly erased. In other words, you can never unring the proverbial bell. It is important to think about the potential impact of that communication before posting and electronically communicating. Only communicate something that you would be comfortable defending in court.
Dr. Skolnik is professor of family and community medicine at Jefferson Medical College, Philadelphia, and associate director of the family medicine residency program at Abington (Pa.) Jefferson Health. Mr. Shear is an associate attorney in the health care department at Marshall Dennehey Warner Coleman & Goggin in Pittsburgh. He represents physicians, medical professionals, and hospitals in medical malpractice actions.
Small study: Vitamin D repletion may decrease insulin resistance
WASHINGTON – Normalizing vitamin D levels correlated with lower insulin resistance and decreased adipose fibrosis in obese patients, according to a study presented at the Eastern regional meeting of the American Federation for Medical Research.
Approximately 86 million U.S. patients have prediabetes, according to Diabetes Report Card 2014, the most recent estimates from the Centers for Disease Control and Prevention. Vitamin D therapy may be able to help lower that number and prevent diabetes in some patients, Jee Young You, MD, a research fellow at Albert Einstein College of Medicine, New York, said at the meeting.
“When there’s increased adiposity, there is reduction of the blood flow which will further lead to inflammation, macrophage infiltration, and fibrosis, which all together leads to insulin resistance,” Dr. You said. “It is shown that there are vitamin D receptors present on adipocytes, so we hypothesize repleting vitamin D will help in reducing this inflammation.”
In a double blind study, Dr. You and her colleagues randomized 11 obese patients, with an average body mass index of 34 kg/m2, insulin resistance, and vitamin D deficiency to vitamin D repletion therapy. Eight similar patients served as controls. The average age was 43 years.
Patients in the test group were placed on a step schedule for vitamin D supplementation. For 3 months, they received 40,000 IU of vitamin D3 weekly in an effort to reach a target 25-hydroxyvitamin D level of greater than 30 ng/ml. Patients then received another 3 months of the same supplementation with an aim to reach a target level of greater than 50 ng/ml.
“We wanted to see if there was a dose dependent effect for vitamin D in patients,” Dr. You said.
Endogenous glucose production decreased by 24% (P = .04) after normalization of vitamin D levels. Patients who received placebo saw an increase in endogenous glucose, pointing to lower hepatic insulin sensitivity, Dr. You said.
When the vitamin D receptors are activated, they inhibit the profibrotic pathways like TGFb-1, Dr. You explained, decreasing fibrosis.
The researchers also found a decrease in profibrotic gene expression in TGFb-1, HiF-1, MMP7, and Collagen I, V, and VI.
However, while testing for reduction in profibrotic gene expression in whole fat, the investigators found that there was no additional improvement after the first round of vitamin D therapy, leading them to assert that raising vitamin D levels above the normal range does not give any additional benefit.
[email protected]
On Twitter @eaztweets
WASHINGTON – Normalizing vitamin D levels correlated with lower insulin resistance and decreased adipose fibrosis in obese patients, according to a study presented at the Eastern regional meeting of the American Federation for Medical Research.
Approximately 86 million U.S. patients have prediabetes, according to Diabetes Report Card 2014, the most recent estimates from the Centers for Disease Control and Prevention. Vitamin D therapy may be able to help lower that number and prevent diabetes in some patients, Jee Young You, MD, a research fellow at Albert Einstein College of Medicine, New York, said at the meeting.
“When there’s increased adiposity, there is reduction of the blood flow which will further lead to inflammation, macrophage infiltration, and fibrosis, which all together leads to insulin resistance,” Dr. You said. “It is shown that there are vitamin D receptors present on adipocytes, so we hypothesize repleting vitamin D will help in reducing this inflammation.”
In a double blind study, Dr. You and her colleagues randomized 11 obese patients, with an average body mass index of 34 kg/m2, insulin resistance, and vitamin D deficiency to vitamin D repletion therapy. Eight similar patients served as controls. The average age was 43 years.
Patients in the test group were placed on a step schedule for vitamin D supplementation. For 3 months, they received 40,000 IU of vitamin D3 weekly in an effort to reach a target 25-hydroxyvitamin D level of greater than 30 ng/ml. Patients then received another 3 months of the same supplementation with an aim to reach a target level of greater than 50 ng/ml.
“We wanted to see if there was a dose dependent effect for vitamin D in patients,” Dr. You said.
Endogenous glucose production decreased by 24% (P = .04) after normalization of vitamin D levels. Patients who received placebo saw an increase in endogenous glucose, pointing to lower hepatic insulin sensitivity, Dr. You said.
When the vitamin D receptors are activated, they inhibit the profibrotic pathways like TGFb-1, Dr. You explained, decreasing fibrosis.
The researchers also found a decrease in profibrotic gene expression in TGFb-1, HiF-1, MMP7, and Collagen I, V, and VI.
However, while testing for reduction in profibrotic gene expression in whole fat, the investigators found that there was no additional improvement after the first round of vitamin D therapy, leading them to assert that raising vitamin D levels above the normal range does not give any additional benefit.
[email protected]
On Twitter @eaztweets
WASHINGTON – Normalizing vitamin D levels correlated with lower insulin resistance and decreased adipose fibrosis in obese patients, according to a study presented at the Eastern regional meeting of the American Federation for Medical Research.
Approximately 86 million U.S. patients have prediabetes, according to Diabetes Report Card 2014, the most recent estimates from the Centers for Disease Control and Prevention. Vitamin D therapy may be able to help lower that number and prevent diabetes in some patients, Jee Young You, MD, a research fellow at Albert Einstein College of Medicine, New York, said at the meeting.
“When there’s increased adiposity, there is reduction of the blood flow which will further lead to inflammation, macrophage infiltration, and fibrosis, which all together leads to insulin resistance,” Dr. You said. “It is shown that there are vitamin D receptors present on adipocytes, so we hypothesize repleting vitamin D will help in reducing this inflammation.”
In a double blind study, Dr. You and her colleagues randomized 11 obese patients, with an average body mass index of 34 kg/m2, insulin resistance, and vitamin D deficiency to vitamin D repletion therapy. Eight similar patients served as controls. The average age was 43 years.
Patients in the test group were placed on a step schedule for vitamin D supplementation. For 3 months, they received 40,000 IU of vitamin D3 weekly in an effort to reach a target 25-hydroxyvitamin D level of greater than 30 ng/ml. Patients then received another 3 months of the same supplementation with an aim to reach a target level of greater than 50 ng/ml.
“We wanted to see if there was a dose dependent effect for vitamin D in patients,” Dr. You said.
Endogenous glucose production decreased by 24% (P = .04) after normalization of vitamin D levels. Patients who received placebo saw an increase in endogenous glucose, pointing to lower hepatic insulin sensitivity, Dr. You said.
When the vitamin D receptors are activated, they inhibit the profibrotic pathways like TGFb-1, Dr. You explained, decreasing fibrosis.
The researchers also found a decrease in profibrotic gene expression in TGFb-1, HiF-1, MMP7, and Collagen I, V, and VI.
However, while testing for reduction in profibrotic gene expression in whole fat, the investigators found that there was no additional improvement after the first round of vitamin D therapy, leading them to assert that raising vitamin D levels above the normal range does not give any additional benefit.
[email protected]
On Twitter @eaztweets
AT THE AFMR EASTERN REGIONAL MEETING
Key clinical point:
Major finding: Of the 19 patients studied, expression of profibrotic genes TGFb-1, HiF-1, MMP7, and Collagen I, V, and VI in those given vitamin D therapy decreased 0.81, 0.72, 0.62,. 0.56, 0.56, and 0.43 times, respectively (P less than .05).
Data source: Randomized, double blind, placebo-controlled study of 19 obese, insulin resistant, vitamin D deficient patients.
Disclosures: The investigators reported no relevant conflicts of interest.
Modifying CAR-T with IL-15 improved activity in glioma models
MONTREAL – Adding an immunostimulatory cytokine to chimeric antigen receptor–T cells (CAR-T) improved the adaptive immunotherapy’s activity against aggressive pediatric brain malignancies both in vitro and in animal models, an investigator reported.
CAR-T cells engineered to express interleukin-15 (IL-15), an inducer of T-cell proliferation and survival, were associated with significantly longer progression-free survival (PFS) and overall survival in mouse models of glioma, compared with regular CAR-T cells, said Giedre Krenciute, PhD, of Baylor College of Medicine in Houston.
The improved T-cell persistence, however, still resulted in the eventual loss of both targeted and nontargeted tumor-associated antigens and tumor recurrence, Dr. Krenciute noted.
The results suggest that T-cell persistence is critical for antitumor activity, and that it will be necessary to perform antigen profiling of recurrent tumors in order to develop follow-on therapies targeting multiple tumor-associated antigens, she said.
Her team had previously reported on the development of a CAR-T cell directed specifically against the IL-13 receptor alpha-2, which is expressed at high frequency in diffuse intrinsic pontine glioma and glioblastoma tumors but not in normal brain tissues.
In preclinical models, the construct had potent antiglioblastoma activity. However, the T-cells had only limited persistence, and tumors positive for IL-13 receptor alpha-2 recurred.
To see whether they could improve on T-cell persistence, they took their CARs back to the shop and modified them with a retroviral vector to express IL-15 transgenes. They then tested the altered cells in vitro using standard assays and found that the addition of IL-15 did not change the T-cell phenotype or affect the cells’ cytotoxicity.
The addition of IL-15 significantly improved the persistence of the T cells when they were injected into the tumors of mice with human glioblastoma xenografts (P less than .05), and this persistence translated into a near-doubling of PFS, compared with regular CAR-T cells (media, 84 days vs. 49 days; P = .008), as well as improved overall survival (P = .02).
Of 10 mice that received the IL-15–expressing CAR-Ts, 4 were free of glioma through at least 80 days of follow-up.
Of five mice with recurring gliomas, three had down-regulated expression of the IL-13 receptor alpha-2 target, indicating immune escape, and all recurring tumors had reduced expression of the human epidermal growth factor receptor-2 antigen, which is associated with gliomas.
The investigators are currently test-driving a new CD20-targeted CAR, transduced to express IL-15, and have seen good expansion and persistence of the T cells for up to 15 days in culture, with in vivo tests in the planning stage, Dr. Krenciute said.
The work is supported by the National Institutes of Health, Alex’s Lemonade Stand Foundation, the James S. McDonnell Foundation, and the American Brain Tumor Association. The laboratory, the Center for Cell and Gene Therapy at Baylor, has or had research collaborations with Celgene, Bluebird Bio, and Tessa Therapeutics, and investigators at the center hold or have applied for patents in T-cell and gene-modified T-cell therapies for cancer.
MONTREAL – Adding an immunostimulatory cytokine to chimeric antigen receptor–T cells (CAR-T) improved the adaptive immunotherapy’s activity against aggressive pediatric brain malignancies both in vitro and in animal models, an investigator reported.
CAR-T cells engineered to express interleukin-15 (IL-15), an inducer of T-cell proliferation and survival, were associated with significantly longer progression-free survival (PFS) and overall survival in mouse models of glioma, compared with regular CAR-T cells, said Giedre Krenciute, PhD, of Baylor College of Medicine in Houston.
The improved T-cell persistence, however, still resulted in the eventual loss of both targeted and nontargeted tumor-associated antigens and tumor recurrence, Dr. Krenciute noted.
The results suggest that T-cell persistence is critical for antitumor activity, and that it will be necessary to perform antigen profiling of recurrent tumors in order to develop follow-on therapies targeting multiple tumor-associated antigens, she said.
Her team had previously reported on the development of a CAR-T cell directed specifically against the IL-13 receptor alpha-2, which is expressed at high frequency in diffuse intrinsic pontine glioma and glioblastoma tumors but not in normal brain tissues.
In preclinical models, the construct had potent antiglioblastoma activity. However, the T-cells had only limited persistence, and tumors positive for IL-13 receptor alpha-2 recurred.
To see whether they could improve on T-cell persistence, they took their CARs back to the shop and modified them with a retroviral vector to express IL-15 transgenes. They then tested the altered cells in vitro using standard assays and found that the addition of IL-15 did not change the T-cell phenotype or affect the cells’ cytotoxicity.
The addition of IL-15 significantly improved the persistence of the T cells when they were injected into the tumors of mice with human glioblastoma xenografts (P less than .05), and this persistence translated into a near-doubling of PFS, compared with regular CAR-T cells (media, 84 days vs. 49 days; P = .008), as well as improved overall survival (P = .02).
Of 10 mice that received the IL-15–expressing CAR-Ts, 4 were free of glioma through at least 80 days of follow-up.
Of five mice with recurring gliomas, three had down-regulated expression of the IL-13 receptor alpha-2 target, indicating immune escape, and all recurring tumors had reduced expression of the human epidermal growth factor receptor-2 antigen, which is associated with gliomas.
The investigators are currently test-driving a new CD20-targeted CAR, transduced to express IL-15, and have seen good expansion and persistence of the T cells for up to 15 days in culture, with in vivo tests in the planning stage, Dr. Krenciute said.
The work is supported by the National Institutes of Health, Alex’s Lemonade Stand Foundation, the James S. McDonnell Foundation, and the American Brain Tumor Association. The laboratory, the Center for Cell and Gene Therapy at Baylor, has or had research collaborations with Celgene, Bluebird Bio, and Tessa Therapeutics, and investigators at the center hold or have applied for patents in T-cell and gene-modified T-cell therapies for cancer.
MONTREAL – Adding an immunostimulatory cytokine to chimeric antigen receptor–T cells (CAR-T) improved the adaptive immunotherapy’s activity against aggressive pediatric brain malignancies both in vitro and in animal models, an investigator reported.
CAR-T cells engineered to express interleukin-15 (IL-15), an inducer of T-cell proliferation and survival, were associated with significantly longer progression-free survival (PFS) and overall survival in mouse models of glioma, compared with regular CAR-T cells, said Giedre Krenciute, PhD, of Baylor College of Medicine in Houston.
The improved T-cell persistence, however, still resulted in the eventual loss of both targeted and nontargeted tumor-associated antigens and tumor recurrence, Dr. Krenciute noted.
The results suggest that T-cell persistence is critical for antitumor activity, and that it will be necessary to perform antigen profiling of recurrent tumors in order to develop follow-on therapies targeting multiple tumor-associated antigens, she said.
Her team had previously reported on the development of a CAR-T cell directed specifically against the IL-13 receptor alpha-2, which is expressed at high frequency in diffuse intrinsic pontine glioma and glioblastoma tumors but not in normal brain tissues.
In preclinical models, the construct had potent antiglioblastoma activity. However, the T-cells had only limited persistence, and tumors positive for IL-13 receptor alpha-2 recurred.
To see whether they could improve on T-cell persistence, they took their CARs back to the shop and modified them with a retroviral vector to express IL-15 transgenes. They then tested the altered cells in vitro using standard assays and found that the addition of IL-15 did not change the T-cell phenotype or affect the cells’ cytotoxicity.
The addition of IL-15 significantly improved the persistence of the T cells when they were injected into the tumors of mice with human glioblastoma xenografts (P less than .05), and this persistence translated into a near-doubling of PFS, compared with regular CAR-T cells (media, 84 days vs. 49 days; P = .008), as well as improved overall survival (P = .02).
Of 10 mice that received the IL-15–expressing CAR-Ts, 4 were free of glioma through at least 80 days of follow-up.
Of five mice with recurring gliomas, three had down-regulated expression of the IL-13 receptor alpha-2 target, indicating immune escape, and all recurring tumors had reduced expression of the human epidermal growth factor receptor-2 antigen, which is associated with gliomas.
The investigators are currently test-driving a new CD20-targeted CAR, transduced to express IL-15, and have seen good expansion and persistence of the T cells for up to 15 days in culture, with in vivo tests in the planning stage, Dr. Krenciute said.
The work is supported by the National Institutes of Health, Alex’s Lemonade Stand Foundation, the James S. McDonnell Foundation, and the American Brain Tumor Association. The laboratory, the Center for Cell and Gene Therapy at Baylor, has or had research collaborations with Celgene, Bluebird Bio, and Tessa Therapeutics, and investigators at the center hold or have applied for patents in T-cell and gene-modified T-cell therapies for cancer.
FROM ASPHO
Key clinical point: CAR-T cells, modified to express IL-15, have improved activity against aggressive pediatric gliomas.
Major finding: IL-15 expressed T cells were associated with improved progression-free and overall survival in animal models of glioblastoma.
Data source: In vitro and in vivo experiments of CAR-T cells modified to improve T-cell persistence and clinical efficacy.
Disclosures: The work is supported by the National Institutes of Health, Alex’s Lemonade Stand Foundation, the James S. McDonnell Foundation, and the American Brain Tumor Association. The laboratory, the Center for Cell and Gene Therapy at Baylor, has or had research collaborations with Celgene, Bluebird Bio, and Tessa Therapeutics, and investigators at the center hold or have applied for patents in T-cell and gene-modified T-cell therapies for cancer.
Medicaid acceptance at 33% for dermatologists
Medicaid acceptance was just over 33% among dermatologists in the 2017 edition of an ongoing survey conducted in 15 large cities by physician recruitment firm Merritt Hawkins.
That was up from 27% in the previous survey, conducted in 2014, but lower than the average of 41% for dermatologists in 15 midsized cities that were included for the first time in 2017, the company reported.
Investigators called 286 randomly selected dermatologists in the large cities and 93 dermatologists in the midsized cities in January and February. It was the fourth such survey the company has conducted since 2004.
The survey also included four other specialties – cardiology, family medicine, ob.gyn., and orthopedic surgery. The Medicaid acceptance rate for all 1,414 physicians in all five specialties in the 15 large cities was 53%, and the average rate for all specialties in the midsized cities was 60% for the 494 offices surveyed. Cardiology had the highest rates by specialty and dermatology the lowest in both the large and midsized cities, the company said.
Medicaid acceptance was just over 33% among dermatologists in the 2017 edition of an ongoing survey conducted in 15 large cities by physician recruitment firm Merritt Hawkins.
That was up from 27% in the previous survey, conducted in 2014, but lower than the average of 41% for dermatologists in 15 midsized cities that were included for the first time in 2017, the company reported.
Investigators called 286 randomly selected dermatologists in the large cities and 93 dermatologists in the midsized cities in January and February. It was the fourth such survey the company has conducted since 2004.
The survey also included four other specialties – cardiology, family medicine, ob.gyn., and orthopedic surgery. The Medicaid acceptance rate for all 1,414 physicians in all five specialties in the 15 large cities was 53%, and the average rate for all specialties in the midsized cities was 60% for the 494 offices surveyed. Cardiology had the highest rates by specialty and dermatology the lowest in both the large and midsized cities, the company said.
Medicaid acceptance was just over 33% among dermatologists in the 2017 edition of an ongoing survey conducted in 15 large cities by physician recruitment firm Merritt Hawkins.
That was up from 27% in the previous survey, conducted in 2014, but lower than the average of 41% for dermatologists in 15 midsized cities that were included for the first time in 2017, the company reported.
Investigators called 286 randomly selected dermatologists in the large cities and 93 dermatologists in the midsized cities in January and February. It was the fourth such survey the company has conducted since 2004.
The survey also included four other specialties – cardiology, family medicine, ob.gyn., and orthopedic surgery. The Medicaid acceptance rate for all 1,414 physicians in all five specialties in the 15 large cities was 53%, and the average rate for all specialties in the midsized cities was 60% for the 494 offices surveyed. Cardiology had the highest rates by specialty and dermatology the lowest in both the large and midsized cities, the company said.
Project Sonar brings gastroenterologists one step closer to a specialty-specific APM
Gastroenterologists wanting to participate in the advanced alternative payment model track of the new Quality Payment Program developed under the Medicare Access and CHIP Reauthorization Act (MACRA) may soon have an option as early as 2018.
Project Sonar, a program that helps gastroenterologists and their patients help manage inflammatory bowel diseases such as Crohn’s disease and ulcerative colitis was the first physician-focused gastroenterology-specific payment model to receive a recommendation from the Physician-Focused Payment Model Technical Advisory Committee (PTAC). The proposal was supported by public comments from AGA and the American Medical Association. It now heads to the U.S. Department of Health & Human Services for final approval.
“The intensive medical home Blue Cross initiated with us because of the success of the pilot pays us a supplemental management fee for every patient that is enrolled,” Lawrence Kosinski, MD, MBA, managing partner at IGG, and a Practice Councillor for the AGA Institute Governing Board, said in an interview. “That management fee is adjusted based on how much savings we produce for the payer. It ultimately winds up being a shared savings program based on our ability to control the cost of care, but we get a management fee upfront in order to make it happen.”
And getting those savings was simply a matter of getting patients engaged in their care. The way Project Sonar works is patients are “pinged” once a month to report on their symptoms. They generally receive a text alert with a link to a secure website where they answer five questions that are derived from the Crohn’s Disease Activity Index. The first one asks how many bowel movements per day over the last 7 days. The second one asks for a rating of abdominal pain. The third one is a rating of the patient’s general state of well-being. Then they are asked whether they are taking drugs for diarrhea. Finally, there are some check boxes for whether they have any eye symptoms or skin rashes or joint pains.
The answers are then weighted and a score is given both to the patient and the doctor. Doctors are alerted to which patients might require more focused attention over those who have their symptoms well managed.
But what is making this program work is that IGG has been able to get an 80% sustained response rate from patients using the program.
“The entire savings that we are generating is coming solely from the patients who participate in the platform,” Dr. Kosinski said.
From an analysis of BCBS of Illinois’ claims data, Dr. Kosinski and his colleagues determined that “ it costs about $24,000 a year to take care of a Crohn’s patient, and over half the money that is spent is spent for inpatient care, complications, bad things happening to these patients.”
He continued: “The difference in annual costs between a pinger and a nonpinger is $6,300. That is a 25% drop in the cost of care.” He added that Project Sonar is leading to a 10% savings in the overall cost of care for these patients when total costs are factored in.
One surprise aspect that Dr. Kosinski found was that patients needed no additional incentive to respond to their pings.
“We had thought we were going to have to get into some gameification and we actually ran a few lotteries to reward people,” he said. “We haven’t had to do it. The patients have participated because I think they feel like they are getting excellent care this way, and I’m very impressed by the fact that the patients have not had to be stimulated to do it.”
At the end of the day, it’s all about improving patients’ lives.
“Patients are doing better,” he noted. “They are staying out of the hospital. They are staying out of the operating room. They are staying at work. They are staying with their families. We have to realize, we look at these as patients with diseases. These are human beings that just happen to have a disease, and they have a life, they have jobs, family, responsibility, and if our Sonar system is allowing them to have a more normal life, there is a lot of traction there.”
Dr. Kosinski is also an Associate Editor for GI & Hepatology News.
Gastroenterologists wanting to participate in the advanced alternative payment model track of the new Quality Payment Program developed under the Medicare Access and CHIP Reauthorization Act (MACRA) may soon have an option as early as 2018.
Project Sonar, a program that helps gastroenterologists and their patients help manage inflammatory bowel diseases such as Crohn’s disease and ulcerative colitis was the first physician-focused gastroenterology-specific payment model to receive a recommendation from the Physician-Focused Payment Model Technical Advisory Committee (PTAC). The proposal was supported by public comments from AGA and the American Medical Association. It now heads to the U.S. Department of Health & Human Services for final approval.
“The intensive medical home Blue Cross initiated with us because of the success of the pilot pays us a supplemental management fee for every patient that is enrolled,” Lawrence Kosinski, MD, MBA, managing partner at IGG, and a Practice Councillor for the AGA Institute Governing Board, said in an interview. “That management fee is adjusted based on how much savings we produce for the payer. It ultimately winds up being a shared savings program based on our ability to control the cost of care, but we get a management fee upfront in order to make it happen.”
And getting those savings was simply a matter of getting patients engaged in their care. The way Project Sonar works is patients are “pinged” once a month to report on their symptoms. They generally receive a text alert with a link to a secure website where they answer five questions that are derived from the Crohn’s Disease Activity Index. The first one asks how many bowel movements per day over the last 7 days. The second one asks for a rating of abdominal pain. The third one is a rating of the patient’s general state of well-being. Then they are asked whether they are taking drugs for diarrhea. Finally, there are some check boxes for whether they have any eye symptoms or skin rashes or joint pains.
The answers are then weighted and a score is given both to the patient and the doctor. Doctors are alerted to which patients might require more focused attention over those who have their symptoms well managed.
But what is making this program work is that IGG has been able to get an 80% sustained response rate from patients using the program.
“The entire savings that we are generating is coming solely from the patients who participate in the platform,” Dr. Kosinski said.
From an analysis of BCBS of Illinois’ claims data, Dr. Kosinski and his colleagues determined that “ it costs about $24,000 a year to take care of a Crohn’s patient, and over half the money that is spent is spent for inpatient care, complications, bad things happening to these patients.”
He continued: “The difference in annual costs between a pinger and a nonpinger is $6,300. That is a 25% drop in the cost of care.” He added that Project Sonar is leading to a 10% savings in the overall cost of care for these patients when total costs are factored in.
One surprise aspect that Dr. Kosinski found was that patients needed no additional incentive to respond to their pings.
“We had thought we were going to have to get into some gameification and we actually ran a few lotteries to reward people,” he said. “We haven’t had to do it. The patients have participated because I think they feel like they are getting excellent care this way, and I’m very impressed by the fact that the patients have not had to be stimulated to do it.”
At the end of the day, it’s all about improving patients’ lives.
“Patients are doing better,” he noted. “They are staying out of the hospital. They are staying out of the operating room. They are staying at work. They are staying with their families. We have to realize, we look at these as patients with diseases. These are human beings that just happen to have a disease, and they have a life, they have jobs, family, responsibility, and if our Sonar system is allowing them to have a more normal life, there is a lot of traction there.”
Dr. Kosinski is also an Associate Editor for GI & Hepatology News.
Gastroenterologists wanting to participate in the advanced alternative payment model track of the new Quality Payment Program developed under the Medicare Access and CHIP Reauthorization Act (MACRA) may soon have an option as early as 2018.
Project Sonar, a program that helps gastroenterologists and their patients help manage inflammatory bowel diseases such as Crohn’s disease and ulcerative colitis was the first physician-focused gastroenterology-specific payment model to receive a recommendation from the Physician-Focused Payment Model Technical Advisory Committee (PTAC). The proposal was supported by public comments from AGA and the American Medical Association. It now heads to the U.S. Department of Health & Human Services for final approval.
“The intensive medical home Blue Cross initiated with us because of the success of the pilot pays us a supplemental management fee for every patient that is enrolled,” Lawrence Kosinski, MD, MBA, managing partner at IGG, and a Practice Councillor for the AGA Institute Governing Board, said in an interview. “That management fee is adjusted based on how much savings we produce for the payer. It ultimately winds up being a shared savings program based on our ability to control the cost of care, but we get a management fee upfront in order to make it happen.”
And getting those savings was simply a matter of getting patients engaged in their care. The way Project Sonar works is patients are “pinged” once a month to report on their symptoms. They generally receive a text alert with a link to a secure website where they answer five questions that are derived from the Crohn’s Disease Activity Index. The first one asks how many bowel movements per day over the last 7 days. The second one asks for a rating of abdominal pain. The third one is a rating of the patient’s general state of well-being. Then they are asked whether they are taking drugs for diarrhea. Finally, there are some check boxes for whether they have any eye symptoms or skin rashes or joint pains.
The answers are then weighted and a score is given both to the patient and the doctor. Doctors are alerted to which patients might require more focused attention over those who have their symptoms well managed.
But what is making this program work is that IGG has been able to get an 80% sustained response rate from patients using the program.
“The entire savings that we are generating is coming solely from the patients who participate in the platform,” Dr. Kosinski said.
From an analysis of BCBS of Illinois’ claims data, Dr. Kosinski and his colleagues determined that “ it costs about $24,000 a year to take care of a Crohn’s patient, and over half the money that is spent is spent for inpatient care, complications, bad things happening to these patients.”
He continued: “The difference in annual costs between a pinger and a nonpinger is $6,300. That is a 25% drop in the cost of care.” He added that Project Sonar is leading to a 10% savings in the overall cost of care for these patients when total costs are factored in.
One surprise aspect that Dr. Kosinski found was that patients needed no additional incentive to respond to their pings.
“We had thought we were going to have to get into some gameification and we actually ran a few lotteries to reward people,” he said. “We haven’t had to do it. The patients have participated because I think they feel like they are getting excellent care this way, and I’m very impressed by the fact that the patients have not had to be stimulated to do it.”
At the end of the day, it’s all about improving patients’ lives.
“Patients are doing better,” he noted. “They are staying out of the hospital. They are staying out of the operating room. They are staying at work. They are staying with their families. We have to realize, we look at these as patients with diseases. These are human beings that just happen to have a disease, and they have a life, they have jobs, family, responsibility, and if our Sonar system is allowing them to have a more normal life, there is a lot of traction there.”
Dr. Kosinski is also an Associate Editor for GI & Hepatology News.