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Childhood adversities tied to depressive symptoms in older homeless adults
Childhood adversities, which are known contributors to psychiatric morbidity in adults, continue to be disruptive later in life, a cross-sectional study of 350 older homeless adults shows.
“Clinicians should collect information about childhood adversities among this high-risk population to inform risk assessment and treatment recommendations,” wrote Chuan-Mei Lee, MD, and her associates (Am J Geriatr Psychiatry. 2017 Feb;25[2]:107-17).
At the start of the study, Dr. Lee and her associates recruited 350 adults who met the participation criteria from several places frequented by homeless individuals in Oakland, Calif., including shelters and encampments.
The median age of the participants was 58.1 years, 77.1% were men, and 79.7% were African American. All of the participants were English speakers and were homeless as defined by the Homeless Emergency Assistance and Rapid Transition to Housing Act (Psychiatr Ser. 2009;60[4]:465-72). Many of the participants (43.4%) had experienced their first homeless episode at age 50 years or later, reported Dr. Lee of the department of psychiatry at the University of California, San Francisco, and her associates.
The older homeless adults were accessed clinically and asked whether a health care provider had ever told them that they had any of several conditions, including hypertension, coronary artery disease, diabetes, stroke, cancer, and HIV/AIDS. The investigators used the Modified Mini-Mental State examination to assess the participants’ cognitive statuses.
The participants were asked about seven categories of adverse events that they might have experienced before age 18. Specifically, they were asked if they had experienced physical neglect, verbal abuse, physical abuse, sexual abuse, the death of either parent, incarceration of a parent for 1 month or more, or placement in the child welfare system. Each person received a childhood adversity score ranging from 0 to 7.
“Because of the low prevalence of scores of 5 or greater, we grouped study participants with four or more childhood adversities together,” Dr. Lee and her associates wrote.
Depressive symptoms were assessed using the Center for Epidemiologic Studies Depression Scale (CESD). A CESD score equal to or greater than 22 was used to define moderate to severe depressive symptoms.
Participants who completed the enrollment procedures received a $5 gift card, and those who completed the enrollment interview received a $20 gift card.
Of the 350 total participants, 251 reported a history of childhood adversity, and 99 reported no such history. Verbal abuse was the most commonly reported childhood adversity (49.3%), followed by physical abuse (33.3%) and parental death (21.4%).
Overall, the investigators found that more than one-third of the participants (38.3%) received CESD scores high enough to place them in the moderate to severe depressive symptoms category. Furthermore, they found a dose-response relationship between the number of adverse experiences and higher odds of moderate to severe depressive symptoms.
Participants with “exposure to one childhood adversity had a twofold increase in odds of reporting moderate to severe depressive symptoms (adjusted odds ratio, 2.0; 95% confidence interval, 1.1-3.7), whereas those with exposure to four or more childhood adversities had a sixfold increase (AOR, 6.0; 95% CI, 2.4-15.4), compared with those with no adverse events,” the investigators noted.
Similar dose-response relationships were found between the number of adverse childhood events and the number of lifetime suicide attempts.
Dr. Lee and her associates said their findings have implications for clinical practice. The Substance Abuse and Mental Health Services Administration recommends that clinicians screen all patients for physical and sexual trauma but not for parental loss, they said.
“Our findings suggest that mental health and primary care providers should consider screening older homeless adults for all childhood adversities,” they wrote. “This may enhance suicide risk assessment by identifying those with multiple adversities, who are at highest risk.”
The investigators cited several limitations. For example, estimates of childhood adversity might have been underreported. Also, the study’s cross-sectional design made it difficult to establish causation between childhood adversity and psychiatric morbidity.
Nevertheless, “psychiatrists working with low-income, older populations should screen for homelessness,” they wrote. “The high prevalence of psychiatric morbidity in this medically complex population presents challenges to the mental health workforce [amid] a shortage of geriatric psychiatrists.”
Dr. Lee reported no conflicts of interest. The principal investigator, Margot Kushel, MD, reported serving on the leadership board of EveryOne Home, a group that seeks to bring an end to homelessness in Alameda County, Calif. The National Institute on Aging, the National Institute of Mental Health, and SAMHSA provided funding support.
[email protected]
On Twitter @ginalhenderson
Childhood adversities, which are known contributors to psychiatric morbidity in adults, continue to be disruptive later in life, a cross-sectional study of 350 older homeless adults shows.
“Clinicians should collect information about childhood adversities among this high-risk population to inform risk assessment and treatment recommendations,” wrote Chuan-Mei Lee, MD, and her associates (Am J Geriatr Psychiatry. 2017 Feb;25[2]:107-17).
At the start of the study, Dr. Lee and her associates recruited 350 adults who met the participation criteria from several places frequented by homeless individuals in Oakland, Calif., including shelters and encampments.
The median age of the participants was 58.1 years, 77.1% were men, and 79.7% were African American. All of the participants were English speakers and were homeless as defined by the Homeless Emergency Assistance and Rapid Transition to Housing Act (Psychiatr Ser. 2009;60[4]:465-72). Many of the participants (43.4%) had experienced their first homeless episode at age 50 years or later, reported Dr. Lee of the department of psychiatry at the University of California, San Francisco, and her associates.
The older homeless adults were accessed clinically and asked whether a health care provider had ever told them that they had any of several conditions, including hypertension, coronary artery disease, diabetes, stroke, cancer, and HIV/AIDS. The investigators used the Modified Mini-Mental State examination to assess the participants’ cognitive statuses.
The participants were asked about seven categories of adverse events that they might have experienced before age 18. Specifically, they were asked if they had experienced physical neglect, verbal abuse, physical abuse, sexual abuse, the death of either parent, incarceration of a parent for 1 month or more, or placement in the child welfare system. Each person received a childhood adversity score ranging from 0 to 7.
“Because of the low prevalence of scores of 5 or greater, we grouped study participants with four or more childhood adversities together,” Dr. Lee and her associates wrote.
Depressive symptoms were assessed using the Center for Epidemiologic Studies Depression Scale (CESD). A CESD score equal to or greater than 22 was used to define moderate to severe depressive symptoms.
Participants who completed the enrollment procedures received a $5 gift card, and those who completed the enrollment interview received a $20 gift card.
Of the 350 total participants, 251 reported a history of childhood adversity, and 99 reported no such history. Verbal abuse was the most commonly reported childhood adversity (49.3%), followed by physical abuse (33.3%) and parental death (21.4%).
Overall, the investigators found that more than one-third of the participants (38.3%) received CESD scores high enough to place them in the moderate to severe depressive symptoms category. Furthermore, they found a dose-response relationship between the number of adverse experiences and higher odds of moderate to severe depressive symptoms.
Participants with “exposure to one childhood adversity had a twofold increase in odds of reporting moderate to severe depressive symptoms (adjusted odds ratio, 2.0; 95% confidence interval, 1.1-3.7), whereas those with exposure to four or more childhood adversities had a sixfold increase (AOR, 6.0; 95% CI, 2.4-15.4), compared with those with no adverse events,” the investigators noted.
Similar dose-response relationships were found between the number of adverse childhood events and the number of lifetime suicide attempts.
Dr. Lee and her associates said their findings have implications for clinical practice. The Substance Abuse and Mental Health Services Administration recommends that clinicians screen all patients for physical and sexual trauma but not for parental loss, they said.
“Our findings suggest that mental health and primary care providers should consider screening older homeless adults for all childhood adversities,” they wrote. “This may enhance suicide risk assessment by identifying those with multiple adversities, who are at highest risk.”
The investigators cited several limitations. For example, estimates of childhood adversity might have been underreported. Also, the study’s cross-sectional design made it difficult to establish causation between childhood adversity and psychiatric morbidity.
Nevertheless, “psychiatrists working with low-income, older populations should screen for homelessness,” they wrote. “The high prevalence of psychiatric morbidity in this medically complex population presents challenges to the mental health workforce [amid] a shortage of geriatric psychiatrists.”
Dr. Lee reported no conflicts of interest. The principal investigator, Margot Kushel, MD, reported serving on the leadership board of EveryOne Home, a group that seeks to bring an end to homelessness in Alameda County, Calif. The National Institute on Aging, the National Institute of Mental Health, and SAMHSA provided funding support.
[email protected]
On Twitter @ginalhenderson
Childhood adversities, which are known contributors to psychiatric morbidity in adults, continue to be disruptive later in life, a cross-sectional study of 350 older homeless adults shows.
“Clinicians should collect information about childhood adversities among this high-risk population to inform risk assessment and treatment recommendations,” wrote Chuan-Mei Lee, MD, and her associates (Am J Geriatr Psychiatry. 2017 Feb;25[2]:107-17).
At the start of the study, Dr. Lee and her associates recruited 350 adults who met the participation criteria from several places frequented by homeless individuals in Oakland, Calif., including shelters and encampments.
The median age of the participants was 58.1 years, 77.1% were men, and 79.7% were African American. All of the participants were English speakers and were homeless as defined by the Homeless Emergency Assistance and Rapid Transition to Housing Act (Psychiatr Ser. 2009;60[4]:465-72). Many of the participants (43.4%) had experienced their first homeless episode at age 50 years or later, reported Dr. Lee of the department of psychiatry at the University of California, San Francisco, and her associates.
The older homeless adults were accessed clinically and asked whether a health care provider had ever told them that they had any of several conditions, including hypertension, coronary artery disease, diabetes, stroke, cancer, and HIV/AIDS. The investigators used the Modified Mini-Mental State examination to assess the participants’ cognitive statuses.
The participants were asked about seven categories of adverse events that they might have experienced before age 18. Specifically, they were asked if they had experienced physical neglect, verbal abuse, physical abuse, sexual abuse, the death of either parent, incarceration of a parent for 1 month or more, or placement in the child welfare system. Each person received a childhood adversity score ranging from 0 to 7.
“Because of the low prevalence of scores of 5 or greater, we grouped study participants with four or more childhood adversities together,” Dr. Lee and her associates wrote.
Depressive symptoms were assessed using the Center for Epidemiologic Studies Depression Scale (CESD). A CESD score equal to or greater than 22 was used to define moderate to severe depressive symptoms.
Participants who completed the enrollment procedures received a $5 gift card, and those who completed the enrollment interview received a $20 gift card.
Of the 350 total participants, 251 reported a history of childhood adversity, and 99 reported no such history. Verbal abuse was the most commonly reported childhood adversity (49.3%), followed by physical abuse (33.3%) and parental death (21.4%).
Overall, the investigators found that more than one-third of the participants (38.3%) received CESD scores high enough to place them in the moderate to severe depressive symptoms category. Furthermore, they found a dose-response relationship between the number of adverse experiences and higher odds of moderate to severe depressive symptoms.
Participants with “exposure to one childhood adversity had a twofold increase in odds of reporting moderate to severe depressive symptoms (adjusted odds ratio, 2.0; 95% confidence interval, 1.1-3.7), whereas those with exposure to four or more childhood adversities had a sixfold increase (AOR, 6.0; 95% CI, 2.4-15.4), compared with those with no adverse events,” the investigators noted.
Similar dose-response relationships were found between the number of adverse childhood events and the number of lifetime suicide attempts.
Dr. Lee and her associates said their findings have implications for clinical practice. The Substance Abuse and Mental Health Services Administration recommends that clinicians screen all patients for physical and sexual trauma but not for parental loss, they said.
“Our findings suggest that mental health and primary care providers should consider screening older homeless adults for all childhood adversities,” they wrote. “This may enhance suicide risk assessment by identifying those with multiple adversities, who are at highest risk.”
The investigators cited several limitations. For example, estimates of childhood adversity might have been underreported. Also, the study’s cross-sectional design made it difficult to establish causation between childhood adversity and psychiatric morbidity.
Nevertheless, “psychiatrists working with low-income, older populations should screen for homelessness,” they wrote. “The high prevalence of psychiatric morbidity in this medically complex population presents challenges to the mental health workforce [amid] a shortage of geriatric psychiatrists.”
Dr. Lee reported no conflicts of interest. The principal investigator, Margot Kushel, MD, reported serving on the leadership board of EveryOne Home, a group that seeks to bring an end to homelessness in Alameda County, Calif. The National Institute on Aging, the National Institute of Mental Health, and SAMHSA provided funding support.
[email protected]
On Twitter @ginalhenderson
FROM THE AMERICAN JOURNAL OF GERIATRIC PSYCHIATRY
Experts warn against readmissions as sole quality measure in ovarian cancer
NATIONAL HARBOR, MD. – For patients with ovarian cancer, focusing solely on hospital readmission rates as a quality measure might worsen long-term outcomes while unfairly penalizing the best hospitals, suggest the results of two analyses of the National Cancer Database presented at the annual meeting of the Society of Gynecologic Oncology.
Hospitals with the highest ovarian cancer caseloads had the best rates of overall survival and postsurgical mortality, but also had the highest rates of readmission within 30 days after postsurgical discharge, reported Shitanshu Uppal, MBBS, of the obstetrics and gynecology department at the University of Michigan in Ann Arbor.
A separate analysis linked neoadjuvant chemotherapy with significantly fewer readmissions, but also with significantly worse overall survival compared with primary debulking surgery, reported Emma L. Barber, MD, of the University of North Carolina at Chapel Hill.
“Policies that prioritize decreased readmission rates inherently encourage neoadjuvant chemotherapy over primary debulking surgery,” Dr. Barber stressed. She recommended that policies and incentive programs incorporate both short- and long-term outcomes for patients with ovarian cancer.
Thirty-day hospital readmissions cost Medicare $17.4 billion in 2004 alone, noted Dr. Uppal. Research shows that almost one in seven patients is readmitted to the hospital within 30 days of discharge after major surgery, and that high-volume hospitals with low surgical mortality rates have lower surgical readmission rates than other hospitals do (N Engl J Med. 2013;369:1134-42).
Accordingly, the Centers for Medicare and Medicaid Services limits reimbursements if hospitals exceed 30-day readmission thresholds after surgeries for certain conditions, including acute myocardial infarction, heart failure, pneumonia, chronic obstructive pulmonary disease, coronary artery disease, and total hip and total knee arthroplasty. For now, these procedures do not include primary or interval debulking, but hospitals do monitor readmission rates, in general, as part of the Hospital Readmission Reduction Program, Dr. Barber noted.
Studies of ovarian cancer have shown postsurgical readmission rates of 10%-20%, Dr. Uppal said. To evaluate readmissions as a quality metric in this setting, he and his associates identified patients diagnosed with stage III or stage IV high-grade serous carcinoma between 2004 and 2013 who underwent cytoreductive surgery as primary treatment. More than 44,000 patients meeting these criteria were treated at hospitals that handled anywhere from under 10 to more than 30 cases annually.
The overall rate of unplanned readmissions was 6.2% (95% confidence interval, 5.2%-6.4%), and patients resembled each other clinically and demographically, irrespective of hospital caseload, Dr. Uppal said. After adjustment for other risk factors for readmission, including higher-stage disease, hospitals that treated more than 30 cases of ovarian cancer per year had significantly higher 30-day readmission rates than did the lowest-volume hospitals – nearly 10%, compared with about 7.5% (adjusted odd ratio, 1.25; 95% CI, 1.1-1.5; P less than .05). However, high-volume hospitals had the lowest 30-day and 90-day mortality rates (P less than .05), the highest rate of 5-year overall survival (adjusted hazard ratio, 0.83; 95% CI, 0.78-0.88; P less than .05), and a significantly higher frequency of adherence to NCCN guidelines compared with low-volume hospitals.
“Not all readmissions reflect a failed discharge,” Dr. Uppal emphasized. “Certain readmissions may be appropriate and necessary, and some surgeries merit appropriate aggression and result in a high readmission rate.”
The study by Dr. Barber included data from nearly 27,000 patients who underwent chemotherapy and surgery for stage IIIC epithelial ovarian cancer at Commission on Cancer–accredited institutions between 2006 and 2012. The overall 30-day readmission rate was 11%, and 57% of readmissions were unplanned. About 16% of patients received neoadjuvant chemotherapy followed by interval debulking surgery, and the rest underwent primary debulking surgery, Dr. Barber said.
Rates of 30-day readmissions were 6.5% after neoadjuvant chemotherapy with interval debulking, compared with 12% after primary debulking. Neoadjuvant chemotherapy was associated with a 48% drop in the risk of readmission and with a 37% decrease in the chances of unplanned readmission after the researchers controlled for age, race, insurance status, comorbidities, and histology, Dr. Barber said. However, primary debulking significantly increased the chances of survival at next follow-up (HR, 1.36; 95% CI, 1.29-1.42; P less than .001). Median overall survival was 47 months with primary debulking surgery and 37 months with neoadjuvant chemotherapy (P less than .001).
These findings show how broad health policies that are not designed for specific patient subgroups can create unique, unintended, and undesirable incentives and consequences, Dr. Barber said. Unfairly penalizing high-volume hospitals by concentrating solely on readmissions, rather than taking a more holistic view of cancer care, could inadvertently encourage the use of less aggressive debulking surgeries and increase the use of neoadjuvant therapies in cases where primary debulking is more appropriate, Dr. Uppal added.
Dr. Barber and Dr. Uppal acknowledged no external funding sources and reported having no conflicts of interest.
NATIONAL HARBOR, MD. – For patients with ovarian cancer, focusing solely on hospital readmission rates as a quality measure might worsen long-term outcomes while unfairly penalizing the best hospitals, suggest the results of two analyses of the National Cancer Database presented at the annual meeting of the Society of Gynecologic Oncology.
Hospitals with the highest ovarian cancer caseloads had the best rates of overall survival and postsurgical mortality, but also had the highest rates of readmission within 30 days after postsurgical discharge, reported Shitanshu Uppal, MBBS, of the obstetrics and gynecology department at the University of Michigan in Ann Arbor.
A separate analysis linked neoadjuvant chemotherapy with significantly fewer readmissions, but also with significantly worse overall survival compared with primary debulking surgery, reported Emma L. Barber, MD, of the University of North Carolina at Chapel Hill.
“Policies that prioritize decreased readmission rates inherently encourage neoadjuvant chemotherapy over primary debulking surgery,” Dr. Barber stressed. She recommended that policies and incentive programs incorporate both short- and long-term outcomes for patients with ovarian cancer.
Thirty-day hospital readmissions cost Medicare $17.4 billion in 2004 alone, noted Dr. Uppal. Research shows that almost one in seven patients is readmitted to the hospital within 30 days of discharge after major surgery, and that high-volume hospitals with low surgical mortality rates have lower surgical readmission rates than other hospitals do (N Engl J Med. 2013;369:1134-42).
Accordingly, the Centers for Medicare and Medicaid Services limits reimbursements if hospitals exceed 30-day readmission thresholds after surgeries for certain conditions, including acute myocardial infarction, heart failure, pneumonia, chronic obstructive pulmonary disease, coronary artery disease, and total hip and total knee arthroplasty. For now, these procedures do not include primary or interval debulking, but hospitals do monitor readmission rates, in general, as part of the Hospital Readmission Reduction Program, Dr. Barber noted.
Studies of ovarian cancer have shown postsurgical readmission rates of 10%-20%, Dr. Uppal said. To evaluate readmissions as a quality metric in this setting, he and his associates identified patients diagnosed with stage III or stage IV high-grade serous carcinoma between 2004 and 2013 who underwent cytoreductive surgery as primary treatment. More than 44,000 patients meeting these criteria were treated at hospitals that handled anywhere from under 10 to more than 30 cases annually.
The overall rate of unplanned readmissions was 6.2% (95% confidence interval, 5.2%-6.4%), and patients resembled each other clinically and demographically, irrespective of hospital caseload, Dr. Uppal said. After adjustment for other risk factors for readmission, including higher-stage disease, hospitals that treated more than 30 cases of ovarian cancer per year had significantly higher 30-day readmission rates than did the lowest-volume hospitals – nearly 10%, compared with about 7.5% (adjusted odd ratio, 1.25; 95% CI, 1.1-1.5; P less than .05). However, high-volume hospitals had the lowest 30-day and 90-day mortality rates (P less than .05), the highest rate of 5-year overall survival (adjusted hazard ratio, 0.83; 95% CI, 0.78-0.88; P less than .05), and a significantly higher frequency of adherence to NCCN guidelines compared with low-volume hospitals.
“Not all readmissions reflect a failed discharge,” Dr. Uppal emphasized. “Certain readmissions may be appropriate and necessary, and some surgeries merit appropriate aggression and result in a high readmission rate.”
The study by Dr. Barber included data from nearly 27,000 patients who underwent chemotherapy and surgery for stage IIIC epithelial ovarian cancer at Commission on Cancer–accredited institutions between 2006 and 2012. The overall 30-day readmission rate was 11%, and 57% of readmissions were unplanned. About 16% of patients received neoadjuvant chemotherapy followed by interval debulking surgery, and the rest underwent primary debulking surgery, Dr. Barber said.
Rates of 30-day readmissions were 6.5% after neoadjuvant chemotherapy with interval debulking, compared with 12% after primary debulking. Neoadjuvant chemotherapy was associated with a 48% drop in the risk of readmission and with a 37% decrease in the chances of unplanned readmission after the researchers controlled for age, race, insurance status, comorbidities, and histology, Dr. Barber said. However, primary debulking significantly increased the chances of survival at next follow-up (HR, 1.36; 95% CI, 1.29-1.42; P less than .001). Median overall survival was 47 months with primary debulking surgery and 37 months with neoadjuvant chemotherapy (P less than .001).
These findings show how broad health policies that are not designed for specific patient subgroups can create unique, unintended, and undesirable incentives and consequences, Dr. Barber said. Unfairly penalizing high-volume hospitals by concentrating solely on readmissions, rather than taking a more holistic view of cancer care, could inadvertently encourage the use of less aggressive debulking surgeries and increase the use of neoadjuvant therapies in cases where primary debulking is more appropriate, Dr. Uppal added.
Dr. Barber and Dr. Uppal acknowledged no external funding sources and reported having no conflicts of interest.
NATIONAL HARBOR, MD. – For patients with ovarian cancer, focusing solely on hospital readmission rates as a quality measure might worsen long-term outcomes while unfairly penalizing the best hospitals, suggest the results of two analyses of the National Cancer Database presented at the annual meeting of the Society of Gynecologic Oncology.
Hospitals with the highest ovarian cancer caseloads had the best rates of overall survival and postsurgical mortality, but also had the highest rates of readmission within 30 days after postsurgical discharge, reported Shitanshu Uppal, MBBS, of the obstetrics and gynecology department at the University of Michigan in Ann Arbor.
A separate analysis linked neoadjuvant chemotherapy with significantly fewer readmissions, but also with significantly worse overall survival compared with primary debulking surgery, reported Emma L. Barber, MD, of the University of North Carolina at Chapel Hill.
“Policies that prioritize decreased readmission rates inherently encourage neoadjuvant chemotherapy over primary debulking surgery,” Dr. Barber stressed. She recommended that policies and incentive programs incorporate both short- and long-term outcomes for patients with ovarian cancer.
Thirty-day hospital readmissions cost Medicare $17.4 billion in 2004 alone, noted Dr. Uppal. Research shows that almost one in seven patients is readmitted to the hospital within 30 days of discharge after major surgery, and that high-volume hospitals with low surgical mortality rates have lower surgical readmission rates than other hospitals do (N Engl J Med. 2013;369:1134-42).
Accordingly, the Centers for Medicare and Medicaid Services limits reimbursements if hospitals exceed 30-day readmission thresholds after surgeries for certain conditions, including acute myocardial infarction, heart failure, pneumonia, chronic obstructive pulmonary disease, coronary artery disease, and total hip and total knee arthroplasty. For now, these procedures do not include primary or interval debulking, but hospitals do monitor readmission rates, in general, as part of the Hospital Readmission Reduction Program, Dr. Barber noted.
Studies of ovarian cancer have shown postsurgical readmission rates of 10%-20%, Dr. Uppal said. To evaluate readmissions as a quality metric in this setting, he and his associates identified patients diagnosed with stage III or stage IV high-grade serous carcinoma between 2004 and 2013 who underwent cytoreductive surgery as primary treatment. More than 44,000 patients meeting these criteria were treated at hospitals that handled anywhere from under 10 to more than 30 cases annually.
The overall rate of unplanned readmissions was 6.2% (95% confidence interval, 5.2%-6.4%), and patients resembled each other clinically and demographically, irrespective of hospital caseload, Dr. Uppal said. After adjustment for other risk factors for readmission, including higher-stage disease, hospitals that treated more than 30 cases of ovarian cancer per year had significantly higher 30-day readmission rates than did the lowest-volume hospitals – nearly 10%, compared with about 7.5% (adjusted odd ratio, 1.25; 95% CI, 1.1-1.5; P less than .05). However, high-volume hospitals had the lowest 30-day and 90-day mortality rates (P less than .05), the highest rate of 5-year overall survival (adjusted hazard ratio, 0.83; 95% CI, 0.78-0.88; P less than .05), and a significantly higher frequency of adherence to NCCN guidelines compared with low-volume hospitals.
“Not all readmissions reflect a failed discharge,” Dr. Uppal emphasized. “Certain readmissions may be appropriate and necessary, and some surgeries merit appropriate aggression and result in a high readmission rate.”
The study by Dr. Barber included data from nearly 27,000 patients who underwent chemotherapy and surgery for stage IIIC epithelial ovarian cancer at Commission on Cancer–accredited institutions between 2006 and 2012. The overall 30-day readmission rate was 11%, and 57% of readmissions were unplanned. About 16% of patients received neoadjuvant chemotherapy followed by interval debulking surgery, and the rest underwent primary debulking surgery, Dr. Barber said.
Rates of 30-day readmissions were 6.5% after neoadjuvant chemotherapy with interval debulking, compared with 12% after primary debulking. Neoadjuvant chemotherapy was associated with a 48% drop in the risk of readmission and with a 37% decrease in the chances of unplanned readmission after the researchers controlled for age, race, insurance status, comorbidities, and histology, Dr. Barber said. However, primary debulking significantly increased the chances of survival at next follow-up (HR, 1.36; 95% CI, 1.29-1.42; P less than .001). Median overall survival was 47 months with primary debulking surgery and 37 months with neoadjuvant chemotherapy (P less than .001).
These findings show how broad health policies that are not designed for specific patient subgroups can create unique, unintended, and undesirable incentives and consequences, Dr. Barber said. Unfairly penalizing high-volume hospitals by concentrating solely on readmissions, rather than taking a more holistic view of cancer care, could inadvertently encourage the use of less aggressive debulking surgeries and increase the use of neoadjuvant therapies in cases where primary debulking is more appropriate, Dr. Uppal added.
Dr. Barber and Dr. Uppal acknowledged no external funding sources and reported having no conflicts of interest.
AT THE ANNUAL MEETING ON WOMEN’S CANCER
Key clinical point: For patients with ovarian cancer, focusing solely on postsurgical hospital readmissions as a quality measure could worsen outcomes and might penalize the best hospitals.
Major finding: Hospitals that treated the most cases of ovarian cancer annually had significantly better rates of overall survival and postsurgical mortality, as well as the highest 30-day readmission rates (P less than .05). A separate analysis linked neoadjuvant chemotherapy with significantly fewer readmissions, but also with significantly worse overall survival compared with primary debulking surgery.
Data source: Two large retrospective analyses of the National Cancer Database.
Disclosures: Dr. Barber and Dr. Uppal acknowledged no external funding sources and reported having no conflicts of interest.
HM17: Plenaries – Conway and DeSalvo
The first two plenary addresses at HM17 are focused on policy at a time when the dynamically evolving U.S. health care delivery system may seem daunting, opaque, and labyrinthine.
Some might view the health care landscape as hopelessly confusing. Yet both of the keynote speakers use the same word for what they hope to leave their listeners with: optimism.
“Though it feels uncertain in the headlines, the reality is that the health care world feels pretty united in that we need to continue the progress we’ve made on moving away from the fee-for-service model and to let people practice medicine the way they want – to work better as teams and focus on patients and outcomes,” said Karen DeSalvo, MD, MPH, MSc, former acting assistant secretary for health in the U.S. Department of Health and Human Services (HHS) and former national coordinator for health information technology.
“I would view it as an opportunity as well,” said Dr. Conway, who still moonlights as a pediatric academic hospitalist on weekends in greater Washington, D.C. “I think the pieces are coming together. Everything from data, to new payment models, to the MACRA Medicare Physician payment legislation, really suggests a time of positive change.”
Dr. DeSalvo, a former political appointee, joined HHS as the national coordinator for health information technology in 2014 and soon thereafter assumed the acting assistant secretary role. Dr. Conway has attained one of the country’s highest-ranking public health care jobs since joining CMS in 2011. He retained the top post at CMS while President Donald Trump’s nominee to lead the agency, Seema Verma, awaited a confirmation hearing before the U.S. Senate. Dr. Conway’s prior title was principal deputy administrator and CMS chief medical officer.
“I don’t want people to lose sight of the fact that there’s this entire care system that everybody’s working and innovating in every day, trying to find more efficient, effective ways to get better outcomes,” she said. “Hospitalists, quite frankly, have been leading that for their entire existence. They really understand in great granular detail what it takes.”
Dr. DeSalvo believes that the progress of the past 5 years has established a path that must be followed. The public sector move away from fee-for-service has combined with emerging technology platforms to create a new age where physicians and insurers can judge, in real time, how well care is working.
“We’re now in a feedback loop where we can say – ‘When we’ve built a care system like this or when we pay this way, we are actually seeing improved outcomes’ – and change doesn’t take as long,” Dr. DeSalvo said.
Dr. Conway, whose working title for his speech is “Health care System Transformation,” said hospitalists should be encouraged by how well the field has already adapted to the proliferation of accountable care organizations (ACOs), value-based purchasing (VBP), alternative payment models (APM), and the Medicare Access and CHIP Reauthorization Act (MACRA) of 2015. He noted that, as innovations lead to better and more coordinated patient care, hospitalists, patients, and hospitals would all benefit.
“I want to leave people with the idea that value-based payment innovation and delivery system reform will continue to be critical aspects of improving our health system,” he said. “I also want hospitalists to continue to stay engaged with these new payment models, help lead them, and provide better patient care as a part of them.”
The first two plenary addresses at HM17 are focused on policy at a time when the dynamically evolving U.S. health care delivery system may seem daunting, opaque, and labyrinthine.
Some might view the health care landscape as hopelessly confusing. Yet both of the keynote speakers use the same word for what they hope to leave their listeners with: optimism.
“Though it feels uncertain in the headlines, the reality is that the health care world feels pretty united in that we need to continue the progress we’ve made on moving away from the fee-for-service model and to let people practice medicine the way they want – to work better as teams and focus on patients and outcomes,” said Karen DeSalvo, MD, MPH, MSc, former acting assistant secretary for health in the U.S. Department of Health and Human Services (HHS) and former national coordinator for health information technology.
“I would view it as an opportunity as well,” said Dr. Conway, who still moonlights as a pediatric academic hospitalist on weekends in greater Washington, D.C. “I think the pieces are coming together. Everything from data, to new payment models, to the MACRA Medicare Physician payment legislation, really suggests a time of positive change.”
Dr. DeSalvo, a former political appointee, joined HHS as the national coordinator for health information technology in 2014 and soon thereafter assumed the acting assistant secretary role. Dr. Conway has attained one of the country’s highest-ranking public health care jobs since joining CMS in 2011. He retained the top post at CMS while President Donald Trump’s nominee to lead the agency, Seema Verma, awaited a confirmation hearing before the U.S. Senate. Dr. Conway’s prior title was principal deputy administrator and CMS chief medical officer.
“I don’t want people to lose sight of the fact that there’s this entire care system that everybody’s working and innovating in every day, trying to find more efficient, effective ways to get better outcomes,” she said. “Hospitalists, quite frankly, have been leading that for their entire existence. They really understand in great granular detail what it takes.”
Dr. DeSalvo believes that the progress of the past 5 years has established a path that must be followed. The public sector move away from fee-for-service has combined with emerging technology platforms to create a new age where physicians and insurers can judge, in real time, how well care is working.
“We’re now in a feedback loop where we can say – ‘When we’ve built a care system like this or when we pay this way, we are actually seeing improved outcomes’ – and change doesn’t take as long,” Dr. DeSalvo said.
Dr. Conway, whose working title for his speech is “Health care System Transformation,” said hospitalists should be encouraged by how well the field has already adapted to the proliferation of accountable care organizations (ACOs), value-based purchasing (VBP), alternative payment models (APM), and the Medicare Access and CHIP Reauthorization Act (MACRA) of 2015. He noted that, as innovations lead to better and more coordinated patient care, hospitalists, patients, and hospitals would all benefit.
“I want to leave people with the idea that value-based payment innovation and delivery system reform will continue to be critical aspects of improving our health system,” he said. “I also want hospitalists to continue to stay engaged with these new payment models, help lead them, and provide better patient care as a part of them.”
The first two plenary addresses at HM17 are focused on policy at a time when the dynamically evolving U.S. health care delivery system may seem daunting, opaque, and labyrinthine.
Some might view the health care landscape as hopelessly confusing. Yet both of the keynote speakers use the same word for what they hope to leave their listeners with: optimism.
“Though it feels uncertain in the headlines, the reality is that the health care world feels pretty united in that we need to continue the progress we’ve made on moving away from the fee-for-service model and to let people practice medicine the way they want – to work better as teams and focus on patients and outcomes,” said Karen DeSalvo, MD, MPH, MSc, former acting assistant secretary for health in the U.S. Department of Health and Human Services (HHS) and former national coordinator for health information technology.
“I would view it as an opportunity as well,” said Dr. Conway, who still moonlights as a pediatric academic hospitalist on weekends in greater Washington, D.C. “I think the pieces are coming together. Everything from data, to new payment models, to the MACRA Medicare Physician payment legislation, really suggests a time of positive change.”
Dr. DeSalvo, a former political appointee, joined HHS as the national coordinator for health information technology in 2014 and soon thereafter assumed the acting assistant secretary role. Dr. Conway has attained one of the country’s highest-ranking public health care jobs since joining CMS in 2011. He retained the top post at CMS while President Donald Trump’s nominee to lead the agency, Seema Verma, awaited a confirmation hearing before the U.S. Senate. Dr. Conway’s prior title was principal deputy administrator and CMS chief medical officer.
“I don’t want people to lose sight of the fact that there’s this entire care system that everybody’s working and innovating in every day, trying to find more efficient, effective ways to get better outcomes,” she said. “Hospitalists, quite frankly, have been leading that for their entire existence. They really understand in great granular detail what it takes.”
Dr. DeSalvo believes that the progress of the past 5 years has established a path that must be followed. The public sector move away from fee-for-service has combined with emerging technology platforms to create a new age where physicians and insurers can judge, in real time, how well care is working.
“We’re now in a feedback loop where we can say – ‘When we’ve built a care system like this or when we pay this way, we are actually seeing improved outcomes’ – and change doesn’t take as long,” Dr. DeSalvo said.
Dr. Conway, whose working title for his speech is “Health care System Transformation,” said hospitalists should be encouraged by how well the field has already adapted to the proliferation of accountable care organizations (ACOs), value-based purchasing (VBP), alternative payment models (APM), and the Medicare Access and CHIP Reauthorization Act (MACRA) of 2015. He noted that, as innovations lead to better and more coordinated patient care, hospitalists, patients, and hospitals would all benefit.
“I want to leave people with the idea that value-based payment innovation and delivery system reform will continue to be critical aspects of improving our health system,” he said. “I also want hospitalists to continue to stay engaged with these new payment models, help lead them, and provide better patient care as a part of them.”
New self-persuasion app to promote HPV vaccine appears effective
A new tablet application using a self-persuasion method has been successful in convincing parents in underserved communities to have their children vaccinated for human papillomavirus (HPV), according to a study.
Of 45 participating parents, 27 of the 33 (82%) parents whose adolescents were not vaccinated reported that they decided to get their children vaccinated after completing the application. The remaining 12 already had an HPV-vaccinated adolescent. Children of participating parents were aged 11-17 years (Patient Educ Couns. 2016. doi: 10.1016/j.pec.2016.11.014).
Of the 45 parents, 31 (69%) were Hispanic and 29 (64%) held a high school education or less, according to the study.
To test the effectiveness of self-persuasion, researchers developed a tablet application which started with a 5 minute video on HPV and vaccine efficacy, and then asked parents to complete two tasks: answer questions about the HPV vaccine that prompt thought on its benefits and come up with personal reasons for why having their child vaccinated is important.
Parents then participated in a 45-60 minute interview with one of six research assistants, who prompted participants to address four research points: Did they like the application? Which questions generated interest in the HPV vaccine without raising concerns? Were they able to communicate reasons for vaccination? Were they convinced to have their children vaccinated?
After watching the video, 18 (55%) of the 33 parents whose children were not vaccinated changed their minds, and, after participating in the self-persuasion questionnaire, an additional 9 parents decided to vaccinate their children, according to the study. Five parents remained undecided, and one decided against HPV vaccination.
Overall, participants reported that the application questions were helpful in their decision to vaccinate their children, with question ratings ranging from 4.33 to 4.98 on a scale of 1 to 5.
Mr. Baldwin and his colleagues said that, while the initial test showed promise, further research must be done on actual vaccine behavior, as these tests only studied verbally reported decisions by parents.
One of the limitations to the study was that the research was primarily conducted at a research facility. While some was conducted in local clinics, Mr. Baldwin and his colleagues consider that further studies should be conducted in more public areas. All but one of the participants were female, which may make it hard to generalize about the effects of this application with male parents.
The researchers reported no relevant financial disclosures.
[email protected]
On Twitter @EAZTweets
The media has not been kind when it comes to HPV vaccinations. When most parents are approached with the option to have their children vaccinated, they are hesitant because of what they have heard from television, news articles, or online mom chat rooms about the dangerous side effects of the vaccine. When a mother hears about other mothers’ daughters fainting or being subjected to pain, she usually wonders if it is really worth the risk.
The same goes for parents who expect their daughters to practice celibacy until marriage. After all, why expose a child to negative side effects when she won’t be having sex anyway? The problem with this thinking, however, is that, often, it is not based in reality. When I approach families about HPV vaccine, or any other vaccine for that matter, I make sure to present studies that explain the lack of evidence on negative vaccine side effects, as well as information pertaining to how common HPV is.
However, simply handing out a fact sheet is not enough. Parents who are convinced that their children do not need to be vaccinated will not be persuaded through statistics but through personal anecdotes. I like to tell mothers to ask their girlfriends about being vaccinated, to not only see how common HPV is but to break the stigma as well. I explain to parents who do not want their child having sex now that, at some point, they might want their child to grow their family, and, when that time comes, don’t they want their child to be safe? Even if it is just one time, shouldn’t their child be protected? From that point on, the language of conversation has changed, and the channels of communication are more open.
As pediatricians, we are the medical advocates for our patients and their families, not just someone to prescribe medication for them. Establish that role through knowledge and conversation, and persuasion will soon follow.
Francine Pearce, MD, is a pediatrician in Frankfort, Ill. She writes the Pediatric News teen column, Pearce-ings .
The media has not been kind when it comes to HPV vaccinations. When most parents are approached with the option to have their children vaccinated, they are hesitant because of what they have heard from television, news articles, or online mom chat rooms about the dangerous side effects of the vaccine. When a mother hears about other mothers’ daughters fainting or being subjected to pain, she usually wonders if it is really worth the risk.
The same goes for parents who expect their daughters to practice celibacy until marriage. After all, why expose a child to negative side effects when she won’t be having sex anyway? The problem with this thinking, however, is that, often, it is not based in reality. When I approach families about HPV vaccine, or any other vaccine for that matter, I make sure to present studies that explain the lack of evidence on negative vaccine side effects, as well as information pertaining to how common HPV is.
However, simply handing out a fact sheet is not enough. Parents who are convinced that their children do not need to be vaccinated will not be persuaded through statistics but through personal anecdotes. I like to tell mothers to ask their girlfriends about being vaccinated, to not only see how common HPV is but to break the stigma as well. I explain to parents who do not want their child having sex now that, at some point, they might want their child to grow their family, and, when that time comes, don’t they want their child to be safe? Even if it is just one time, shouldn’t their child be protected? From that point on, the language of conversation has changed, and the channels of communication are more open.
As pediatricians, we are the medical advocates for our patients and their families, not just someone to prescribe medication for them. Establish that role through knowledge and conversation, and persuasion will soon follow.
Francine Pearce, MD, is a pediatrician in Frankfort, Ill. She writes the Pediatric News teen column, Pearce-ings .
The media has not been kind when it comes to HPV vaccinations. When most parents are approached with the option to have their children vaccinated, they are hesitant because of what they have heard from television, news articles, or online mom chat rooms about the dangerous side effects of the vaccine. When a mother hears about other mothers’ daughters fainting or being subjected to pain, she usually wonders if it is really worth the risk.
The same goes for parents who expect their daughters to practice celibacy until marriage. After all, why expose a child to negative side effects when she won’t be having sex anyway? The problem with this thinking, however, is that, often, it is not based in reality. When I approach families about HPV vaccine, or any other vaccine for that matter, I make sure to present studies that explain the lack of evidence on negative vaccine side effects, as well as information pertaining to how common HPV is.
However, simply handing out a fact sheet is not enough. Parents who are convinced that their children do not need to be vaccinated will not be persuaded through statistics but through personal anecdotes. I like to tell mothers to ask their girlfriends about being vaccinated, to not only see how common HPV is but to break the stigma as well. I explain to parents who do not want their child having sex now that, at some point, they might want their child to grow their family, and, when that time comes, don’t they want their child to be safe? Even if it is just one time, shouldn’t their child be protected? From that point on, the language of conversation has changed, and the channels of communication are more open.
As pediatricians, we are the medical advocates for our patients and their families, not just someone to prescribe medication for them. Establish that role through knowledge and conversation, and persuasion will soon follow.
Francine Pearce, MD, is a pediatrician in Frankfort, Ill. She writes the Pediatric News teen column, Pearce-ings .
A new tablet application using a self-persuasion method has been successful in convincing parents in underserved communities to have their children vaccinated for human papillomavirus (HPV), according to a study.
Of 45 participating parents, 27 of the 33 (82%) parents whose adolescents were not vaccinated reported that they decided to get their children vaccinated after completing the application. The remaining 12 already had an HPV-vaccinated adolescent. Children of participating parents were aged 11-17 years (Patient Educ Couns. 2016. doi: 10.1016/j.pec.2016.11.014).
Of the 45 parents, 31 (69%) were Hispanic and 29 (64%) held a high school education or less, according to the study.
To test the effectiveness of self-persuasion, researchers developed a tablet application which started with a 5 minute video on HPV and vaccine efficacy, and then asked parents to complete two tasks: answer questions about the HPV vaccine that prompt thought on its benefits and come up with personal reasons for why having their child vaccinated is important.
Parents then participated in a 45-60 minute interview with one of six research assistants, who prompted participants to address four research points: Did they like the application? Which questions generated interest in the HPV vaccine without raising concerns? Were they able to communicate reasons for vaccination? Were they convinced to have their children vaccinated?
After watching the video, 18 (55%) of the 33 parents whose children were not vaccinated changed their minds, and, after participating in the self-persuasion questionnaire, an additional 9 parents decided to vaccinate their children, according to the study. Five parents remained undecided, and one decided against HPV vaccination.
Overall, participants reported that the application questions were helpful in their decision to vaccinate their children, with question ratings ranging from 4.33 to 4.98 on a scale of 1 to 5.
Mr. Baldwin and his colleagues said that, while the initial test showed promise, further research must be done on actual vaccine behavior, as these tests only studied verbally reported decisions by parents.
One of the limitations to the study was that the research was primarily conducted at a research facility. While some was conducted in local clinics, Mr. Baldwin and his colleagues consider that further studies should be conducted in more public areas. All but one of the participants were female, which may make it hard to generalize about the effects of this application with male parents.
The researchers reported no relevant financial disclosures.
[email protected]
On Twitter @EAZTweets
A new tablet application using a self-persuasion method has been successful in convincing parents in underserved communities to have their children vaccinated for human papillomavirus (HPV), according to a study.
Of 45 participating parents, 27 of the 33 (82%) parents whose adolescents were not vaccinated reported that they decided to get their children vaccinated after completing the application. The remaining 12 already had an HPV-vaccinated adolescent. Children of participating parents were aged 11-17 years (Patient Educ Couns. 2016. doi: 10.1016/j.pec.2016.11.014).
Of the 45 parents, 31 (69%) were Hispanic and 29 (64%) held a high school education or less, according to the study.
To test the effectiveness of self-persuasion, researchers developed a tablet application which started with a 5 minute video on HPV and vaccine efficacy, and then asked parents to complete two tasks: answer questions about the HPV vaccine that prompt thought on its benefits and come up with personal reasons for why having their child vaccinated is important.
Parents then participated in a 45-60 minute interview with one of six research assistants, who prompted participants to address four research points: Did they like the application? Which questions generated interest in the HPV vaccine without raising concerns? Were they able to communicate reasons for vaccination? Were they convinced to have their children vaccinated?
After watching the video, 18 (55%) of the 33 parents whose children were not vaccinated changed their minds, and, after participating in the self-persuasion questionnaire, an additional 9 parents decided to vaccinate their children, according to the study. Five parents remained undecided, and one decided against HPV vaccination.
Overall, participants reported that the application questions were helpful in their decision to vaccinate their children, with question ratings ranging from 4.33 to 4.98 on a scale of 1 to 5.
Mr. Baldwin and his colleagues said that, while the initial test showed promise, further research must be done on actual vaccine behavior, as these tests only studied verbally reported decisions by parents.
One of the limitations to the study was that the research was primarily conducted at a research facility. While some was conducted in local clinics, Mr. Baldwin and his colleagues consider that further studies should be conducted in more public areas. All but one of the participants were female, which may make it hard to generalize about the effects of this application with male parents.
The researchers reported no relevant financial disclosures.
[email protected]
On Twitter @EAZTweets
FROM PATIENT EDUCATION & COUNSELING
Key clinical point:
Major finding: Of the 33 parents whose children were not vaccinated, 27 (818%) decided to have their children vaccinated after using the application.
Data source: A study of 45 parents in low-income communities, evaluated through self-reporting questionnaires and in-person interviews conducted by research assistants.
Disclosures: Researchers reported no relevant financial disclosures.
Spousal suicide linked to higher risk of mental, physical disorders
The spouses of people who died by suicide are at increased risk of mental health disorders, physical problems, and social health problems within 5 years of their partner’s death, based on data from a cohort study of about 7 million adults in Denmark. The findings were published online March 22.
“To our knowledge, this is the largest and most comprehensive study of spouses bereaved by a partner’s suicide,” wrote Annette Erlangsen, PhD, of Mental Health Centre Copenhagen, Hellerup, Denmark, and her colleagues. Although bereavement by any means is associated with increased risk of mental disorders in a surviving spouse, “whether any aspects of loss by suicide are worse than bereavement in general remains unexamined,” they wrote.
The researchers identified suicides since 1970 using a cause of death registry. The study population included 4,814 men (mean age 54 years) and 10,793 women (mean age 50 years) whose spouses committed suicide (JAMA Psychiatry. 2017 Mar 22. doi: 10.1001/jamapsychiatry.2017.0226).
Overall, both male and female spouses of people who took their own lives were more likely than was the general population to develop mental disorders within 5 years, with an incidence rate ratio (IRR) of 1.8 and 1.7, respectively, reported Dr. Erlangsen and her colleagues.
In addition, both male and female spouses of bereaved by a spouse’s suicide had increased risk for mental disorders, compared with spouses bereaved by other causes of death, with IRRs of 1.7 and 2.0, respectively. Specifically, the investigators found an excess risk after bereavement tied to a spouse’s suicide of mood disorders (men: IRR, 1.7; 95% confidence interval, 1.4-2.1; women: IRR, 1.3; 95% CI, 1.2-1.5), posttraumatic stress disorder (men: IRR, 5.6; 95% CI, 2.7-11.4; women: IRR, 3.6, 95% CI, 2.3-5.5), anxiety (men: IRR, 1.4; 95% CI, 1.0-1.9; women: IRR, 1.1; 95% CI, 0.9-1.3), drug use disorders (men: IRR, 1.4; 95% CI, 1.0-2.1; women: IRR, 1.0; 95% CI, 0.8-1.3), and deliberate self-harm (men: IRR, 1.3; 95% CI, 1.0-1.8; women: IRR, 1.5, 95% CI, 1.2-1.8).
The spouses of people who died by suicide also were more likely to use municipal family support, sick leave, unemployment, disability, and mental health care services, compared with the general population.
From a physical standpoint, spouses of people who died by suicide were at increased risk for cirrhosis and sleep disorders, and the risk of dying from any cause was higher in both men and women (IRR, 1.2 and 1.4, respectively). The risk of the spouse committing suicide was higher than in the general population for men (IRR, 3.5) and women (IRR, 4.2).
Women whose spouses committed suicide also were at significantly increased risk of becoming homicide victims (IRR, 33.8).
The data were limited by several factors, including the inclusion only of adults in formal unions, and the possibility that the hospital diagnoses might underestimate the actual incidence of health problems, the researchers noted.
“Bereavement following suicide constitutes a psychological stressor and remains a public health burden,” Dr. Erlangsen and her colleagues wrote. “More proactive outreach and linkage to support mechanisms is needed for people bereaved by spousal suicide to help them navigate their grief.”
The researchers had no financial conflicts to disclose. The American Foundation for Suicide Prevention and the Danish Health Insurance Foundation supported the study.
The findings by Annette Erlangsen, PhD, and her associates do not establish causation between spousal suicide and the health risks for their surviving spouses, Eric D. Caine, MD, wrote in an editorial (JAMA Psychiatry. 2017 March 22. doi: 10.1001/jamapsychiatry.2017.0218). Issues tied to assortative mating, for example, cannot be ruled out. Still, the data inspire confidence in light of their “consistency across multiple outcome domains, and they build on many real-world observations as well as past research.”
“Right now we know that those who remain behind following a spouse’s suicide carry as a group increased risk for greater disease burdens and for premature mortality when compared with peers,” Dr. Caine wrote. “Thus, they deserve sustained attention beyond support during their time of acute grieving to promote health and to stave off potentially predictable, longer-term adverse consequences.”
Dr. Caine is affiliated with the Injury Control Research Center for Suicide Prevention at the University of Rochester (N.Y.). He reported no financial conflicts.
The findings by Annette Erlangsen, PhD, and her associates do not establish causation between spousal suicide and the health risks for their surviving spouses, Eric D. Caine, MD, wrote in an editorial (JAMA Psychiatry. 2017 March 22. doi: 10.1001/jamapsychiatry.2017.0218). Issues tied to assortative mating, for example, cannot be ruled out. Still, the data inspire confidence in light of their “consistency across multiple outcome domains, and they build on many real-world observations as well as past research.”
“Right now we know that those who remain behind following a spouse’s suicide carry as a group increased risk for greater disease burdens and for premature mortality when compared with peers,” Dr. Caine wrote. “Thus, they deserve sustained attention beyond support during their time of acute grieving to promote health and to stave off potentially predictable, longer-term adverse consequences.”
Dr. Caine is affiliated with the Injury Control Research Center for Suicide Prevention at the University of Rochester (N.Y.). He reported no financial conflicts.
The findings by Annette Erlangsen, PhD, and her associates do not establish causation between spousal suicide and the health risks for their surviving spouses, Eric D. Caine, MD, wrote in an editorial (JAMA Psychiatry. 2017 March 22. doi: 10.1001/jamapsychiatry.2017.0218). Issues tied to assortative mating, for example, cannot be ruled out. Still, the data inspire confidence in light of their “consistency across multiple outcome domains, and they build on many real-world observations as well as past research.”
“Right now we know that those who remain behind following a spouse’s suicide carry as a group increased risk for greater disease burdens and for premature mortality when compared with peers,” Dr. Caine wrote. “Thus, they deserve sustained attention beyond support during their time of acute grieving to promote health and to stave off potentially predictable, longer-term adverse consequences.”
Dr. Caine is affiliated with the Injury Control Research Center for Suicide Prevention at the University of Rochester (N.Y.). He reported no financial conflicts.
The spouses of people who died by suicide are at increased risk of mental health disorders, physical problems, and social health problems within 5 years of their partner’s death, based on data from a cohort study of about 7 million adults in Denmark. The findings were published online March 22.
“To our knowledge, this is the largest and most comprehensive study of spouses bereaved by a partner’s suicide,” wrote Annette Erlangsen, PhD, of Mental Health Centre Copenhagen, Hellerup, Denmark, and her colleagues. Although bereavement by any means is associated with increased risk of mental disorders in a surviving spouse, “whether any aspects of loss by suicide are worse than bereavement in general remains unexamined,” they wrote.
The researchers identified suicides since 1970 using a cause of death registry. The study population included 4,814 men (mean age 54 years) and 10,793 women (mean age 50 years) whose spouses committed suicide (JAMA Psychiatry. 2017 Mar 22. doi: 10.1001/jamapsychiatry.2017.0226).
Overall, both male and female spouses of people who took their own lives were more likely than was the general population to develop mental disorders within 5 years, with an incidence rate ratio (IRR) of 1.8 and 1.7, respectively, reported Dr. Erlangsen and her colleagues.
In addition, both male and female spouses of bereaved by a spouse’s suicide had increased risk for mental disorders, compared with spouses bereaved by other causes of death, with IRRs of 1.7 and 2.0, respectively. Specifically, the investigators found an excess risk after bereavement tied to a spouse’s suicide of mood disorders (men: IRR, 1.7; 95% confidence interval, 1.4-2.1; women: IRR, 1.3; 95% CI, 1.2-1.5), posttraumatic stress disorder (men: IRR, 5.6; 95% CI, 2.7-11.4; women: IRR, 3.6, 95% CI, 2.3-5.5), anxiety (men: IRR, 1.4; 95% CI, 1.0-1.9; women: IRR, 1.1; 95% CI, 0.9-1.3), drug use disorders (men: IRR, 1.4; 95% CI, 1.0-2.1; women: IRR, 1.0; 95% CI, 0.8-1.3), and deliberate self-harm (men: IRR, 1.3; 95% CI, 1.0-1.8; women: IRR, 1.5, 95% CI, 1.2-1.8).
The spouses of people who died by suicide also were more likely to use municipal family support, sick leave, unemployment, disability, and mental health care services, compared with the general population.
From a physical standpoint, spouses of people who died by suicide were at increased risk for cirrhosis and sleep disorders, and the risk of dying from any cause was higher in both men and women (IRR, 1.2 and 1.4, respectively). The risk of the spouse committing suicide was higher than in the general population for men (IRR, 3.5) and women (IRR, 4.2).
Women whose spouses committed suicide also were at significantly increased risk of becoming homicide victims (IRR, 33.8).
The data were limited by several factors, including the inclusion only of adults in formal unions, and the possibility that the hospital diagnoses might underestimate the actual incidence of health problems, the researchers noted.
“Bereavement following suicide constitutes a psychological stressor and remains a public health burden,” Dr. Erlangsen and her colleagues wrote. “More proactive outreach and linkage to support mechanisms is needed for people bereaved by spousal suicide to help them navigate their grief.”
The researchers had no financial conflicts to disclose. The American Foundation for Suicide Prevention and the Danish Health Insurance Foundation supported the study.
The spouses of people who died by suicide are at increased risk of mental health disorders, physical problems, and social health problems within 5 years of their partner’s death, based on data from a cohort study of about 7 million adults in Denmark. The findings were published online March 22.
“To our knowledge, this is the largest and most comprehensive study of spouses bereaved by a partner’s suicide,” wrote Annette Erlangsen, PhD, of Mental Health Centre Copenhagen, Hellerup, Denmark, and her colleagues. Although bereavement by any means is associated with increased risk of mental disorders in a surviving spouse, “whether any aspects of loss by suicide are worse than bereavement in general remains unexamined,” they wrote.
The researchers identified suicides since 1970 using a cause of death registry. The study population included 4,814 men (mean age 54 years) and 10,793 women (mean age 50 years) whose spouses committed suicide (JAMA Psychiatry. 2017 Mar 22. doi: 10.1001/jamapsychiatry.2017.0226).
Overall, both male and female spouses of people who took their own lives were more likely than was the general population to develop mental disorders within 5 years, with an incidence rate ratio (IRR) of 1.8 and 1.7, respectively, reported Dr. Erlangsen and her colleagues.
In addition, both male and female spouses of bereaved by a spouse’s suicide had increased risk for mental disorders, compared with spouses bereaved by other causes of death, with IRRs of 1.7 and 2.0, respectively. Specifically, the investigators found an excess risk after bereavement tied to a spouse’s suicide of mood disorders (men: IRR, 1.7; 95% confidence interval, 1.4-2.1; women: IRR, 1.3; 95% CI, 1.2-1.5), posttraumatic stress disorder (men: IRR, 5.6; 95% CI, 2.7-11.4; women: IRR, 3.6, 95% CI, 2.3-5.5), anxiety (men: IRR, 1.4; 95% CI, 1.0-1.9; women: IRR, 1.1; 95% CI, 0.9-1.3), drug use disorders (men: IRR, 1.4; 95% CI, 1.0-2.1; women: IRR, 1.0; 95% CI, 0.8-1.3), and deliberate self-harm (men: IRR, 1.3; 95% CI, 1.0-1.8; women: IRR, 1.5, 95% CI, 1.2-1.8).
The spouses of people who died by suicide also were more likely to use municipal family support, sick leave, unemployment, disability, and mental health care services, compared with the general population.
From a physical standpoint, spouses of people who died by suicide were at increased risk for cirrhosis and sleep disorders, and the risk of dying from any cause was higher in both men and women (IRR, 1.2 and 1.4, respectively). The risk of the spouse committing suicide was higher than in the general population for men (IRR, 3.5) and women (IRR, 4.2).
Women whose spouses committed suicide also were at significantly increased risk of becoming homicide victims (IRR, 33.8).
The data were limited by several factors, including the inclusion only of adults in formal unions, and the possibility that the hospital diagnoses might underestimate the actual incidence of health problems, the researchers noted.
“Bereavement following suicide constitutes a psychological stressor and remains a public health burden,” Dr. Erlangsen and her colleagues wrote. “More proactive outreach and linkage to support mechanisms is needed for people bereaved by spousal suicide to help them navigate their grief.”
The researchers had no financial conflicts to disclose. The American Foundation for Suicide Prevention and the Danish Health Insurance Foundation supported the study.
FROM JAMA PSYCHIATRY
Key clinical point: The spouses of people who died by suicide are at increased risk for mental, physical, and social problems.
Major finding: Mental disorders, especially mood disorders, were more likely among adults whose spouse had committed suicide within the past 5 years (incidence rate ratio, 1.8).
Data source: A nationwide cohort study of 6.7 million people aged 18 and older in Denmark.
Disclosures: The researchers had no financial conflicts to disclose. The American Foundation for Suicide Prevention and the Danish Health Insurance Foundation supported the study.
GAO to launch investigation of FDA’s Orphan Drug program
Acting on a request from three influential U.S. senators, the government’s accountability arm confirmed that it will investigate potential abuses of the Orphan Drug Act.
The Government Accountability Office still must determine the full scope of what it will look into and the methodology to be used. Determining the scope will take some months, said Chuck Young, GAO’s managing director for public affairs.
Earlier this month, senators Orrin Hatch (R-Utah), Chuck Grassley (R-Iowa), and Tom Cotton (R-Ark.) sent a letter to the GAO and raised the possibility that regulatory or legislative changes might be needed “to preserve the intent of this vital law” that gives drug makers lucrative incentives to develop drugs for rare diseases.
Sen. Grassley’s office said Tuesday they expected the GAO to begin its work in about 9 months. The delay is typical as the agency has a queue of requests it is pursuing.
The senators have asked the GAO to “investigate whether the ODA [Orphan Drug Act] is still incentivizing product development for diseases with fewer than 200,000 affected individuals, as intended.”
Congress overwhelmingly passed the 1983 Orphan Drug Act to motivate pharmaceutical companies to develop drugs for people whose rare diseases had been ignored. Drugs approved as orphans are granted tax incentives and seven years of exclusive rights to market drugs that are needed by fewer than 200,000 patients in the United States.
In recent months, reports of five- and six-figure annual price tags for orphan drugs have amplified long-simmering concerns about abuse of the law. The senators’ call for a GAO investigation reflects that sentiment.
“While few will argue against the importance of the development of these drugs, several recent press reports suggest that some pharmaceutical manufacturers might be taking advantage of the multiple designation allowance in the orphan drug approval process,” the letter states.
In January, Kaiser Health News published an investigation that found the orphan drug program is being manipulated by drug makers to maximize profits and to protect niche markets for medicines being taken by millions.
That investigation, which also was published and aired by NPR, National Public Radio, found that many drugs that now have orphan status aren’t entirely new. More than 70 were drugs first approved by the Food and Drug Administration for mass-market use. Those include cholesterol blockbuster, Crestor; Abilify for psychiatric disorders; and the rheumatoid arthritis drug, Humira, the world’s best-selling drug.
Others are drugs that have received multiple exclusivity periods for two or more rare conditions.
The senators asked the GAO for a list of drugs approved or denied orphan status by the FDA. It also asked whether FDA resources, which oversees the law, have “kept up with the number of requests” from drug makers and if there is consistency in the department’s reviews.
They stated that it would be important to include patient experiences in the GAO review. The GAO does not provide updates on ongoing work but rather reports its findings once the assignment has been completed.
The rare-disease drugs have become increasingly popular with pharmaceutical and biotech companies and are expected to comprise 21.% of worldwide prescription sales by 2022, not including generics, according to consulting firm EvaluatePharma’s 2017 orphan drug report.
That’s in part because of the exorbitant prices that can be charged. Of the top 100 drugs in the United States, the average cost per patient per year for an orphan drug was $140,443 in 2016, compared with $27,756 for a nonorphan, EvaluatePharma said.
Kaiser Health News is a national health policy news service that is part of the nonpartisan Henry J. Kaiser Family Foundation. KHN’s coverage of prescription drug development, costs, and pricing is supported in part by the Laura and John Arnold Foundation.
Acting on a request from three influential U.S. senators, the government’s accountability arm confirmed that it will investigate potential abuses of the Orphan Drug Act.
The Government Accountability Office still must determine the full scope of what it will look into and the methodology to be used. Determining the scope will take some months, said Chuck Young, GAO’s managing director for public affairs.
Earlier this month, senators Orrin Hatch (R-Utah), Chuck Grassley (R-Iowa), and Tom Cotton (R-Ark.) sent a letter to the GAO and raised the possibility that regulatory or legislative changes might be needed “to preserve the intent of this vital law” that gives drug makers lucrative incentives to develop drugs for rare diseases.
Sen. Grassley’s office said Tuesday they expected the GAO to begin its work in about 9 months. The delay is typical as the agency has a queue of requests it is pursuing.
The senators have asked the GAO to “investigate whether the ODA [Orphan Drug Act] is still incentivizing product development for diseases with fewer than 200,000 affected individuals, as intended.”
Congress overwhelmingly passed the 1983 Orphan Drug Act to motivate pharmaceutical companies to develop drugs for people whose rare diseases had been ignored. Drugs approved as orphans are granted tax incentives and seven years of exclusive rights to market drugs that are needed by fewer than 200,000 patients in the United States.
In recent months, reports of five- and six-figure annual price tags for orphan drugs have amplified long-simmering concerns about abuse of the law. The senators’ call for a GAO investigation reflects that sentiment.
“While few will argue against the importance of the development of these drugs, several recent press reports suggest that some pharmaceutical manufacturers might be taking advantage of the multiple designation allowance in the orphan drug approval process,” the letter states.
In January, Kaiser Health News published an investigation that found the orphan drug program is being manipulated by drug makers to maximize profits and to protect niche markets for medicines being taken by millions.
That investigation, which also was published and aired by NPR, National Public Radio, found that many drugs that now have orphan status aren’t entirely new. More than 70 were drugs first approved by the Food and Drug Administration for mass-market use. Those include cholesterol blockbuster, Crestor; Abilify for psychiatric disorders; and the rheumatoid arthritis drug, Humira, the world’s best-selling drug.
Others are drugs that have received multiple exclusivity periods for two or more rare conditions.
The senators asked the GAO for a list of drugs approved or denied orphan status by the FDA. It also asked whether FDA resources, which oversees the law, have “kept up with the number of requests” from drug makers and if there is consistency in the department’s reviews.
They stated that it would be important to include patient experiences in the GAO review. The GAO does not provide updates on ongoing work but rather reports its findings once the assignment has been completed.
The rare-disease drugs have become increasingly popular with pharmaceutical and biotech companies and are expected to comprise 21.% of worldwide prescription sales by 2022, not including generics, according to consulting firm EvaluatePharma’s 2017 orphan drug report.
That’s in part because of the exorbitant prices that can be charged. Of the top 100 drugs in the United States, the average cost per patient per year for an orphan drug was $140,443 in 2016, compared with $27,756 for a nonorphan, EvaluatePharma said.
Kaiser Health News is a national health policy news service that is part of the nonpartisan Henry J. Kaiser Family Foundation. KHN’s coverage of prescription drug development, costs, and pricing is supported in part by the Laura and John Arnold Foundation.
Acting on a request from three influential U.S. senators, the government’s accountability arm confirmed that it will investigate potential abuses of the Orphan Drug Act.
The Government Accountability Office still must determine the full scope of what it will look into and the methodology to be used. Determining the scope will take some months, said Chuck Young, GAO’s managing director for public affairs.
Earlier this month, senators Orrin Hatch (R-Utah), Chuck Grassley (R-Iowa), and Tom Cotton (R-Ark.) sent a letter to the GAO and raised the possibility that regulatory or legislative changes might be needed “to preserve the intent of this vital law” that gives drug makers lucrative incentives to develop drugs for rare diseases.
Sen. Grassley’s office said Tuesday they expected the GAO to begin its work in about 9 months. The delay is typical as the agency has a queue of requests it is pursuing.
The senators have asked the GAO to “investigate whether the ODA [Orphan Drug Act] is still incentivizing product development for diseases with fewer than 200,000 affected individuals, as intended.”
Congress overwhelmingly passed the 1983 Orphan Drug Act to motivate pharmaceutical companies to develop drugs for people whose rare diseases had been ignored. Drugs approved as orphans are granted tax incentives and seven years of exclusive rights to market drugs that are needed by fewer than 200,000 patients in the United States.
In recent months, reports of five- and six-figure annual price tags for orphan drugs have amplified long-simmering concerns about abuse of the law. The senators’ call for a GAO investigation reflects that sentiment.
“While few will argue against the importance of the development of these drugs, several recent press reports suggest that some pharmaceutical manufacturers might be taking advantage of the multiple designation allowance in the orphan drug approval process,” the letter states.
In January, Kaiser Health News published an investigation that found the orphan drug program is being manipulated by drug makers to maximize profits and to protect niche markets for medicines being taken by millions.
That investigation, which also was published and aired by NPR, National Public Radio, found that many drugs that now have orphan status aren’t entirely new. More than 70 were drugs first approved by the Food and Drug Administration for mass-market use. Those include cholesterol blockbuster, Crestor; Abilify for psychiatric disorders; and the rheumatoid arthritis drug, Humira, the world’s best-selling drug.
Others are drugs that have received multiple exclusivity periods for two or more rare conditions.
The senators asked the GAO for a list of drugs approved or denied orphan status by the FDA. It also asked whether FDA resources, which oversees the law, have “kept up with the number of requests” from drug makers and if there is consistency in the department’s reviews.
They stated that it would be important to include patient experiences in the GAO review. The GAO does not provide updates on ongoing work but rather reports its findings once the assignment has been completed.
The rare-disease drugs have become increasingly popular with pharmaceutical and biotech companies and are expected to comprise 21.% of worldwide prescription sales by 2022, not including generics, according to consulting firm EvaluatePharma’s 2017 orphan drug report.
That’s in part because of the exorbitant prices that can be charged. Of the top 100 drugs in the United States, the average cost per patient per year for an orphan drug was $140,443 in 2016, compared with $27,756 for a nonorphan, EvaluatePharma said.
Kaiser Health News is a national health policy news service that is part of the nonpartisan Henry J. Kaiser Family Foundation. KHN’s coverage of prescription drug development, costs, and pricing is supported in part by the Laura and John Arnold Foundation.
Ixekizumab found superior to ustekinumab in psoriasis at 24 weeks
ORLANDO – The interleukin-17A inhibitor ixekizumab was associated with superior efficacy and safety when compared with ustekinumab at 24 weeks, a head-to-head trial of the two monoclonal antibodies in plaque psoriasis has shown.
The 24-week data from the IXORA-S trial were presented during a late-breaking clinical trial session at the annual meeting of the American Academy of Dermatology by Kristian Reich, MD, PhD, a founder of SCIderm in Hamburg, Germany.
At 24 weeks, 49% in the ixekizumab arm achieved a Psoriasis Area and Severity Index (PASI) 100 level of skin clearance, compared with 24% in the ustekinumab arm (P = .001). Ixekizumab treatment also reached significantly higher skin clearances than ustekinumab at 24 weeks at the level of PASI 90 (83% vs. 59%; P less than .001) and PASI 75 (91% vs. 82%; P = .015).
Treatment with ixekizumab produced a Static Physician’s Global Assessment (sPGA) score of 0 in 54% at 24 weeks, compared with 24% with ustekinumab (P less than .001). A sPGA score of 0 or 1 occurred in 87% of patients who took ixekizumab and in 59% of the ustekinumab group.
An improvement of 4 or more points in the pruritus Numeric Rating Scale was reported by 86% of ixekizumab patients at 24 weeks, compared with 72% of those who took ustekinumab (P = .018).
Dr. Reich reported that there were no deaths or any significant differences in overall treatment-related adverse events across both arms, although he cautioned against putting too much stock in 24-week safety data. “I hesitate to show safety data for only 300 patients at 24 weeks, but it’s good to see here that there doesn’t seem to be a difference. I still would want to see larger patient numbers and more long-term data,” he said.
Dr. Reich had numerous disclosures, including honoraria for serving as a speaker for Eli Lilly, the sponsor of this trial.
[email protected]
On Twitter @whitneymcknight
ORLANDO – The interleukin-17A inhibitor ixekizumab was associated with superior efficacy and safety when compared with ustekinumab at 24 weeks, a head-to-head trial of the two monoclonal antibodies in plaque psoriasis has shown.
The 24-week data from the IXORA-S trial were presented during a late-breaking clinical trial session at the annual meeting of the American Academy of Dermatology by Kristian Reich, MD, PhD, a founder of SCIderm in Hamburg, Germany.
At 24 weeks, 49% in the ixekizumab arm achieved a Psoriasis Area and Severity Index (PASI) 100 level of skin clearance, compared with 24% in the ustekinumab arm (P = .001). Ixekizumab treatment also reached significantly higher skin clearances than ustekinumab at 24 weeks at the level of PASI 90 (83% vs. 59%; P less than .001) and PASI 75 (91% vs. 82%; P = .015).
Treatment with ixekizumab produced a Static Physician’s Global Assessment (sPGA) score of 0 in 54% at 24 weeks, compared with 24% with ustekinumab (P less than .001). A sPGA score of 0 or 1 occurred in 87% of patients who took ixekizumab and in 59% of the ustekinumab group.
An improvement of 4 or more points in the pruritus Numeric Rating Scale was reported by 86% of ixekizumab patients at 24 weeks, compared with 72% of those who took ustekinumab (P = .018).
Dr. Reich reported that there were no deaths or any significant differences in overall treatment-related adverse events across both arms, although he cautioned against putting too much stock in 24-week safety data. “I hesitate to show safety data for only 300 patients at 24 weeks, but it’s good to see here that there doesn’t seem to be a difference. I still would want to see larger patient numbers and more long-term data,” he said.
Dr. Reich had numerous disclosures, including honoraria for serving as a speaker for Eli Lilly, the sponsor of this trial.
[email protected]
On Twitter @whitneymcknight
ORLANDO – The interleukin-17A inhibitor ixekizumab was associated with superior efficacy and safety when compared with ustekinumab at 24 weeks, a head-to-head trial of the two monoclonal antibodies in plaque psoriasis has shown.
The 24-week data from the IXORA-S trial were presented during a late-breaking clinical trial session at the annual meeting of the American Academy of Dermatology by Kristian Reich, MD, PhD, a founder of SCIderm in Hamburg, Germany.
At 24 weeks, 49% in the ixekizumab arm achieved a Psoriasis Area and Severity Index (PASI) 100 level of skin clearance, compared with 24% in the ustekinumab arm (P = .001). Ixekizumab treatment also reached significantly higher skin clearances than ustekinumab at 24 weeks at the level of PASI 90 (83% vs. 59%; P less than .001) and PASI 75 (91% vs. 82%; P = .015).
Treatment with ixekizumab produced a Static Physician’s Global Assessment (sPGA) score of 0 in 54% at 24 weeks, compared with 24% with ustekinumab (P less than .001). A sPGA score of 0 or 1 occurred in 87% of patients who took ixekizumab and in 59% of the ustekinumab group.
An improvement of 4 or more points in the pruritus Numeric Rating Scale was reported by 86% of ixekizumab patients at 24 weeks, compared with 72% of those who took ustekinumab (P = .018).
Dr. Reich reported that there were no deaths or any significant differences in overall treatment-related adverse events across both arms, although he cautioned against putting too much stock in 24-week safety data. “I hesitate to show safety data for only 300 patients at 24 weeks, but it’s good to see here that there doesn’t seem to be a difference. I still would want to see larger patient numbers and more long-term data,” he said.
Dr. Reich had numerous disclosures, including honoraria for serving as a speaker for Eli Lilly, the sponsor of this trial.
[email protected]
On Twitter @whitneymcknight
AT AAD 2017
Key clinical point:
Major finding: At 24 weeks, ixekizumab was associated with significantly better PASI response rates and reduction in itch than ustekinumab in patients with moderate to severe plaque psoriasis.
Data source: Head-to-head trial of 302 adults with moderate to severe plaque psoriasis treated with either ixekizumab or ustekinumab.
Disclosures: Dr. Reich had numerous disclosures, including honoraria for serving as a speaker for Eli Lilly, the sponsor of this trial.
FDA approves safinamide to treat Parkinson’s disease
The U.S. Food and Drug Administration approved safinamide tablets on March 21 as an add-on treatment for patients with Parkinson’s disease who are currently taking levodopa/carbidopa and experiencing “off” episodes.
Newron Pharmaceuticals will market safinamide under the brand name Xadago.
The most common adverse reactions observed in patients taking safinamide were uncontrolled involuntary movement, falls, nausea, and insomnia.
In its announcement of the approval, the FDA noted that patients should not take safinamide if they have severe liver problems, take dextromethorphan, or take a monoamine oxidase inhibitor, because the two together may cause a sudden severe increase in blood pressure. Safinamide also should not be taken by patients who use a opioid drug, St. John’s wort, certain antidepressants (such as serotonin-norepinephrine reuptake inhibitors, tricyclics, tetracyclics, and triazolopyridines), or cyclobenzaprine, because it may cause a life-threatening reaction called serotonin syndrome.
The U.S. Food and Drug Administration approved safinamide tablets on March 21 as an add-on treatment for patients with Parkinson’s disease who are currently taking levodopa/carbidopa and experiencing “off” episodes.
Newron Pharmaceuticals will market safinamide under the brand name Xadago.
The most common adverse reactions observed in patients taking safinamide were uncontrolled involuntary movement, falls, nausea, and insomnia.
In its announcement of the approval, the FDA noted that patients should not take safinamide if they have severe liver problems, take dextromethorphan, or take a monoamine oxidase inhibitor, because the two together may cause a sudden severe increase in blood pressure. Safinamide also should not be taken by patients who use a opioid drug, St. John’s wort, certain antidepressants (such as serotonin-norepinephrine reuptake inhibitors, tricyclics, tetracyclics, and triazolopyridines), or cyclobenzaprine, because it may cause a life-threatening reaction called serotonin syndrome.
The U.S. Food and Drug Administration approved safinamide tablets on March 21 as an add-on treatment for patients with Parkinson’s disease who are currently taking levodopa/carbidopa and experiencing “off” episodes.
Newron Pharmaceuticals will market safinamide under the brand name Xadago.
The most common adverse reactions observed in patients taking safinamide were uncontrolled involuntary movement, falls, nausea, and insomnia.
In its announcement of the approval, the FDA noted that patients should not take safinamide if they have severe liver problems, take dextromethorphan, or take a monoamine oxidase inhibitor, because the two together may cause a sudden severe increase in blood pressure. Safinamide also should not be taken by patients who use a opioid drug, St. John’s wort, certain antidepressants (such as serotonin-norepinephrine reuptake inhibitors, tricyclics, tetracyclics, and triazolopyridines), or cyclobenzaprine, because it may cause a life-threatening reaction called serotonin syndrome.
Trump’s promise to rein in drug prices could open floodgate to importation laws
With prescription drug prices soaring and President Donald Trump vowing to take action, an old idea is gaining fresh traction: allowing Americans to buy medicines from foreign pharmacies at far lower prices. A new bill in Congress to allow the practice would modify previous safety standards and remove a barrier that proved insurmountable in past attempts to enable progress.
Congress came close to allowing importation through the Medicare Modernization Act in 2003 but added one firm precondition that has proved a nonstarter. The secretary of Health & Human Services had to guarantee that imported medications posed no additional risk to public safety and would save money.
“That is a fairly absolute standard and a high bar to cross,” said Elizabeth Jungman, director of public health at the Pew Charitable Trusts. Such an exacting standard – guaranteeing that no imported prescriptions posed a threat – has kept any secretary of HHS from condoning it.
In an open letter to Congress, four former commissioners of the Food and Drug Administration argue consumer drug importation remains too risky to permit. “It could lead to a host of unintended consequences and undesirable effects, including serious harm stemming from the use of adulterated, substandard, or counterfeit drugs,” they said in the letter distributed to media organizations. It was signed by Robert Califf, Margaret Hamburg, Mark McClellan, and Andrew von Eschenbach, who each headed the FDA at various times during 2002 through 2016.
The recent proposal, from senators Bernie Sanders (I-Vt.) and Cory Booker (D-N.J.) and Bob Casey (D-Pa.) drops that requirement. Instead, it sets up a regulatory system in which Canadian pharmacies that purchase supplies from manufacturers inspected by the FDA would be licensed to sell to customers across the border. The bill allows not only individuals but also drug wholesalers and pharmacies to buy from Canada.
After 2 years, HHS could allow importation from other countries that meet standards comparable to those of the United States.
Another bill in Congress, proposed in January by senators John McCain (R-Ariz.) and Amy Klobuchar (D-Minn.), focuses solely on allowing individuals to purchase drugs from such pharmacies.
President Trump has promised that “pricing for the American people will come way down.” Last week, he had a high-profile meeting at the White House with congressmen Elijah Cummings (D-Md.) and Peter Welch (D-Vt.) and the president of Johns Hopkins Hospital, Baltimore, Redonda Miller, MD, to discuss allowing Medicare to negotiate prices on outpatient medicines. Cong. Cummings told reporters later that President Trump said he supports Medicare price negotiation as well as the Sanders bill.
PhRMA, the drug industry’s trade group, has denounced Sanders’ proposal as it has others that enabled imports in the past.
“The bill lacks sufficient safety controls [and] would exacerbate threats to public health from counterfeit, adulterated, or diverted medicines, and increase the burden on law enforcement to prevent unregulated medicines and other dangerous products from harming consumers,” said PhRMA spokeswoman Nicole Longo.
Surveys indicate that up to 8% of Americans have bought medicines outside the United States, even though the practice is technically illegal and imported pills are subject to confiscation.
Around 45 million Americans – 18% of the adult population – said last year that they did not fill a prescription because of cost, according to an analysis of data from the Commonwealth Fund by Gabe Levitt, president of pharmacychecker.com, whose company helps Americans buy medications online by vetting overseas pharmacies and comparing prices for different drugs. Data compiled by the company compare Canadian prescription prices with those offered in New York and show drugs that frequently are three or more times as expensive in the United States as across the border.
For example, a simple Proventil asthma inhaler costs $73.19 in the United States vs. $21.66 in Canada. Crestor, the cholesterol-lowering drug, is $6.82 per pill in U.S. pharmacies but $2.58 in Canada. Abilify, a psychiatric medicine, is $29.88 vs. $7.58, according to pharmacychecker.com.
Many previous bills that permitted importation or that allowed Medicare to negotiate prices for its beneficiaries have failed in the face of $1.9 billion in congressional lobbying by the pharmaceutical industry since 2003, according to Open Secrets. But Americans may be reaching a tipping point of intolerance. In polling just before the election by the Kaiser Family Foundation, 77% of Americans called drug prices “unreasonable” and well over half favored a variety of proposals to address them.
To address safety concerns, the Sanders bill institutes several new strategies. Canadian pharmacies that want to be registered to sell to Americans would have to pay a fee to pay for additional FDA monitoring. A Government Accountability Office study would be required within 18 months of the final rule to address outcomes related to importation processes, drug safety, consumer savings, and regulatory expenses.
Allowing people to legally import medications would not completely solve the problem of high prescription drugs prices, advocates say, but would be a step in the right direction. Said Mr. Levitt, “the best way for Americans to afford their meds is to enact policies here to bring the prices down here.”
Kaiser Health News is a national health policy news service that is part of the nonpartisan Henry J. Kaiser Family Foundation. KHN’s coverage of prescription drug development, costs and pricing is supported in part by the Laura and John Arnold Foundation.
With prescription drug prices soaring and President Donald Trump vowing to take action, an old idea is gaining fresh traction: allowing Americans to buy medicines from foreign pharmacies at far lower prices. A new bill in Congress to allow the practice would modify previous safety standards and remove a barrier that proved insurmountable in past attempts to enable progress.
Congress came close to allowing importation through the Medicare Modernization Act in 2003 but added one firm precondition that has proved a nonstarter. The secretary of Health & Human Services had to guarantee that imported medications posed no additional risk to public safety and would save money.
“That is a fairly absolute standard and a high bar to cross,” said Elizabeth Jungman, director of public health at the Pew Charitable Trusts. Such an exacting standard – guaranteeing that no imported prescriptions posed a threat – has kept any secretary of HHS from condoning it.
In an open letter to Congress, four former commissioners of the Food and Drug Administration argue consumer drug importation remains too risky to permit. “It could lead to a host of unintended consequences and undesirable effects, including serious harm stemming from the use of adulterated, substandard, or counterfeit drugs,” they said in the letter distributed to media organizations. It was signed by Robert Califf, Margaret Hamburg, Mark McClellan, and Andrew von Eschenbach, who each headed the FDA at various times during 2002 through 2016.
The recent proposal, from senators Bernie Sanders (I-Vt.) and Cory Booker (D-N.J.) and Bob Casey (D-Pa.) drops that requirement. Instead, it sets up a regulatory system in which Canadian pharmacies that purchase supplies from manufacturers inspected by the FDA would be licensed to sell to customers across the border. The bill allows not only individuals but also drug wholesalers and pharmacies to buy from Canada.
After 2 years, HHS could allow importation from other countries that meet standards comparable to those of the United States.
Another bill in Congress, proposed in January by senators John McCain (R-Ariz.) and Amy Klobuchar (D-Minn.), focuses solely on allowing individuals to purchase drugs from such pharmacies.
President Trump has promised that “pricing for the American people will come way down.” Last week, he had a high-profile meeting at the White House with congressmen Elijah Cummings (D-Md.) and Peter Welch (D-Vt.) and the president of Johns Hopkins Hospital, Baltimore, Redonda Miller, MD, to discuss allowing Medicare to negotiate prices on outpatient medicines. Cong. Cummings told reporters later that President Trump said he supports Medicare price negotiation as well as the Sanders bill.
PhRMA, the drug industry’s trade group, has denounced Sanders’ proposal as it has others that enabled imports in the past.
“The bill lacks sufficient safety controls [and] would exacerbate threats to public health from counterfeit, adulterated, or diverted medicines, and increase the burden on law enforcement to prevent unregulated medicines and other dangerous products from harming consumers,” said PhRMA spokeswoman Nicole Longo.
Surveys indicate that up to 8% of Americans have bought medicines outside the United States, even though the practice is technically illegal and imported pills are subject to confiscation.
Around 45 million Americans – 18% of the adult population – said last year that they did not fill a prescription because of cost, according to an analysis of data from the Commonwealth Fund by Gabe Levitt, president of pharmacychecker.com, whose company helps Americans buy medications online by vetting overseas pharmacies and comparing prices for different drugs. Data compiled by the company compare Canadian prescription prices with those offered in New York and show drugs that frequently are three or more times as expensive in the United States as across the border.
For example, a simple Proventil asthma inhaler costs $73.19 in the United States vs. $21.66 in Canada. Crestor, the cholesterol-lowering drug, is $6.82 per pill in U.S. pharmacies but $2.58 in Canada. Abilify, a psychiatric medicine, is $29.88 vs. $7.58, according to pharmacychecker.com.
Many previous bills that permitted importation or that allowed Medicare to negotiate prices for its beneficiaries have failed in the face of $1.9 billion in congressional lobbying by the pharmaceutical industry since 2003, according to Open Secrets. But Americans may be reaching a tipping point of intolerance. In polling just before the election by the Kaiser Family Foundation, 77% of Americans called drug prices “unreasonable” and well over half favored a variety of proposals to address them.
To address safety concerns, the Sanders bill institutes several new strategies. Canadian pharmacies that want to be registered to sell to Americans would have to pay a fee to pay for additional FDA monitoring. A Government Accountability Office study would be required within 18 months of the final rule to address outcomes related to importation processes, drug safety, consumer savings, and regulatory expenses.
Allowing people to legally import medications would not completely solve the problem of high prescription drugs prices, advocates say, but would be a step in the right direction. Said Mr. Levitt, “the best way for Americans to afford their meds is to enact policies here to bring the prices down here.”
Kaiser Health News is a national health policy news service that is part of the nonpartisan Henry J. Kaiser Family Foundation. KHN’s coverage of prescription drug development, costs and pricing is supported in part by the Laura and John Arnold Foundation.
With prescription drug prices soaring and President Donald Trump vowing to take action, an old idea is gaining fresh traction: allowing Americans to buy medicines from foreign pharmacies at far lower prices. A new bill in Congress to allow the practice would modify previous safety standards and remove a barrier that proved insurmountable in past attempts to enable progress.
Congress came close to allowing importation through the Medicare Modernization Act in 2003 but added one firm precondition that has proved a nonstarter. The secretary of Health & Human Services had to guarantee that imported medications posed no additional risk to public safety and would save money.
“That is a fairly absolute standard and a high bar to cross,” said Elizabeth Jungman, director of public health at the Pew Charitable Trusts. Such an exacting standard – guaranteeing that no imported prescriptions posed a threat – has kept any secretary of HHS from condoning it.
In an open letter to Congress, four former commissioners of the Food and Drug Administration argue consumer drug importation remains too risky to permit. “It could lead to a host of unintended consequences and undesirable effects, including serious harm stemming from the use of adulterated, substandard, or counterfeit drugs,” they said in the letter distributed to media organizations. It was signed by Robert Califf, Margaret Hamburg, Mark McClellan, and Andrew von Eschenbach, who each headed the FDA at various times during 2002 through 2016.
The recent proposal, from senators Bernie Sanders (I-Vt.) and Cory Booker (D-N.J.) and Bob Casey (D-Pa.) drops that requirement. Instead, it sets up a regulatory system in which Canadian pharmacies that purchase supplies from manufacturers inspected by the FDA would be licensed to sell to customers across the border. The bill allows not only individuals but also drug wholesalers and pharmacies to buy from Canada.
After 2 years, HHS could allow importation from other countries that meet standards comparable to those of the United States.
Another bill in Congress, proposed in January by senators John McCain (R-Ariz.) and Amy Klobuchar (D-Minn.), focuses solely on allowing individuals to purchase drugs from such pharmacies.
President Trump has promised that “pricing for the American people will come way down.” Last week, he had a high-profile meeting at the White House with congressmen Elijah Cummings (D-Md.) and Peter Welch (D-Vt.) and the president of Johns Hopkins Hospital, Baltimore, Redonda Miller, MD, to discuss allowing Medicare to negotiate prices on outpatient medicines. Cong. Cummings told reporters later that President Trump said he supports Medicare price negotiation as well as the Sanders bill.
PhRMA, the drug industry’s trade group, has denounced Sanders’ proposal as it has others that enabled imports in the past.
“The bill lacks sufficient safety controls [and] would exacerbate threats to public health from counterfeit, adulterated, or diverted medicines, and increase the burden on law enforcement to prevent unregulated medicines and other dangerous products from harming consumers,” said PhRMA spokeswoman Nicole Longo.
Surveys indicate that up to 8% of Americans have bought medicines outside the United States, even though the practice is technically illegal and imported pills are subject to confiscation.
Around 45 million Americans – 18% of the adult population – said last year that they did not fill a prescription because of cost, according to an analysis of data from the Commonwealth Fund by Gabe Levitt, president of pharmacychecker.com, whose company helps Americans buy medications online by vetting overseas pharmacies and comparing prices for different drugs. Data compiled by the company compare Canadian prescription prices with those offered in New York and show drugs that frequently are three or more times as expensive in the United States as across the border.
For example, a simple Proventil asthma inhaler costs $73.19 in the United States vs. $21.66 in Canada. Crestor, the cholesterol-lowering drug, is $6.82 per pill in U.S. pharmacies but $2.58 in Canada. Abilify, a psychiatric medicine, is $29.88 vs. $7.58, according to pharmacychecker.com.
Many previous bills that permitted importation or that allowed Medicare to negotiate prices for its beneficiaries have failed in the face of $1.9 billion in congressional lobbying by the pharmaceutical industry since 2003, according to Open Secrets. But Americans may be reaching a tipping point of intolerance. In polling just before the election by the Kaiser Family Foundation, 77% of Americans called drug prices “unreasonable” and well over half favored a variety of proposals to address them.
To address safety concerns, the Sanders bill institutes several new strategies. Canadian pharmacies that want to be registered to sell to Americans would have to pay a fee to pay for additional FDA monitoring. A Government Accountability Office study would be required within 18 months of the final rule to address outcomes related to importation processes, drug safety, consumer savings, and regulatory expenses.
Allowing people to legally import medications would not completely solve the problem of high prescription drugs prices, advocates say, but would be a step in the right direction. Said Mr. Levitt, “the best way for Americans to afford their meds is to enact policies here to bring the prices down here.”
Kaiser Health News is a national health policy news service that is part of the nonpartisan Henry J. Kaiser Family Foundation. KHN’s coverage of prescription drug development, costs and pricing is supported in part by the Laura and John Arnold Foundation.
Disappointment in article on NP, PA roles in HM groups
Editor’s note: The following “Letter to the Editor” was first emailed to the Society of Hospital Medicine, its board president, and John Nelson, MD, MHM, the author of the article, “Hospitalist Roles for NPs and PAs,” which published in the January 2017 issue. All parties agreed to publish the email exchange in The Hospitalist.
Sent: Sunday, February 12, 2017 9:59 AM
Subject: Offensive article on hospitalist roles for NPs, PAs
All,
I have been a hospitalist NP (nurse practitioner) for a decade and found the article in the January issue of The Hospitalist, Volume 21, Number 1, on the Hospitalist Roles for NPs and PAs, offensive and uninformed, with an intolerable amount of personal opinion not backed by research.
I am disappointed that The Hospitalist would publish such a low-class article. Your [magazine] promotes membership to all APPs (advanced practice providers), yet you publish articles that show a study with a positive finding yet allow and highlight an incredibly negative and offensive snippet. The highlighted box states that “Any group that thinks this study is evidence that adding more APPs and having them manage a high number of patients relatively independently will go well in any setting is MISTAKEN ... But it does offer a STORY of one place where, with careful planning and execution, it went OK.”
I can only say that the physicians, APPs, and hospital group who did this study would likely also be offended for taking their study and turning it into a “story.”
EDUCATE yourselves. There are numerous studies out there showing care by APP’s is cost effective, efficient, and with excellent care outcomes. There is a national group, APPex (Advanced Practice Provider Executives), that can give you all the studies you would want showing this information. Or contact the national NP or PA groups.
I am a working hospitalist NP and appreciate my physician colleagues and have their respect. This “John” person obviously doesn’t respect APPs and to publish him is just disheartening.
This publication could have and should have done better. You have one APP on your editorial advisory board – it appears you need more.
Marci Harris, MSN, FNP, ACNP
Acute Care Nurse Practitioner
Hospitalist/Internal Medicine
McKee Medical Center, Loveland, Colo.
Dr. Nelson responds:
Thanks for your message, Marci. It seems clear you’ve thought a lot about NPs and PAs in hospitalist practices and have arrived at conclusions that differ from what I wrote. Your voice and views are welcome.
I certainly didn’t intend to offend anyone, including those who might see all of this very differently from me.
As I mention in the first paragraph, I’m very supportive of NPs and PAs in hospitalist practices. And I wanted to write about this particular study precisely because it provides data that is very supportive of their contributions.
The point I was trying to make in the column is that there is value in careful planning around roles and who does what. A sports team could recruit the most talented players but still won’t perform well if they don’t develop and execute a good plan around who does what and how they work together. Simply having talented people on the team isn’t enough. I think the same is true of hospitalist teams.
The hospitalist group in the study has an impressively detailed plan for new provider (APC and MD alike) orientation and has a lot of operating processes that help ensure the PAs and MDs work effectively together. My experience is that many hospitalists groups have never developed such a plan.
John Nelson, MD, MHM
Partner, Nelson Flores Hospital Medicine Consultants, Bellevue, Wash.
Editor’s note: The following “Letter to the Editor” was first emailed to the Society of Hospital Medicine, its board president, and John Nelson, MD, MHM, the author of the article, “Hospitalist Roles for NPs and PAs,” which published in the January 2017 issue. All parties agreed to publish the email exchange in The Hospitalist.
Sent: Sunday, February 12, 2017 9:59 AM
Subject: Offensive article on hospitalist roles for NPs, PAs
All,
I have been a hospitalist NP (nurse practitioner) for a decade and found the article in the January issue of The Hospitalist, Volume 21, Number 1, on the Hospitalist Roles for NPs and PAs, offensive and uninformed, with an intolerable amount of personal opinion not backed by research.
I am disappointed that The Hospitalist would publish such a low-class article. Your [magazine] promotes membership to all APPs (advanced practice providers), yet you publish articles that show a study with a positive finding yet allow and highlight an incredibly negative and offensive snippet. The highlighted box states that “Any group that thinks this study is evidence that adding more APPs and having them manage a high number of patients relatively independently will go well in any setting is MISTAKEN ... But it does offer a STORY of one place where, with careful planning and execution, it went OK.”
I can only say that the physicians, APPs, and hospital group who did this study would likely also be offended for taking their study and turning it into a “story.”
EDUCATE yourselves. There are numerous studies out there showing care by APP’s is cost effective, efficient, and with excellent care outcomes. There is a national group, APPex (Advanced Practice Provider Executives), that can give you all the studies you would want showing this information. Or contact the national NP or PA groups.
I am a working hospitalist NP and appreciate my physician colleagues and have their respect. This “John” person obviously doesn’t respect APPs and to publish him is just disheartening.
This publication could have and should have done better. You have one APP on your editorial advisory board – it appears you need more.
Marci Harris, MSN, FNP, ACNP
Acute Care Nurse Practitioner
Hospitalist/Internal Medicine
McKee Medical Center, Loveland, Colo.
Dr. Nelson responds:
Thanks for your message, Marci. It seems clear you’ve thought a lot about NPs and PAs in hospitalist practices and have arrived at conclusions that differ from what I wrote. Your voice and views are welcome.
I certainly didn’t intend to offend anyone, including those who might see all of this very differently from me.
As I mention in the first paragraph, I’m very supportive of NPs and PAs in hospitalist practices. And I wanted to write about this particular study precisely because it provides data that is very supportive of their contributions.
The point I was trying to make in the column is that there is value in careful planning around roles and who does what. A sports team could recruit the most talented players but still won’t perform well if they don’t develop and execute a good plan around who does what and how they work together. Simply having talented people on the team isn’t enough. I think the same is true of hospitalist teams.
The hospitalist group in the study has an impressively detailed plan for new provider (APC and MD alike) orientation and has a lot of operating processes that help ensure the PAs and MDs work effectively together. My experience is that many hospitalists groups have never developed such a plan.
John Nelson, MD, MHM
Partner, Nelson Flores Hospital Medicine Consultants, Bellevue, Wash.
Editor’s note: The following “Letter to the Editor” was first emailed to the Society of Hospital Medicine, its board president, and John Nelson, MD, MHM, the author of the article, “Hospitalist Roles for NPs and PAs,” which published in the January 2017 issue. All parties agreed to publish the email exchange in The Hospitalist.
Sent: Sunday, February 12, 2017 9:59 AM
Subject: Offensive article on hospitalist roles for NPs, PAs
All,
I have been a hospitalist NP (nurse practitioner) for a decade and found the article in the January issue of The Hospitalist, Volume 21, Number 1, on the Hospitalist Roles for NPs and PAs, offensive and uninformed, with an intolerable amount of personal opinion not backed by research.
I am disappointed that The Hospitalist would publish such a low-class article. Your [magazine] promotes membership to all APPs (advanced practice providers), yet you publish articles that show a study with a positive finding yet allow and highlight an incredibly negative and offensive snippet. The highlighted box states that “Any group that thinks this study is evidence that adding more APPs and having them manage a high number of patients relatively independently will go well in any setting is MISTAKEN ... But it does offer a STORY of one place where, with careful planning and execution, it went OK.”
I can only say that the physicians, APPs, and hospital group who did this study would likely also be offended for taking their study and turning it into a “story.”
EDUCATE yourselves. There are numerous studies out there showing care by APP’s is cost effective, efficient, and with excellent care outcomes. There is a national group, APPex (Advanced Practice Provider Executives), that can give you all the studies you would want showing this information. Or contact the national NP or PA groups.
I am a working hospitalist NP and appreciate my physician colleagues and have their respect. This “John” person obviously doesn’t respect APPs and to publish him is just disheartening.
This publication could have and should have done better. You have one APP on your editorial advisory board – it appears you need more.
Marci Harris, MSN, FNP, ACNP
Acute Care Nurse Practitioner
Hospitalist/Internal Medicine
McKee Medical Center, Loveland, Colo.
Dr. Nelson responds:
Thanks for your message, Marci. It seems clear you’ve thought a lot about NPs and PAs in hospitalist practices and have arrived at conclusions that differ from what I wrote. Your voice and views are welcome.
I certainly didn’t intend to offend anyone, including those who might see all of this very differently from me.
As I mention in the first paragraph, I’m very supportive of NPs and PAs in hospitalist practices. And I wanted to write about this particular study precisely because it provides data that is very supportive of their contributions.
The point I was trying to make in the column is that there is value in careful planning around roles and who does what. A sports team could recruit the most talented players but still won’t perform well if they don’t develop and execute a good plan around who does what and how they work together. Simply having talented people on the team isn’t enough. I think the same is true of hospitalist teams.
The hospitalist group in the study has an impressively detailed plan for new provider (APC and MD alike) orientation and has a lot of operating processes that help ensure the PAs and MDs work effectively together. My experience is that many hospitalists groups have never developed such a plan.
John Nelson, MD, MHM
Partner, Nelson Flores Hospital Medicine Consultants, Bellevue, Wash.