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Taking a leap of faith
After a grueling first two years of surgical residency, I welcomed with open arms my surgical research years. Junior surgical residency was arguably the toughest years of my training to date. Long hours at the hospital; the uncertainty of being called in to the hospital when on-call, which led to chronic anxiety and at times insomnia; and the pressures I put on myself to excel in all aspects of my training were draining, to say the least.
Of course, when it came time to leave my clinical responsibilities and pursue my Master’s degree, I was overcome with relief. First, I got my life back on track, leading a life of optimal nutrition, physical activity, and sleep and exploring different horizons in surgery.
Second, this time allowed me to grow as a person, learning techniques to remain calm in the face of adversity, to take at least 10 minutes a day for mindfulness, and to be cognizant and gauge when I am creeping upon that tipping point. I believe the key to success and happiness is to keep re-evaluating and being honest with ourselves, our happiness, our stresses, and our anxieties and to reach out to pillars of support, whoever they may be.
And finally, we are fundamentally teachers and inspirations to the next generation of surgeons who will follow in our footsteps. By being open, encouraging, and sharing our enthusiasm for our specialty, our patients, and our research, we may see the seeds of the future flourish under our wings.
That being said, I am terrified of returning to vascular surgery. I know it will be a challenge transitioning to senior resident, and I am scared that the progress I made over these years in terms of wellness and wellbeing will regress; however, in the end, I have to take a leap of faith and hope it all pulls together ... seamlessly.
Dr. Drudi is a vascular surgery resident at McGill University, Montreal, and the resident medical editor of Vascular Specialist.
After a grueling first two years of surgical residency, I welcomed with open arms my surgical research years. Junior surgical residency was arguably the toughest years of my training to date. Long hours at the hospital; the uncertainty of being called in to the hospital when on-call, which led to chronic anxiety and at times insomnia; and the pressures I put on myself to excel in all aspects of my training were draining, to say the least.
Of course, when it came time to leave my clinical responsibilities and pursue my Master’s degree, I was overcome with relief. First, I got my life back on track, leading a life of optimal nutrition, physical activity, and sleep and exploring different horizons in surgery.
Second, this time allowed me to grow as a person, learning techniques to remain calm in the face of adversity, to take at least 10 minutes a day for mindfulness, and to be cognizant and gauge when I am creeping upon that tipping point. I believe the key to success and happiness is to keep re-evaluating and being honest with ourselves, our happiness, our stresses, and our anxieties and to reach out to pillars of support, whoever they may be.
And finally, we are fundamentally teachers and inspirations to the next generation of surgeons who will follow in our footsteps. By being open, encouraging, and sharing our enthusiasm for our specialty, our patients, and our research, we may see the seeds of the future flourish under our wings.
That being said, I am terrified of returning to vascular surgery. I know it will be a challenge transitioning to senior resident, and I am scared that the progress I made over these years in terms of wellness and wellbeing will regress; however, in the end, I have to take a leap of faith and hope it all pulls together ... seamlessly.
Dr. Drudi is a vascular surgery resident at McGill University, Montreal, and the resident medical editor of Vascular Specialist.
After a grueling first two years of surgical residency, I welcomed with open arms my surgical research years. Junior surgical residency was arguably the toughest years of my training to date. Long hours at the hospital; the uncertainty of being called in to the hospital when on-call, which led to chronic anxiety and at times insomnia; and the pressures I put on myself to excel in all aspects of my training were draining, to say the least.
Of course, when it came time to leave my clinical responsibilities and pursue my Master’s degree, I was overcome with relief. First, I got my life back on track, leading a life of optimal nutrition, physical activity, and sleep and exploring different horizons in surgery.
Second, this time allowed me to grow as a person, learning techniques to remain calm in the face of adversity, to take at least 10 minutes a day for mindfulness, and to be cognizant and gauge when I am creeping upon that tipping point. I believe the key to success and happiness is to keep re-evaluating and being honest with ourselves, our happiness, our stresses, and our anxieties and to reach out to pillars of support, whoever they may be.
And finally, we are fundamentally teachers and inspirations to the next generation of surgeons who will follow in our footsteps. By being open, encouraging, and sharing our enthusiasm for our specialty, our patients, and our research, we may see the seeds of the future flourish under our wings.
That being said, I am terrified of returning to vascular surgery. I know it will be a challenge transitioning to senior resident, and I am scared that the progress I made over these years in terms of wellness and wellbeing will regress; however, in the end, I have to take a leap of faith and hope it all pulls together ... seamlessly.
Dr. Drudi is a vascular surgery resident at McGill University, Montreal, and the resident medical editor of Vascular Specialist.
Chronic rhinosinusitis associated with poor sleep quality
ATLANTA – Answers on a popular self-reported sleep questionnaire correlated positively with sinonasal inflammation, suggesting that patients with chronic rhinosinusitis should be assessed for sleep-related problems, results from a single-center study showed.
“We need to be recognizing the symptoms of chronic rhinosinusitis patients more in order to help them improve their quality of life,” lead study author Jessica Hui, MD, said in an interview at the annual meeting of the American Academy of Allergy, Asthma, and Immunology. “Asking them about sleep is important.”
Dr. Hui, who is a second-year pediatrics resident at Rush University Medical Center, reported that CRS patients had significant worse sleep quality, compared with controls (a mean PSQI score of 7.44 vs. 3.31, respectively) and that a higher Lund-Mackay Score correlated with greater PSQI (Pearson correlation coefficient of 0.25; P = .03).
The mean age of CRS cases without sleep disruption was 12.08 years, while the mean age of CRS cases with sleep disruption was 34.74 years.
Poor sleep quality was also associated with higher pain index scores (Pearson correlation coefficient of 0.35; P = .002) and higher scores on the SNOT-22 (Pearson correlation coefficient of 0.25; P = .025). The researchers observed that CRS patients without nasal polyps trended towards a higher PSQI, compared with controls (a mean of 8.14 vs. 6.36; P=0.10). Sinus histopathology variables and comorbid diseases did not correlate with PSQI scores.
Dr. Hui reported having no financial disclosures.
ATLANTA – Answers on a popular self-reported sleep questionnaire correlated positively with sinonasal inflammation, suggesting that patients with chronic rhinosinusitis should be assessed for sleep-related problems, results from a single-center study showed.
“We need to be recognizing the symptoms of chronic rhinosinusitis patients more in order to help them improve their quality of life,” lead study author Jessica Hui, MD, said in an interview at the annual meeting of the American Academy of Allergy, Asthma, and Immunology. “Asking them about sleep is important.”
Dr. Hui, who is a second-year pediatrics resident at Rush University Medical Center, reported that CRS patients had significant worse sleep quality, compared with controls (a mean PSQI score of 7.44 vs. 3.31, respectively) and that a higher Lund-Mackay Score correlated with greater PSQI (Pearson correlation coefficient of 0.25; P = .03).
The mean age of CRS cases without sleep disruption was 12.08 years, while the mean age of CRS cases with sleep disruption was 34.74 years.
Poor sleep quality was also associated with higher pain index scores (Pearson correlation coefficient of 0.35; P = .002) and higher scores on the SNOT-22 (Pearson correlation coefficient of 0.25; P = .025). The researchers observed that CRS patients without nasal polyps trended towards a higher PSQI, compared with controls (a mean of 8.14 vs. 6.36; P=0.10). Sinus histopathology variables and comorbid diseases did not correlate with PSQI scores.
Dr. Hui reported having no financial disclosures.
ATLANTA – Answers on a popular self-reported sleep questionnaire correlated positively with sinonasal inflammation, suggesting that patients with chronic rhinosinusitis should be assessed for sleep-related problems, results from a single-center study showed.
“We need to be recognizing the symptoms of chronic rhinosinusitis patients more in order to help them improve their quality of life,” lead study author Jessica Hui, MD, said in an interview at the annual meeting of the American Academy of Allergy, Asthma, and Immunology. “Asking them about sleep is important.”
Dr. Hui, who is a second-year pediatrics resident at Rush University Medical Center, reported that CRS patients had significant worse sleep quality, compared with controls (a mean PSQI score of 7.44 vs. 3.31, respectively) and that a higher Lund-Mackay Score correlated with greater PSQI (Pearson correlation coefficient of 0.25; P = .03).
The mean age of CRS cases without sleep disruption was 12.08 years, while the mean age of CRS cases with sleep disruption was 34.74 years.
Poor sleep quality was also associated with higher pain index scores (Pearson correlation coefficient of 0.35; P = .002) and higher scores on the SNOT-22 (Pearson correlation coefficient of 0.25; P = .025). The researchers observed that CRS patients without nasal polyps trended towards a higher PSQI, compared with controls (a mean of 8.14 vs. 6.36; P=0.10). Sinus histopathology variables and comorbid diseases did not correlate with PSQI scores.
Dr. Hui reported having no financial disclosures.
AT 2017 AAAAI ANNUAL MEETING
Key clinical point:
Major finding: CRS patients had significant worse sleep quality, compared with controls (a mean Pittsburgh Sleep Quality Index score of 7.44 vs. 3.31, respectively).
Data source: A cohort study of 125 CRS patients with refractory disease and 41 controls.
Disclosures: Dr. Hui reported having no financial disclosures.
More time in aftercare improves abstinence
Patients treated for addiction for longer than 30 days showed a significantly higher abstinence success rate of 84%, compared with 55% for patients whose treatment stopped at 30 days, a study of 72 adults shows.
The findings were not significantly different among different kinds of addictions, such as alcohol and amphetamine addiction or opioid and benzodiazepine dependency (Open J Psychiatr. Jan 2017;7:51-60).
“Recovery is an ongoing process once a client leaves treatment,” wrote Akikur R. Mohammad, MD, CEO/founder of the Inspire Malibu drug and alcohol treatment center in Southern California, and his colleagues. “Clients who adhere to their discharge plan and immerse themselves in recovery-related activities and lifestyle are likely to achieve sobriety for longer periods of time, if not indefinitely.”
To assess the efficacy of treatment and the predictors of relapse, the researchers enrolled 32 men and 40 women who were undergoing clinical treatment for various types of addiction. The average age was 30 years for the men and 30.7 years for the women.
In addition, the researchers developed models of treatment outcomes. They found a relative risk of substance abuse relapse of 18.1 for patients who failed to answer the phone at least three times during a 12-month follow-up period, compared with patients who only failed to answer the phone either zero, one, or two times.
Although the results were limited by the use of self reports, the findings support the role of aftercare follow-up in identifying addiction patients at risk for relapse, noted Dr. Mohammad of the University of California, Los Angeles, and his colleagues.
The researchers had no financial conflicts to disclose.
Patients treated for addiction for longer than 30 days showed a significantly higher abstinence success rate of 84%, compared with 55% for patients whose treatment stopped at 30 days, a study of 72 adults shows.
The findings were not significantly different among different kinds of addictions, such as alcohol and amphetamine addiction or opioid and benzodiazepine dependency (Open J Psychiatr. Jan 2017;7:51-60).
“Recovery is an ongoing process once a client leaves treatment,” wrote Akikur R. Mohammad, MD, CEO/founder of the Inspire Malibu drug and alcohol treatment center in Southern California, and his colleagues. “Clients who adhere to their discharge plan and immerse themselves in recovery-related activities and lifestyle are likely to achieve sobriety for longer periods of time, if not indefinitely.”
To assess the efficacy of treatment and the predictors of relapse, the researchers enrolled 32 men and 40 women who were undergoing clinical treatment for various types of addiction. The average age was 30 years for the men and 30.7 years for the women.
In addition, the researchers developed models of treatment outcomes. They found a relative risk of substance abuse relapse of 18.1 for patients who failed to answer the phone at least three times during a 12-month follow-up period, compared with patients who only failed to answer the phone either zero, one, or two times.
Although the results were limited by the use of self reports, the findings support the role of aftercare follow-up in identifying addiction patients at risk for relapse, noted Dr. Mohammad of the University of California, Los Angeles, and his colleagues.
The researchers had no financial conflicts to disclose.
Patients treated for addiction for longer than 30 days showed a significantly higher abstinence success rate of 84%, compared with 55% for patients whose treatment stopped at 30 days, a study of 72 adults shows.
The findings were not significantly different among different kinds of addictions, such as alcohol and amphetamine addiction or opioid and benzodiazepine dependency (Open J Psychiatr. Jan 2017;7:51-60).
“Recovery is an ongoing process once a client leaves treatment,” wrote Akikur R. Mohammad, MD, CEO/founder of the Inspire Malibu drug and alcohol treatment center in Southern California, and his colleagues. “Clients who adhere to their discharge plan and immerse themselves in recovery-related activities and lifestyle are likely to achieve sobriety for longer periods of time, if not indefinitely.”
To assess the efficacy of treatment and the predictors of relapse, the researchers enrolled 32 men and 40 women who were undergoing clinical treatment for various types of addiction. The average age was 30 years for the men and 30.7 years for the women.
In addition, the researchers developed models of treatment outcomes. They found a relative risk of substance abuse relapse of 18.1 for patients who failed to answer the phone at least three times during a 12-month follow-up period, compared with patients who only failed to answer the phone either zero, one, or two times.
Although the results were limited by the use of self reports, the findings support the role of aftercare follow-up in identifying addiction patients at risk for relapse, noted Dr. Mohammad of the University of California, Los Angeles, and his colleagues.
The researchers had no financial conflicts to disclose.
FROM THE OPEN JOURNAL OF PSYCHIATRY
Decision support tool appears to safely reduce CSF use
ORLANDO – A decision support tool safely reduces use of colony-stimulating factors (CSFs) in patients undergoing chemotherapy for lung cancer, suggests a retrospective claims-based cohort study of nearly 3,500 patients across the country.
The rate of CSF use fell among patients treated in the nine states that implemented the tool – a library of chemotherapy regimens and their expected FN risk that uses preauthorization and an algorithm to promote risk-appropriate, guideline-adherent use – but it remained unchanged in the 39 states and the District of Columbia, where usual practice continued, investigators reported at a symposium on quality care sponsored by the American Society of Clinical Oncology and simultaneously published (J Oncol Pract. 2017 March 4. doi: 10.1200/JOP.2017.020867). The adjusted difference was nearly 9%.
“Decision support programs like the one highlighted here could be one way, definitely not the only way, of achieving guideline-adherent CSF use and reducing practice variation across the country,” commented coinvestigator Abiy Agiro, PhD, associate director of payer and provider research at HealthCore, a subsidiary of Anthem, in Wilmington, Delaware.
“Such efforts could also have unintended consequences, so it’s important to study relevant patient outcomes,” he added. “In this case, although it appears that the incidence of febrile neutropenia rising does not seem to relate with the program, the study does not establish the safety of CSF use reduction in lung cancer patients receiving chemotherapy. So, we should take the results with that caveat.”
Parsing the findings
Although the United States makes up just 4% of the world’s population, it uses nearly 80% of CSFs sold by a leading manufacturer, according to invited discussant Thomas J. Smith, MD, a professor of oncology and palliative medicine at Johns Hopkins University in Baltimore.
“When we rewrote the ASCO [American Society of Clinical Oncology] guidelines on CSF use in 2015, there were some specific indications: dose-intense chemo for adjuvant breast cancer and uroepithelial cancer and ... when the risk of febrile neutropenia is about 20% and dose reduction is not an appropriate strategy. We were quick to point out that most regimens have a risk of febrile neutropenia much less than that,” he noted.
Dr. Agiro and his colleagues’ findings are valid, real, and reproducible, Dr. Smith maintained. However, it is unclear to what extent the observed levels of CSF use represented overuse.
“In lung cancer, there are very few regimens that have a febrile neutropenia rate close to 20%,” he elaborated. “What we don’t know is how much of this [use] was actually justified. I would suspect it is 10% or 15%, rather than 40%.”
CSF use, as guided by the new tool, “might not support increased dose density [of chemotherapy], but I would challenge anybody in the audience to show me data in normal solid tumor patients that [show that] dose density maintained by CSFs makes a difference in overall survival,” he said.
Questions yet to be addressed include the difficulty and cost of using the decision support tool and the possible negative impact on practices’ finances, according to Dr. Smith.
“When ESAs [erythropoiesis-stimulating agents] came off being used so much, some of my friends’ practices took a 15% to 20% drop in their revenue, and this is an important source of revenue for a lot of practices,” he explained. “So, I hope that when we take this revenue away, that we are cognizant of that and realize that it’s just another stress on practices, many of which are under significant stress already.”
Study details
An estimated 26% of uses of CSFs in patients with lung cancer are not in accordance with the ASCO practice guidelines, according to Dr. Agiro. “Such variations from recommendations are sometimes the reason why different stakeholders take actions” to improve care, such as ASCO’s Quality Oncology Practice Initiative (QOPI) and the American Board of Internal Medicine’s Choosing Wisely initiative (J Oncol Pract. 2015;11:338-43).
The decision support tool evaluated in the study uses preauthorization before delivery of care and, therefore, differs from point-of-care interventions, he noted.
“The tool allows access to a library of chemotherapy regimens and their associated, expected febrile neutropenia risk based on the myelotoxicity of the planned regimens as indicated in published trials. The tool is accessible online and provides real-time recommendations that are tailored based on disease- and patient-specific factors for either the use of CSF or not,” he elaborated.
According to the tool’s algorithm, use is recommended for patients who are given a regimen with a high risk of febrile neutropenia (greater than 20%) and is not recommended for those given a low-risk regimen (less than 10%). It is tailored according to the presence of additional risk factors for the intermediate-risk group.
Oncologists use the tool only for patients starting a new chemotherapy and only in the first cycle, when the risk of febrile neutropenia is highest, according to Dr. Agiro. “Once the approval is given in the first cycle, it remains in effect for the next 6 months, so they don’t have to use it again and again in additional cycles,” he explained.
The decision support tool was implemented in nine states starting in July 2014. In the study, which was funded by Anthem, the investigators analyzed administrative claims data from commercially insured adult patients starting chemotherapy for lung cancer, assessing changes in outcomes between a preimplementation period (April 2013 to Dec. 2013) and a postimplementation period (July 2014 to March 2015).
Analyses were based on 1,857 patients in the states that implemented the tool and 1,610 patients in the states that did not.
The percentage of patients receiving CSFs in the 6 months after starting chemotherapy fell in states that implemented the decision support tool (from 48.4% to 35.6%) but remained stable in states that did not (43.2% and 44.4%), Dr. Agiro reported. The adjusted difference in differences was –8.7% (P less than .001).
Meanwhile, the percentage of patients admitted for febrile neutropenia or experiencing this outcome while hospitalized increased in both states implementing the tool (from 2.8% to 4.3%) and those not implementing it (from 3.1% to 5.1%). Although the magnitude of increase was smaller in the former (+1.5% vs. +2.0%), the difference was not significant. Findings were essentially the same among the subset of patients aged 65 years and older.
“It’s important to study both intended and unintended consequences of such interventions,” Dr. Agiro noted. “Our study goes beyond financial considerations by looking at unintended outcomes: in this case, focusing on the incidence of febrile neutropenia, an outcome that is of prime interest to patients and oncologists and payers alike.”
The study may have missed some cases of febrile neutropenia, he acknowledged. “Also, there are other important outcomes of concern. For example, were there any delays in chemotherapy administration or immune recovery that could have been triggered by the implementation of the decision support program?”
The impact, both intended and unintended, on practices warrants evaluation as well, he further noted. “An important question could be, ‘Does it take less time to use this decision support tool compared to the time taken with normal care processes?’ ”
Dr. Agiro disclosed that he is employed by, has stock or other ownership interests in, and receives research funding from Anthem.
ORLANDO – A decision support tool safely reduces use of colony-stimulating factors (CSFs) in patients undergoing chemotherapy for lung cancer, suggests a retrospective claims-based cohort study of nearly 3,500 patients across the country.
The rate of CSF use fell among patients treated in the nine states that implemented the tool – a library of chemotherapy regimens and their expected FN risk that uses preauthorization and an algorithm to promote risk-appropriate, guideline-adherent use – but it remained unchanged in the 39 states and the District of Columbia, where usual practice continued, investigators reported at a symposium on quality care sponsored by the American Society of Clinical Oncology and simultaneously published (J Oncol Pract. 2017 March 4. doi: 10.1200/JOP.2017.020867). The adjusted difference was nearly 9%.
“Decision support programs like the one highlighted here could be one way, definitely not the only way, of achieving guideline-adherent CSF use and reducing practice variation across the country,” commented coinvestigator Abiy Agiro, PhD, associate director of payer and provider research at HealthCore, a subsidiary of Anthem, in Wilmington, Delaware.
“Such efforts could also have unintended consequences, so it’s important to study relevant patient outcomes,” he added. “In this case, although it appears that the incidence of febrile neutropenia rising does not seem to relate with the program, the study does not establish the safety of CSF use reduction in lung cancer patients receiving chemotherapy. So, we should take the results with that caveat.”
Parsing the findings
Although the United States makes up just 4% of the world’s population, it uses nearly 80% of CSFs sold by a leading manufacturer, according to invited discussant Thomas J. Smith, MD, a professor of oncology and palliative medicine at Johns Hopkins University in Baltimore.
“When we rewrote the ASCO [American Society of Clinical Oncology] guidelines on CSF use in 2015, there were some specific indications: dose-intense chemo for adjuvant breast cancer and uroepithelial cancer and ... when the risk of febrile neutropenia is about 20% and dose reduction is not an appropriate strategy. We were quick to point out that most regimens have a risk of febrile neutropenia much less than that,” he noted.
Dr. Agiro and his colleagues’ findings are valid, real, and reproducible, Dr. Smith maintained. However, it is unclear to what extent the observed levels of CSF use represented overuse.
“In lung cancer, there are very few regimens that have a febrile neutropenia rate close to 20%,” he elaborated. “What we don’t know is how much of this [use] was actually justified. I would suspect it is 10% or 15%, rather than 40%.”
CSF use, as guided by the new tool, “might not support increased dose density [of chemotherapy], but I would challenge anybody in the audience to show me data in normal solid tumor patients that [show that] dose density maintained by CSFs makes a difference in overall survival,” he said.
Questions yet to be addressed include the difficulty and cost of using the decision support tool and the possible negative impact on practices’ finances, according to Dr. Smith.
“When ESAs [erythropoiesis-stimulating agents] came off being used so much, some of my friends’ practices took a 15% to 20% drop in their revenue, and this is an important source of revenue for a lot of practices,” he explained. “So, I hope that when we take this revenue away, that we are cognizant of that and realize that it’s just another stress on practices, many of which are under significant stress already.”
Study details
An estimated 26% of uses of CSFs in patients with lung cancer are not in accordance with the ASCO practice guidelines, according to Dr. Agiro. “Such variations from recommendations are sometimes the reason why different stakeholders take actions” to improve care, such as ASCO’s Quality Oncology Practice Initiative (QOPI) and the American Board of Internal Medicine’s Choosing Wisely initiative (J Oncol Pract. 2015;11:338-43).
The decision support tool evaluated in the study uses preauthorization before delivery of care and, therefore, differs from point-of-care interventions, he noted.
“The tool allows access to a library of chemotherapy regimens and their associated, expected febrile neutropenia risk based on the myelotoxicity of the planned regimens as indicated in published trials. The tool is accessible online and provides real-time recommendations that are tailored based on disease- and patient-specific factors for either the use of CSF or not,” he elaborated.
According to the tool’s algorithm, use is recommended for patients who are given a regimen with a high risk of febrile neutropenia (greater than 20%) and is not recommended for those given a low-risk regimen (less than 10%). It is tailored according to the presence of additional risk factors for the intermediate-risk group.
Oncologists use the tool only for patients starting a new chemotherapy and only in the first cycle, when the risk of febrile neutropenia is highest, according to Dr. Agiro. “Once the approval is given in the first cycle, it remains in effect for the next 6 months, so they don’t have to use it again and again in additional cycles,” he explained.
The decision support tool was implemented in nine states starting in July 2014. In the study, which was funded by Anthem, the investigators analyzed administrative claims data from commercially insured adult patients starting chemotherapy for lung cancer, assessing changes in outcomes between a preimplementation period (April 2013 to Dec. 2013) and a postimplementation period (July 2014 to March 2015).
Analyses were based on 1,857 patients in the states that implemented the tool and 1,610 patients in the states that did not.
The percentage of patients receiving CSFs in the 6 months after starting chemotherapy fell in states that implemented the decision support tool (from 48.4% to 35.6%) but remained stable in states that did not (43.2% and 44.4%), Dr. Agiro reported. The adjusted difference in differences was –8.7% (P less than .001).
Meanwhile, the percentage of patients admitted for febrile neutropenia or experiencing this outcome while hospitalized increased in both states implementing the tool (from 2.8% to 4.3%) and those not implementing it (from 3.1% to 5.1%). Although the magnitude of increase was smaller in the former (+1.5% vs. +2.0%), the difference was not significant. Findings were essentially the same among the subset of patients aged 65 years and older.
“It’s important to study both intended and unintended consequences of such interventions,” Dr. Agiro noted. “Our study goes beyond financial considerations by looking at unintended outcomes: in this case, focusing on the incidence of febrile neutropenia, an outcome that is of prime interest to patients and oncologists and payers alike.”
The study may have missed some cases of febrile neutropenia, he acknowledged. “Also, there are other important outcomes of concern. For example, were there any delays in chemotherapy administration or immune recovery that could have been triggered by the implementation of the decision support program?”
The impact, both intended and unintended, on practices warrants evaluation as well, he further noted. “An important question could be, ‘Does it take less time to use this decision support tool compared to the time taken with normal care processes?’ ”
Dr. Agiro disclosed that he is employed by, has stock or other ownership interests in, and receives research funding from Anthem.
ORLANDO – A decision support tool safely reduces use of colony-stimulating factors (CSFs) in patients undergoing chemotherapy for lung cancer, suggests a retrospective claims-based cohort study of nearly 3,500 patients across the country.
The rate of CSF use fell among patients treated in the nine states that implemented the tool – a library of chemotherapy regimens and their expected FN risk that uses preauthorization and an algorithm to promote risk-appropriate, guideline-adherent use – but it remained unchanged in the 39 states and the District of Columbia, where usual practice continued, investigators reported at a symposium on quality care sponsored by the American Society of Clinical Oncology and simultaneously published (J Oncol Pract. 2017 March 4. doi: 10.1200/JOP.2017.020867). The adjusted difference was nearly 9%.
“Decision support programs like the one highlighted here could be one way, definitely not the only way, of achieving guideline-adherent CSF use and reducing practice variation across the country,” commented coinvestigator Abiy Agiro, PhD, associate director of payer and provider research at HealthCore, a subsidiary of Anthem, in Wilmington, Delaware.
“Such efforts could also have unintended consequences, so it’s important to study relevant patient outcomes,” he added. “In this case, although it appears that the incidence of febrile neutropenia rising does not seem to relate with the program, the study does not establish the safety of CSF use reduction in lung cancer patients receiving chemotherapy. So, we should take the results with that caveat.”
Parsing the findings
Although the United States makes up just 4% of the world’s population, it uses nearly 80% of CSFs sold by a leading manufacturer, according to invited discussant Thomas J. Smith, MD, a professor of oncology and palliative medicine at Johns Hopkins University in Baltimore.
“When we rewrote the ASCO [American Society of Clinical Oncology] guidelines on CSF use in 2015, there were some specific indications: dose-intense chemo for adjuvant breast cancer and uroepithelial cancer and ... when the risk of febrile neutropenia is about 20% and dose reduction is not an appropriate strategy. We were quick to point out that most regimens have a risk of febrile neutropenia much less than that,” he noted.
Dr. Agiro and his colleagues’ findings are valid, real, and reproducible, Dr. Smith maintained. However, it is unclear to what extent the observed levels of CSF use represented overuse.
“In lung cancer, there are very few regimens that have a febrile neutropenia rate close to 20%,” he elaborated. “What we don’t know is how much of this [use] was actually justified. I would suspect it is 10% or 15%, rather than 40%.”
CSF use, as guided by the new tool, “might not support increased dose density [of chemotherapy], but I would challenge anybody in the audience to show me data in normal solid tumor patients that [show that] dose density maintained by CSFs makes a difference in overall survival,” he said.
Questions yet to be addressed include the difficulty and cost of using the decision support tool and the possible negative impact on practices’ finances, according to Dr. Smith.
“When ESAs [erythropoiesis-stimulating agents] came off being used so much, some of my friends’ practices took a 15% to 20% drop in their revenue, and this is an important source of revenue for a lot of practices,” he explained. “So, I hope that when we take this revenue away, that we are cognizant of that and realize that it’s just another stress on practices, many of which are under significant stress already.”
Study details
An estimated 26% of uses of CSFs in patients with lung cancer are not in accordance with the ASCO practice guidelines, according to Dr. Agiro. “Such variations from recommendations are sometimes the reason why different stakeholders take actions” to improve care, such as ASCO’s Quality Oncology Practice Initiative (QOPI) and the American Board of Internal Medicine’s Choosing Wisely initiative (J Oncol Pract. 2015;11:338-43).
The decision support tool evaluated in the study uses preauthorization before delivery of care and, therefore, differs from point-of-care interventions, he noted.
“The tool allows access to a library of chemotherapy regimens and their associated, expected febrile neutropenia risk based on the myelotoxicity of the planned regimens as indicated in published trials. The tool is accessible online and provides real-time recommendations that are tailored based on disease- and patient-specific factors for either the use of CSF or not,” he elaborated.
According to the tool’s algorithm, use is recommended for patients who are given a regimen with a high risk of febrile neutropenia (greater than 20%) and is not recommended for those given a low-risk regimen (less than 10%). It is tailored according to the presence of additional risk factors for the intermediate-risk group.
Oncologists use the tool only for patients starting a new chemotherapy and only in the first cycle, when the risk of febrile neutropenia is highest, according to Dr. Agiro. “Once the approval is given in the first cycle, it remains in effect for the next 6 months, so they don’t have to use it again and again in additional cycles,” he explained.
The decision support tool was implemented in nine states starting in July 2014. In the study, which was funded by Anthem, the investigators analyzed administrative claims data from commercially insured adult patients starting chemotherapy for lung cancer, assessing changes in outcomes between a preimplementation period (April 2013 to Dec. 2013) and a postimplementation period (July 2014 to March 2015).
Analyses were based on 1,857 patients in the states that implemented the tool and 1,610 patients in the states that did not.
The percentage of patients receiving CSFs in the 6 months after starting chemotherapy fell in states that implemented the decision support tool (from 48.4% to 35.6%) but remained stable in states that did not (43.2% and 44.4%), Dr. Agiro reported. The adjusted difference in differences was –8.7% (P less than .001).
Meanwhile, the percentage of patients admitted for febrile neutropenia or experiencing this outcome while hospitalized increased in both states implementing the tool (from 2.8% to 4.3%) and those not implementing it (from 3.1% to 5.1%). Although the magnitude of increase was smaller in the former (+1.5% vs. +2.0%), the difference was not significant. Findings were essentially the same among the subset of patients aged 65 years and older.
“It’s important to study both intended and unintended consequences of such interventions,” Dr. Agiro noted. “Our study goes beyond financial considerations by looking at unintended outcomes: in this case, focusing on the incidence of febrile neutropenia, an outcome that is of prime interest to patients and oncologists and payers alike.”
The study may have missed some cases of febrile neutropenia, he acknowledged. “Also, there are other important outcomes of concern. For example, were there any delays in chemotherapy administration or immune recovery that could have been triggered by the implementation of the decision support program?”
The impact, both intended and unintended, on practices warrants evaluation as well, he further noted. “An important question could be, ‘Does it take less time to use this decision support tool compared to the time taken with normal care processes?’ ”
Dr. Agiro disclosed that he is employed by, has stock or other ownership interests in, and receives research funding from Anthem.
AT THE QUALITY CARE SYMPOSIUM
Key clinical point:
Major finding: The percentage of patients receiving CSFs fell in states that used the tool, versus those that did not (difference in differences, –8.7%), but changes in admissions for febrile neutropenia did not differ significantly.
Data source: A retrospective cohort study of 3,467 patients from 48 states starting chemotherapy for lung cancer.
Disclosures: Dr. Agiro disclosed that he is employed by, has stock or other ownership interests in, and receives research funding from Anthem. The study was funded by Anthem.
Pneumococcal conjugate vaccine beats Streptococcus pneumoniae bacteremia
Routine use of the 13-valent pneumococcal conjugate vaccine (PCV13) reduced the incidence of Streptococcus pneumoniae bacteremia by 95% from a time period before to a time period after the vaccine was implemented, based on a review of more than 57,000 blood cultures from children aged 3-36 months.
Kaiser Permanente implemented universal immunization with PCV13 in June 2010. “Initial trends through 2012 demonstrated continued decline in pneumococcal infections, with the biggest impact in children less than 5 years old,” wrote Tara Greenhow, MD, of Kaiser Permanente Northern California, San Francisco, and her colleagues.
Overall, the incidence of S. pneumoniae bacteremia declined from 74.5 per 100,000 children during the period before PCV7 (1998-1999) to 3.5 per 100,000 children during a period after routine use of PCV13 (2013-2014). The annual number of bacteremia cases from any cause dropped by 78% between these two time periods.
As bacteremia caused by pneumococci decreased, 77% of cases in the post-PCV13 time period were caused by Escherichia coli, Salmonella spp., and Staphylococcus aureus. “A total of 76% of bacteremia occurred with a source, including 34% urinary tract infections, 17% gastroenteritis, 8% pneumonias, 8% osteomyelitis, 6% skin and soft tissue infections, and 3% other,” Dr. Greenhow and her associates reported.
The large population of the Kaiser Permanente system supports the accuracy of the now rare incidence of bacteremia in young children, the researchers noted. However, “because bacteremia in the post-PCV13 era is more likely to occur with a source, a focused examination should be performed and appropriate studies should be obtained at the time of a blood culture collection,” they said.
Routine use of the 13-valent pneumococcal conjugate vaccine (PCV13) reduced the incidence of Streptococcus pneumoniae bacteremia by 95% from a time period before to a time period after the vaccine was implemented, based on a review of more than 57,000 blood cultures from children aged 3-36 months.
Kaiser Permanente implemented universal immunization with PCV13 in June 2010. “Initial trends through 2012 demonstrated continued decline in pneumococcal infections, with the biggest impact in children less than 5 years old,” wrote Tara Greenhow, MD, of Kaiser Permanente Northern California, San Francisco, and her colleagues.
Overall, the incidence of S. pneumoniae bacteremia declined from 74.5 per 100,000 children during the period before PCV7 (1998-1999) to 3.5 per 100,000 children during a period after routine use of PCV13 (2013-2014). The annual number of bacteremia cases from any cause dropped by 78% between these two time periods.
As bacteremia caused by pneumococci decreased, 77% of cases in the post-PCV13 time period were caused by Escherichia coli, Salmonella spp., and Staphylococcus aureus. “A total of 76% of bacteremia occurred with a source, including 34% urinary tract infections, 17% gastroenteritis, 8% pneumonias, 8% osteomyelitis, 6% skin and soft tissue infections, and 3% other,” Dr. Greenhow and her associates reported.
The large population of the Kaiser Permanente system supports the accuracy of the now rare incidence of bacteremia in young children, the researchers noted. However, “because bacteremia in the post-PCV13 era is more likely to occur with a source, a focused examination should be performed and appropriate studies should be obtained at the time of a blood culture collection,” they said.
Routine use of the 13-valent pneumococcal conjugate vaccine (PCV13) reduced the incidence of Streptococcus pneumoniae bacteremia by 95% from a time period before to a time period after the vaccine was implemented, based on a review of more than 57,000 blood cultures from children aged 3-36 months.
Kaiser Permanente implemented universal immunization with PCV13 in June 2010. “Initial trends through 2012 demonstrated continued decline in pneumococcal infections, with the biggest impact in children less than 5 years old,” wrote Tara Greenhow, MD, of Kaiser Permanente Northern California, San Francisco, and her colleagues.
Overall, the incidence of S. pneumoniae bacteremia declined from 74.5 per 100,000 children during the period before PCV7 (1998-1999) to 3.5 per 100,000 children during a period after routine use of PCV13 (2013-2014). The annual number of bacteremia cases from any cause dropped by 78% between these two time periods.
As bacteremia caused by pneumococci decreased, 77% of cases in the post-PCV13 time period were caused by Escherichia coli, Salmonella spp., and Staphylococcus aureus. “A total of 76% of bacteremia occurred with a source, including 34% urinary tract infections, 17% gastroenteritis, 8% pneumonias, 8% osteomyelitis, 6% skin and soft tissue infections, and 3% other,” Dr. Greenhow and her associates reported.
The large population of the Kaiser Permanente system supports the accuracy of the now rare incidence of bacteremia in young children, the researchers noted. However, “because bacteremia in the post-PCV13 era is more likely to occur with a source, a focused examination should be performed and appropriate studies should be obtained at the time of a blood culture collection,” they said.
FROM PEDIATRICS
2016 Humanitarian Award
The Patient Safety Movement Foundation presented pediatric hospitalist Patrick Conway, MD, MSc, SFHM, with one of its 2016 Humanitarian Awards. The honor recognizes “life-saving achievement” in patient safety and efforts to “improve quality, affordability, access, and health outcomes,” according to a press release. 
The Patient Safety Movement Foundation presented pediatric hospitalist Patrick Conway, MD, MSc, SFHM, with one of its 2016 Humanitarian Awards. The honor recognizes “life-saving achievement” in patient safety and efforts to “improve quality, affordability, access, and health outcomes,” according to a press release.
The Patient Safety Movement Foundation presented pediatric hospitalist Patrick Conway, MD, MSc, SFHM, with one of its 2016 Humanitarian Awards. The honor recognizes “life-saving achievement” in patient safety and efforts to “improve quality, affordability, access, and health outcomes,” according to a press release.
Hospitalist movers and shakers
O’Neil Pike, MD, SFHM, has been promoted to chief medical officer with healthcare staffing company Medicus Healthcare Solutions (MHS) of Windham, N.H. Formerly a hospitalist consultant and chief practice advisor with MHS, Dr. Pike is a practicing hospitalist and serves as an assistant professor of medicine at Geisinger Commonwealth School of Medicine in Scranton, Pa.
Timothy D. Bode, MD, MBA, SFHM, has been named appointed medical officer at Saint Thomas Rutherford Hospital in Murfreesboro, Tenn., as well as several regional hospitals in the Saint Thomas system. Previously, Dr. Bode served as senior vice president and CMO at Memorial Health in Jacksonville, Fla.
Joseph Perras, MD, has been named chief executive officer at Mt. Ascutney Hospital and Health Center (MAHHC) in Windsor, Vt. Dr. Perras will continue as the center’s CMO, as well. He previously held the role of MAHHC’s director of hospital medicine.
Alamjit Virk, MD, has been promoted to medical director of Emergency Medicine and Hospitalist Services at Martha’s Vineyard Hospital in Oak Bluffs, Mass. Dr. Virk was a MVH staff physician for a year and half prior to the elevation, and he previously served as an attending physician in emergency medicine at Emerson Hospital in Concord, Mass.
Business Moves
Dearborn County Hospital (DCH) in Lawrenceburg, Ind., has partnered with TriHealth to provide hospitalist services for its inpatients. TriHealth’s team of more than 30 hospitalists is led by chief of hospital medicine Bryan Strader, MD. TriHealth also provides care for patients at Ohio’s Bethesda North, Good Samaritan and Bethesda Butler Hospitals.
MidMichigan Medical Centers in Alma, Gladwin, and Midland have been recognized with Five Star Excellence Awards by national health care research leader Professional Research Consultants. Awards were received for excellence in providing patients discharge information and pain management.
Pediatric Associates, located in Broward County, Fla., has expanded its pediatric hospitalist program thanks to the success of a pilot program run at Palm Beach Children’s Hospital at St. Mary’s Medical Center (West Palm Beach). Jamilah Grant-Guimaraes, MD, FAAP, and Nina Phillips Bernstein, DO, FAAP, will provide care to Pediatrics Associates patients at Broward General Medical Center.
The University of Pennsylvania Health System announced that it will add Princeton HealthCare System (PHCS) to the UPHS family. Located just 40 miles from Philadelphia, PHCS serves more than 1.3 million people in central New Jersey and includes the University Medical Center of Princeton, which opened in 2012 in Plainsboro, N.J.
Lehigh Valley Health Network, based out of Allentown, Pa., has absorbed Pocono Health System (East Stroudsburg, Pa.) in a move effective Jan. 1. Under the deal’s terms, Pocono Medical Center (the system’s only hospital) now will be known as Lehigh Valley Hospital–Pocono. LVH also absorbs Pocono’s three health centers. LVH now operates 8 hospital campuses and 19 health centers.
O’Neil Pike, MD, SFHM, has been promoted to chief medical officer with healthcare staffing company Medicus Healthcare Solutions (MHS) of Windham, N.H. Formerly a hospitalist consultant and chief practice advisor with MHS, Dr. Pike is a practicing hospitalist and serves as an assistant professor of medicine at Geisinger Commonwealth School of Medicine in Scranton, Pa.
Timothy D. Bode, MD, MBA, SFHM, has been named appointed medical officer at Saint Thomas Rutherford Hospital in Murfreesboro, Tenn., as well as several regional hospitals in the Saint Thomas system. Previously, Dr. Bode served as senior vice president and CMO at Memorial Health in Jacksonville, Fla.
Joseph Perras, MD, has been named chief executive officer at Mt. Ascutney Hospital and Health Center (MAHHC) in Windsor, Vt. Dr. Perras will continue as the center’s CMO, as well. He previously held the role of MAHHC’s director of hospital medicine.
Alamjit Virk, MD, has been promoted to medical director of Emergency Medicine and Hospitalist Services at Martha’s Vineyard Hospital in Oak Bluffs, Mass. Dr. Virk was a MVH staff physician for a year and half prior to the elevation, and he previously served as an attending physician in emergency medicine at Emerson Hospital in Concord, Mass.
Business Moves
Dearborn County Hospital (DCH) in Lawrenceburg, Ind., has partnered with TriHealth to provide hospitalist services for its inpatients. TriHealth’s team of more than 30 hospitalists is led by chief of hospital medicine Bryan Strader, MD. TriHealth also provides care for patients at Ohio’s Bethesda North, Good Samaritan and Bethesda Butler Hospitals.
MidMichigan Medical Centers in Alma, Gladwin, and Midland have been recognized with Five Star Excellence Awards by national health care research leader Professional Research Consultants. Awards were received for excellence in providing patients discharge information and pain management.
Pediatric Associates, located in Broward County, Fla., has expanded its pediatric hospitalist program thanks to the success of a pilot program run at Palm Beach Children’s Hospital at St. Mary’s Medical Center (West Palm Beach). Jamilah Grant-Guimaraes, MD, FAAP, and Nina Phillips Bernstein, DO, FAAP, will provide care to Pediatrics Associates patients at Broward General Medical Center.
The University of Pennsylvania Health System announced that it will add Princeton HealthCare System (PHCS) to the UPHS family. Located just 40 miles from Philadelphia, PHCS serves more than 1.3 million people in central New Jersey and includes the University Medical Center of Princeton, which opened in 2012 in Plainsboro, N.J.
Lehigh Valley Health Network, based out of Allentown, Pa., has absorbed Pocono Health System (East Stroudsburg, Pa.) in a move effective Jan. 1. Under the deal’s terms, Pocono Medical Center (the system’s only hospital) now will be known as Lehigh Valley Hospital–Pocono. LVH also absorbs Pocono’s three health centers. LVH now operates 8 hospital campuses and 19 health centers.
O’Neil Pike, MD, SFHM, has been promoted to chief medical officer with healthcare staffing company Medicus Healthcare Solutions (MHS) of Windham, N.H. Formerly a hospitalist consultant and chief practice advisor with MHS, Dr. Pike is a practicing hospitalist and serves as an assistant professor of medicine at Geisinger Commonwealth School of Medicine in Scranton, Pa.
Timothy D. Bode, MD, MBA, SFHM, has been named appointed medical officer at Saint Thomas Rutherford Hospital in Murfreesboro, Tenn., as well as several regional hospitals in the Saint Thomas system. Previously, Dr. Bode served as senior vice president and CMO at Memorial Health in Jacksonville, Fla.
Joseph Perras, MD, has been named chief executive officer at Mt. Ascutney Hospital and Health Center (MAHHC) in Windsor, Vt. Dr. Perras will continue as the center’s CMO, as well. He previously held the role of MAHHC’s director of hospital medicine.
Alamjit Virk, MD, has been promoted to medical director of Emergency Medicine and Hospitalist Services at Martha’s Vineyard Hospital in Oak Bluffs, Mass. Dr. Virk was a MVH staff physician for a year and half prior to the elevation, and he previously served as an attending physician in emergency medicine at Emerson Hospital in Concord, Mass.
Business Moves
Dearborn County Hospital (DCH) in Lawrenceburg, Ind., has partnered with TriHealth to provide hospitalist services for its inpatients. TriHealth’s team of more than 30 hospitalists is led by chief of hospital medicine Bryan Strader, MD. TriHealth also provides care for patients at Ohio’s Bethesda North, Good Samaritan and Bethesda Butler Hospitals.
MidMichigan Medical Centers in Alma, Gladwin, and Midland have been recognized with Five Star Excellence Awards by national health care research leader Professional Research Consultants. Awards were received for excellence in providing patients discharge information and pain management.
Pediatric Associates, located in Broward County, Fla., has expanded its pediatric hospitalist program thanks to the success of a pilot program run at Palm Beach Children’s Hospital at St. Mary’s Medical Center (West Palm Beach). Jamilah Grant-Guimaraes, MD, FAAP, and Nina Phillips Bernstein, DO, FAAP, will provide care to Pediatrics Associates patients at Broward General Medical Center.
The University of Pennsylvania Health System announced that it will add Princeton HealthCare System (PHCS) to the UPHS family. Located just 40 miles from Philadelphia, PHCS serves more than 1.3 million people in central New Jersey and includes the University Medical Center of Princeton, which opened in 2012 in Plainsboro, N.J.
Lehigh Valley Health Network, based out of Allentown, Pa., has absorbed Pocono Health System (East Stroudsburg, Pa.) in a move effective Jan. 1. Under the deal’s terms, Pocono Medical Center (the system’s only hospital) now will be known as Lehigh Valley Hospital–Pocono. LVH also absorbs Pocono’s three health centers. LVH now operates 8 hospital campuses and 19 health centers.
Seven shortcuts help with diagnosis of CNS vasculitis
SNOWMASS, COLO. – A lumbar puncture is indispensable when entertaining the diagnosis of primary angiitis of the CNS, Leonard H. Calabrese, DO, declared at the Winter Rheumatology Symposium sponsored by the American College of Rheumatology.
“There’s never an excuse short of an absolute surgical contraindication for not doing a lumbar puncture. It’s amazing to me how often this heuristic is overlooked. Virtually all patients with biopsy-proven CNS vasculitis have an inflammatory spinal fluid. This gets you into the club. I always have great unease when I’m seeing a patient – no matter what else I’m seeing that suggests this condition – if the spinal fluid is totally pristine. This does not happen very often at all,” said Dr. Calabrese, professor of medicine and vice chairman of the department of rheumatic and immunological diseases at the Cleveland Clinic in Ohio.
“Not many of us in rheumatology take care of these patients on a regular basis, but the question of whether a patient has CNS vasculitis is actually pretty common. If you do any kind of hospital consultation work, you’ll get called onto the neurology unit to evaluate an obtunded patient with multiple strokes,” he observed.
Neurologists know a lot more about the brain, yet they often seek input from rheumatologists, who are typically much more familiar with the heavy-hitting drugs used in treating PACNS.
In an influential paper published nearly 3 decades ago, Dr. Calabrese and a colleague proposed diagnostic criteria for PACNS which still hold up today. They defined the disorder as a neurologic deficit that remains unexplained after a vigorous diagnostic work-up accompanied by either a high-probability angiogram for vasculitis or biopsy evidence of CNS vasculitis along with exclusion of all conditions capable of either mimicking the angiographic features of arteritis or producing secondary arteritis (Medicine [Baltimore]. 1988 Jan;67[1]:20-39).
Mimickers of PACNS include systemic inflammatory conditions such as Sjögren’s, systemic vasculitis, sarcoidosis, and paraneoplastic conditions, all of which a rheumatologist can typically rule out at the bedside. Other mimickers include coagulation disorders, infections, demyelinating disorders, CNS lymphoma, reversible cerebral vasoconstriction syndromes, and an ever-expanding list of genetic disorders.
“There is no one in the world who’s an expert on all these diseases, so it’s very important for us to work interprofessionally,” the rheumatologist stressed.
At the Snowmass meeting, Dr. Calabrese presented his seven heuristics – that is, loosely defined rules or mental shortcuts – for getting the diagnosis right.
• PACNS can never be securely diagnosed based solely on clinical findings
The findings with the highest pretest probability of PACNS are chronic meningitis for more than 3 weeks, multiple strokes, or unexplained strokes with poststroke cognitive impairment.
Less specific findings in patients with PACNS may include headaches, behavioral changes, encephalopathy, focal sensorimotor abnormalities, ataxia, scotoma and other visual changes, radiculopathy, and myopathy.
• Don’t skip the lumbar puncture
The cerebrospinal fluid (CSF) is abnormal in more than 95% of patients with PACNS. The findings usually are consistent with aseptic meningitis, with modest pleocytosis, elevated protein levels, and a normal glucose.
• Nonvascular imaging is highly sensitive but has low specificity for PACNS
Thus, nonvascular imaging can’t confirm the diagnosis.
“I don’t believe patients can have this diagnosis with a normal MRI with gadolinium enhancement and diffusion-weighted imaging. With true vascular inflammation and parenchymal destruction, something will be seen. So in a patient who has a headache and can’t think properly but has a pristine MRI, it’s probably not this disease, and it’s time to move along,” according to the rheumatologist.
• No angiographic study has 100% specificity for the diagnosis of PACNS
“No one can tell you ‘This is vasculitis’ from an angiogram, just like no one can tell you an abnormal chest x-ray is always pneumonia. While an angiogram can be very, very suggestive, the specificity drops off in small-vessel disease,” Dr. Calabrese said.
• Don’t fear brain biopsy
Brain biopsy is clearly underutilized. It’s a valuable yet imperfect diagnostic tool.
“A well-done biopsy by a good neurosurgeon who’s interested in CNS vasculitis and works interprofessionally probably has greater than 80% sensitivity and 90%-100% specificity for PACNS,” according to Dr. Calabrese.
The brain biopsy is not only helpful in ruling in the diagnosis of PACNS, it’s also an excellent tool for identifying rule outs. In one study, mimickers of PACNS were identified by brain biopsy in 39% of patients.
“You find something else about 40% of the time – and that’s a good thing,” he said.
Physicians who have difficulty getting a patient or family to okay a brain biopsy are generally going about it wrong, Dr. Calabrese continued.
“I can’t think of a single instance in all my years of practice where a patient has refused a brain biopsy after we’ve engaged in a shared decision-making process. Why? Because I tell them I think it’s important. This is a grave diagnosis with a tremendous impact for the patient. It involves serious therapies and a guarded prognosis,” he explained.
“Often the prospect of brain biopsy is presented to the patient as just the worst thing in the world that could happen to them: ‘They’ll take a piece of your brain. You’ll lose your piano lessons.’ When actually there’s good evidence that biopsies taken in the absence of brain edema involve minimal morbidity and virtually no mortality,” he noted.
• Mind the must-rule-outs
“Ask yourself,” Dr. Calabrese said, “‘What’s the worst thing that could happen here if I goof up this diagnosis?’”
The answer is the worst that can happen is that a CNS infection or malignancy gets misdiagnosed as PACNS. Those are the two must-rule-outs: infection – be it viral, tuberculosis, fungal, syphilis, bacteria, parasites, or Rickettsia – and malignancy.
“Malignancies can be insanely complex. Five percent of solid tumors will have leptomeningeal metastasis and present with chronic meningitis; that’s always goofing us up,” Dr. Calabrese said.
Intravascular CNS lymphoma is an important mimicker of PACNS. The affected patient may have headaches, punctate infarctions upon imaging, an abnormal CSF, and a mildly abnormal angiogram. The only way to distinguish it from PACNS is by brain biopsy.
“CNS lymphomas are always angiocentric, so unless you’ve got a really good pathologist and a really good biopsy specimen you may goof this up,” Dr. Calabrese cautioned.
• Failure to respond to cytotoxic agents and glucocorticoids suggests an alternative diagnosis, not refractory disease
It’s very unusual for a patient with PACNS to fail a robust course of cyclophosphamide or methotrexate plus steroids. This is a red flag situation warranting a pause to reconsider the diagnosis.
Other red flags commonly encountered by a consulting rheumatologists are that a neurologist diagnosed PACNS in the absence of a lumbar puncture, or on the basis of angiographic findings with a normal CSF.
Dr. Calabrese reported having no financial conflicts of interest.
SNOWMASS, COLO. – A lumbar puncture is indispensable when entertaining the diagnosis of primary angiitis of the CNS, Leonard H. Calabrese, DO, declared at the Winter Rheumatology Symposium sponsored by the American College of Rheumatology.
“There’s never an excuse short of an absolute surgical contraindication for not doing a lumbar puncture. It’s amazing to me how often this heuristic is overlooked. Virtually all patients with biopsy-proven CNS vasculitis have an inflammatory spinal fluid. This gets you into the club. I always have great unease when I’m seeing a patient – no matter what else I’m seeing that suggests this condition – if the spinal fluid is totally pristine. This does not happen very often at all,” said Dr. Calabrese, professor of medicine and vice chairman of the department of rheumatic and immunological diseases at the Cleveland Clinic in Ohio.
“Not many of us in rheumatology take care of these patients on a regular basis, but the question of whether a patient has CNS vasculitis is actually pretty common. If you do any kind of hospital consultation work, you’ll get called onto the neurology unit to evaluate an obtunded patient with multiple strokes,” he observed.
Neurologists know a lot more about the brain, yet they often seek input from rheumatologists, who are typically much more familiar with the heavy-hitting drugs used in treating PACNS.
In an influential paper published nearly 3 decades ago, Dr. Calabrese and a colleague proposed diagnostic criteria for PACNS which still hold up today. They defined the disorder as a neurologic deficit that remains unexplained after a vigorous diagnostic work-up accompanied by either a high-probability angiogram for vasculitis or biopsy evidence of CNS vasculitis along with exclusion of all conditions capable of either mimicking the angiographic features of arteritis or producing secondary arteritis (Medicine [Baltimore]. 1988 Jan;67[1]:20-39).
Mimickers of PACNS include systemic inflammatory conditions such as Sjögren’s, systemic vasculitis, sarcoidosis, and paraneoplastic conditions, all of which a rheumatologist can typically rule out at the bedside. Other mimickers include coagulation disorders, infections, demyelinating disorders, CNS lymphoma, reversible cerebral vasoconstriction syndromes, and an ever-expanding list of genetic disorders.
“There is no one in the world who’s an expert on all these diseases, so it’s very important for us to work interprofessionally,” the rheumatologist stressed.
At the Snowmass meeting, Dr. Calabrese presented his seven heuristics – that is, loosely defined rules or mental shortcuts – for getting the diagnosis right.
• PACNS can never be securely diagnosed based solely on clinical findings
The findings with the highest pretest probability of PACNS are chronic meningitis for more than 3 weeks, multiple strokes, or unexplained strokes with poststroke cognitive impairment.
Less specific findings in patients with PACNS may include headaches, behavioral changes, encephalopathy, focal sensorimotor abnormalities, ataxia, scotoma and other visual changes, radiculopathy, and myopathy.
• Don’t skip the lumbar puncture
The cerebrospinal fluid (CSF) is abnormal in more than 95% of patients with PACNS. The findings usually are consistent with aseptic meningitis, with modest pleocytosis, elevated protein levels, and a normal glucose.
• Nonvascular imaging is highly sensitive but has low specificity for PACNS
Thus, nonvascular imaging can’t confirm the diagnosis.
“I don’t believe patients can have this diagnosis with a normal MRI with gadolinium enhancement and diffusion-weighted imaging. With true vascular inflammation and parenchymal destruction, something will be seen. So in a patient who has a headache and can’t think properly but has a pristine MRI, it’s probably not this disease, and it’s time to move along,” according to the rheumatologist.
• No angiographic study has 100% specificity for the diagnosis of PACNS
“No one can tell you ‘This is vasculitis’ from an angiogram, just like no one can tell you an abnormal chest x-ray is always pneumonia. While an angiogram can be very, very suggestive, the specificity drops off in small-vessel disease,” Dr. Calabrese said.
• Don’t fear brain biopsy
Brain biopsy is clearly underutilized. It’s a valuable yet imperfect diagnostic tool.
“A well-done biopsy by a good neurosurgeon who’s interested in CNS vasculitis and works interprofessionally probably has greater than 80% sensitivity and 90%-100% specificity for PACNS,” according to Dr. Calabrese.
The brain biopsy is not only helpful in ruling in the diagnosis of PACNS, it’s also an excellent tool for identifying rule outs. In one study, mimickers of PACNS were identified by brain biopsy in 39% of patients.
“You find something else about 40% of the time – and that’s a good thing,” he said.
Physicians who have difficulty getting a patient or family to okay a brain biopsy are generally going about it wrong, Dr. Calabrese continued.
“I can’t think of a single instance in all my years of practice where a patient has refused a brain biopsy after we’ve engaged in a shared decision-making process. Why? Because I tell them I think it’s important. This is a grave diagnosis with a tremendous impact for the patient. It involves serious therapies and a guarded prognosis,” he explained.
“Often the prospect of brain biopsy is presented to the patient as just the worst thing in the world that could happen to them: ‘They’ll take a piece of your brain. You’ll lose your piano lessons.’ When actually there’s good evidence that biopsies taken in the absence of brain edema involve minimal morbidity and virtually no mortality,” he noted.
• Mind the must-rule-outs
“Ask yourself,” Dr. Calabrese said, “‘What’s the worst thing that could happen here if I goof up this diagnosis?’”
The answer is the worst that can happen is that a CNS infection or malignancy gets misdiagnosed as PACNS. Those are the two must-rule-outs: infection – be it viral, tuberculosis, fungal, syphilis, bacteria, parasites, or Rickettsia – and malignancy.
“Malignancies can be insanely complex. Five percent of solid tumors will have leptomeningeal metastasis and present with chronic meningitis; that’s always goofing us up,” Dr. Calabrese said.
Intravascular CNS lymphoma is an important mimicker of PACNS. The affected patient may have headaches, punctate infarctions upon imaging, an abnormal CSF, and a mildly abnormal angiogram. The only way to distinguish it from PACNS is by brain biopsy.
“CNS lymphomas are always angiocentric, so unless you’ve got a really good pathologist and a really good biopsy specimen you may goof this up,” Dr. Calabrese cautioned.
• Failure to respond to cytotoxic agents and glucocorticoids suggests an alternative diagnosis, not refractory disease
It’s very unusual for a patient with PACNS to fail a robust course of cyclophosphamide or methotrexate plus steroids. This is a red flag situation warranting a pause to reconsider the diagnosis.
Other red flags commonly encountered by a consulting rheumatologists are that a neurologist diagnosed PACNS in the absence of a lumbar puncture, or on the basis of angiographic findings with a normal CSF.
Dr. Calabrese reported having no financial conflicts of interest.
SNOWMASS, COLO. – A lumbar puncture is indispensable when entertaining the diagnosis of primary angiitis of the CNS, Leonard H. Calabrese, DO, declared at the Winter Rheumatology Symposium sponsored by the American College of Rheumatology.
“There’s never an excuse short of an absolute surgical contraindication for not doing a lumbar puncture. It’s amazing to me how often this heuristic is overlooked. Virtually all patients with biopsy-proven CNS vasculitis have an inflammatory spinal fluid. This gets you into the club. I always have great unease when I’m seeing a patient – no matter what else I’m seeing that suggests this condition – if the spinal fluid is totally pristine. This does not happen very often at all,” said Dr. Calabrese, professor of medicine and vice chairman of the department of rheumatic and immunological diseases at the Cleveland Clinic in Ohio.
“Not many of us in rheumatology take care of these patients on a regular basis, but the question of whether a patient has CNS vasculitis is actually pretty common. If you do any kind of hospital consultation work, you’ll get called onto the neurology unit to evaluate an obtunded patient with multiple strokes,” he observed.
Neurologists know a lot more about the brain, yet they often seek input from rheumatologists, who are typically much more familiar with the heavy-hitting drugs used in treating PACNS.
In an influential paper published nearly 3 decades ago, Dr. Calabrese and a colleague proposed diagnostic criteria for PACNS which still hold up today. They defined the disorder as a neurologic deficit that remains unexplained after a vigorous diagnostic work-up accompanied by either a high-probability angiogram for vasculitis or biopsy evidence of CNS vasculitis along with exclusion of all conditions capable of either mimicking the angiographic features of arteritis or producing secondary arteritis (Medicine [Baltimore]. 1988 Jan;67[1]:20-39).
Mimickers of PACNS include systemic inflammatory conditions such as Sjögren’s, systemic vasculitis, sarcoidosis, and paraneoplastic conditions, all of which a rheumatologist can typically rule out at the bedside. Other mimickers include coagulation disorders, infections, demyelinating disorders, CNS lymphoma, reversible cerebral vasoconstriction syndromes, and an ever-expanding list of genetic disorders.
“There is no one in the world who’s an expert on all these diseases, so it’s very important for us to work interprofessionally,” the rheumatologist stressed.
At the Snowmass meeting, Dr. Calabrese presented his seven heuristics – that is, loosely defined rules or mental shortcuts – for getting the diagnosis right.
• PACNS can never be securely diagnosed based solely on clinical findings
The findings with the highest pretest probability of PACNS are chronic meningitis for more than 3 weeks, multiple strokes, or unexplained strokes with poststroke cognitive impairment.
Less specific findings in patients with PACNS may include headaches, behavioral changes, encephalopathy, focal sensorimotor abnormalities, ataxia, scotoma and other visual changes, radiculopathy, and myopathy.
• Don’t skip the lumbar puncture
The cerebrospinal fluid (CSF) is abnormal in more than 95% of patients with PACNS. The findings usually are consistent with aseptic meningitis, with modest pleocytosis, elevated protein levels, and a normal glucose.
• Nonvascular imaging is highly sensitive but has low specificity for PACNS
Thus, nonvascular imaging can’t confirm the diagnosis.
“I don’t believe patients can have this diagnosis with a normal MRI with gadolinium enhancement and diffusion-weighted imaging. With true vascular inflammation and parenchymal destruction, something will be seen. So in a patient who has a headache and can’t think properly but has a pristine MRI, it’s probably not this disease, and it’s time to move along,” according to the rheumatologist.
• No angiographic study has 100% specificity for the diagnosis of PACNS
“No one can tell you ‘This is vasculitis’ from an angiogram, just like no one can tell you an abnormal chest x-ray is always pneumonia. While an angiogram can be very, very suggestive, the specificity drops off in small-vessel disease,” Dr. Calabrese said.
• Don’t fear brain biopsy
Brain biopsy is clearly underutilized. It’s a valuable yet imperfect diagnostic tool.
“A well-done biopsy by a good neurosurgeon who’s interested in CNS vasculitis and works interprofessionally probably has greater than 80% sensitivity and 90%-100% specificity for PACNS,” according to Dr. Calabrese.
The brain biopsy is not only helpful in ruling in the diagnosis of PACNS, it’s also an excellent tool for identifying rule outs. In one study, mimickers of PACNS were identified by brain biopsy in 39% of patients.
“You find something else about 40% of the time – and that’s a good thing,” he said.
Physicians who have difficulty getting a patient or family to okay a brain biopsy are generally going about it wrong, Dr. Calabrese continued.
“I can’t think of a single instance in all my years of practice where a patient has refused a brain biopsy after we’ve engaged in a shared decision-making process. Why? Because I tell them I think it’s important. This is a grave diagnosis with a tremendous impact for the patient. It involves serious therapies and a guarded prognosis,” he explained.
“Often the prospect of brain biopsy is presented to the patient as just the worst thing in the world that could happen to them: ‘They’ll take a piece of your brain. You’ll lose your piano lessons.’ When actually there’s good evidence that biopsies taken in the absence of brain edema involve minimal morbidity and virtually no mortality,” he noted.
• Mind the must-rule-outs
“Ask yourself,” Dr. Calabrese said, “‘What’s the worst thing that could happen here if I goof up this diagnosis?’”
The answer is the worst that can happen is that a CNS infection or malignancy gets misdiagnosed as PACNS. Those are the two must-rule-outs: infection – be it viral, tuberculosis, fungal, syphilis, bacteria, parasites, or Rickettsia – and malignancy.
“Malignancies can be insanely complex. Five percent of solid tumors will have leptomeningeal metastasis and present with chronic meningitis; that’s always goofing us up,” Dr. Calabrese said.
Intravascular CNS lymphoma is an important mimicker of PACNS. The affected patient may have headaches, punctate infarctions upon imaging, an abnormal CSF, and a mildly abnormal angiogram. The only way to distinguish it from PACNS is by brain biopsy.
“CNS lymphomas are always angiocentric, so unless you’ve got a really good pathologist and a really good biopsy specimen you may goof this up,” Dr. Calabrese cautioned.
• Failure to respond to cytotoxic agents and glucocorticoids suggests an alternative diagnosis, not refractory disease
It’s very unusual for a patient with PACNS to fail a robust course of cyclophosphamide or methotrexate plus steroids. This is a red flag situation warranting a pause to reconsider the diagnosis.
Other red flags commonly encountered by a consulting rheumatologists are that a neurologist diagnosed PACNS in the absence of a lumbar puncture, or on the basis of angiographic findings with a normal CSF.
Dr. Calabrese reported having no financial conflicts of interest.
EXPERT ANALYSIS FROM THE WINTER RHEUMATOLOGY SYMPOSIUM
STD testing in youth hindered by confidentiality concerns
Adolescents and young adults on their parents’ health insurance plan are less likely to receive sexual preventive health care, such as sexual risk assessments and testing for sexually transmitted disease, a study found.
Further, teen girls (aged 15-17 years), were more than twice as likely to be tested for chlamydia if they met with their provider alone than if they did not, researchers found.
“Confidentiality issues, including concerns that parents might find out, might be barriers to the use of STD [sexually transmitted disease] services among some subpopulations,” Jami S. Leichliter, PhD, and colleagues at the Centers for Disease Control and Prevention wrote. “Public health efforts to reduce these confidentiality concerns might be useful,” such as providers meeting privately for at least part of an appointment with an adolescent (MMWR. 2017 Mar 10;66[9]:237-41).
The researchers examined data collected from the 2013-2015 National Survey of Family Growth regarding sexual and reproductive health care experiences and behaviors of youth with sexual experience, specifically teens aged 15-17 and young adults aged 18-25 who were on their parents’ health plan. Sexual experience refers to having ever had vaginal, anal, or oral sex with any partner.
Overall, 12.7% of these youth avoided seeking care for sexual and reproductive health because they worried their parents could find out. For those aged 15-17 years, the rate was even higher, at 22.6%.
These concerns were also reflected in the overall prevalence of chlamydia screenings: Just 17.1% of young women who worried about confidentiality had been screened for chlamydia, compared with 38.7% of young women who did not report that concern.
The researchers also compared teens aged 15-17 who had and had not received a sexual risk assessment, which includes being asked by a provider about their (or their partners’) sexual orientation, number of sexual partners, condom use, and types of sex. Among teens who met with a provider alone in the past year, 71.1% reported receiving a sexual risk assessment, compared with about 36.6% who did not meet privately with a provider.
Similarly, 34.0% of teen girls (aged 15-17 years) who saw their provider alone were tested for chlamydia, compared with 14.9% who never met with their provider alone. Slightly more teen boys (13.6%) received STD testing if they met with their provider alone than if they didn’t (9.5%), but this difference did not reach statistical significance.
The study was funded by the Centers for Disease Control and Prevention. The authors did not report any disclosures.
Adolescents and young adults on their parents’ health insurance plan are less likely to receive sexual preventive health care, such as sexual risk assessments and testing for sexually transmitted disease, a study found.
Further, teen girls (aged 15-17 years), were more than twice as likely to be tested for chlamydia if they met with their provider alone than if they did not, researchers found.
“Confidentiality issues, including concerns that parents might find out, might be barriers to the use of STD [sexually transmitted disease] services among some subpopulations,” Jami S. Leichliter, PhD, and colleagues at the Centers for Disease Control and Prevention wrote. “Public health efforts to reduce these confidentiality concerns might be useful,” such as providers meeting privately for at least part of an appointment with an adolescent (MMWR. 2017 Mar 10;66[9]:237-41).
The researchers examined data collected from the 2013-2015 National Survey of Family Growth regarding sexual and reproductive health care experiences and behaviors of youth with sexual experience, specifically teens aged 15-17 and young adults aged 18-25 who were on their parents’ health plan. Sexual experience refers to having ever had vaginal, anal, or oral sex with any partner.
Overall, 12.7% of these youth avoided seeking care for sexual and reproductive health because they worried their parents could find out. For those aged 15-17 years, the rate was even higher, at 22.6%.
These concerns were also reflected in the overall prevalence of chlamydia screenings: Just 17.1% of young women who worried about confidentiality had been screened for chlamydia, compared with 38.7% of young women who did not report that concern.
The researchers also compared teens aged 15-17 who had and had not received a sexual risk assessment, which includes being asked by a provider about their (or their partners’) sexual orientation, number of sexual partners, condom use, and types of sex. Among teens who met with a provider alone in the past year, 71.1% reported receiving a sexual risk assessment, compared with about 36.6% who did not meet privately with a provider.
Similarly, 34.0% of teen girls (aged 15-17 years) who saw their provider alone were tested for chlamydia, compared with 14.9% who never met with their provider alone. Slightly more teen boys (13.6%) received STD testing if they met with their provider alone than if they didn’t (9.5%), but this difference did not reach statistical significance.
The study was funded by the Centers for Disease Control and Prevention. The authors did not report any disclosures.
Adolescents and young adults on their parents’ health insurance plan are less likely to receive sexual preventive health care, such as sexual risk assessments and testing for sexually transmitted disease, a study found.
Further, teen girls (aged 15-17 years), were more than twice as likely to be tested for chlamydia if they met with their provider alone than if they did not, researchers found.
“Confidentiality issues, including concerns that parents might find out, might be barriers to the use of STD [sexually transmitted disease] services among some subpopulations,” Jami S. Leichliter, PhD, and colleagues at the Centers for Disease Control and Prevention wrote. “Public health efforts to reduce these confidentiality concerns might be useful,” such as providers meeting privately for at least part of an appointment with an adolescent (MMWR. 2017 Mar 10;66[9]:237-41).
The researchers examined data collected from the 2013-2015 National Survey of Family Growth regarding sexual and reproductive health care experiences and behaviors of youth with sexual experience, specifically teens aged 15-17 and young adults aged 18-25 who were on their parents’ health plan. Sexual experience refers to having ever had vaginal, anal, or oral sex with any partner.
Overall, 12.7% of these youth avoided seeking care for sexual and reproductive health because they worried their parents could find out. For those aged 15-17 years, the rate was even higher, at 22.6%.
These concerns were also reflected in the overall prevalence of chlamydia screenings: Just 17.1% of young women who worried about confidentiality had been screened for chlamydia, compared with 38.7% of young women who did not report that concern.
The researchers also compared teens aged 15-17 who had and had not received a sexual risk assessment, which includes being asked by a provider about their (or their partners’) sexual orientation, number of sexual partners, condom use, and types of sex. Among teens who met with a provider alone in the past year, 71.1% reported receiving a sexual risk assessment, compared with about 36.6% who did not meet privately with a provider.
Similarly, 34.0% of teen girls (aged 15-17 years) who saw their provider alone were tested for chlamydia, compared with 14.9% who never met with their provider alone. Slightly more teen boys (13.6%) received STD testing if they met with their provider alone than if they didn’t (9.5%), but this difference did not reach statistical significance.
The study was funded by the Centers for Disease Control and Prevention. The authors did not report any disclosures.
FROM MMWR
Key clinical point:
Major finding: Overall, 12.7% of sexually experienced youths (aged 15-25 years) who were on their parents’ health plan would not seek sexual and reproductive health care because of confidentiality concerns.
Data source: Responses from sexually experienced youth aged 15-25 years provided during the 2013-2015 U.S. National Survey of Family Growth.
Disclosures: The study was funded by the Centers for Disease Control and Prevention. The authors did not report any disclosures.
Senate confirms Verma as CMS administrator
The Senate confirmed Seema Verma as administrator of the Centers for Medicare & Medicaid Services on March 13 by a largely party line vote of 55-43.
Ms. Verma’s confirmation comes as Republicans begin their efforts to repeal and replace the Affordable Care Act. During the March 13 debate, Senate Finance Committee Chairman Orrin Hatch (R-Utah) reiterated his support for Ms. Verma, saying she will be a needed leader during the transition from the ACA.
Senate Finance Committee Ranking Member Ron Wyden (D-Ore.) continued to criticize Ms. Verma during the debate, stressing that she has presented no clear vision of her plans as the next CMS administrator.
“Ms. Verma gave the Finance Committee and the public virtually nothing to go by in terms of how she’d approach this job,” Sen. Wyden said during floor debate. “If confirmed, she’d be one of the top officials to implement Trumpcare, a bill that would raid Medicaid, slash Medicare, and kick millions of Americans off their health care... So I’m unable to support this nomination.”
A relative unknown before her nomination, Ms. Verma spent 20 years designing policy projects involving Medicaid, including HIP, the nation’s first consumer-directed Medicaid program under Indiana Governor Mitch Daniels and then-Gov. Mike Pence’s HIP 2.0 waiver proposal.
Prior to consulting, Ms. Verma served as vice president of planning for the Health and Hospital Corporation of Marion County (Ind.) and as a director with the Association of State and Territorial Health Officials in Washington.
During her confirmation hearing, senators raised concerns about Ms. Verma’s past consulting agreements with states while working for Hewlett Packard, a company that had financial interests in the health programs she designed. But Ms. Verma argued that she never negotiated on behalf of Hewlett Packard, and that the work she conducted for the states did not overlap with work she completed for Hewlett Packard. Her company sought an ethics opinion to ensure the arrangement was not problematic, she said.
The Association for Community Affiliated Plans (ACAP) pledged to work with Ms. Verma as the Trump administration works toward changing how Medicaid is financed and administered. ACAP represents nonprofit safety net health plans in 28 states that serve patients enrolled in Medicaid, Medicare, the Children’s Health Insurance Program, marketplaces, and other publicly supported health programs.
“Flexibility is one of the great things about the Medicaid program today – this very flexibility is what has allowed the changes Ms. Verma helped to effect in Indiana,” ACAP CEO Margaret A. Murray said in a statement. “We look forward to working with Ms. Verma on pathways to refine the program while maintaining its guarantee of coverage for all eligible individuals, improving transparency and actuarial soundness in rate-setting, and assuring access to needed care and services.”
[email protected]
On Twitter @legal_med
The Senate confirmed Seema Verma as administrator of the Centers for Medicare & Medicaid Services on March 13 by a largely party line vote of 55-43.
Ms. Verma’s confirmation comes as Republicans begin their efforts to repeal and replace the Affordable Care Act. During the March 13 debate, Senate Finance Committee Chairman Orrin Hatch (R-Utah) reiterated his support for Ms. Verma, saying she will be a needed leader during the transition from the ACA.
Senate Finance Committee Ranking Member Ron Wyden (D-Ore.) continued to criticize Ms. Verma during the debate, stressing that she has presented no clear vision of her plans as the next CMS administrator.
“Ms. Verma gave the Finance Committee and the public virtually nothing to go by in terms of how she’d approach this job,” Sen. Wyden said during floor debate. “If confirmed, she’d be one of the top officials to implement Trumpcare, a bill that would raid Medicaid, slash Medicare, and kick millions of Americans off their health care... So I’m unable to support this nomination.”
A relative unknown before her nomination, Ms. Verma spent 20 years designing policy projects involving Medicaid, including HIP, the nation’s first consumer-directed Medicaid program under Indiana Governor Mitch Daniels and then-Gov. Mike Pence’s HIP 2.0 waiver proposal.
Prior to consulting, Ms. Verma served as vice president of planning for the Health and Hospital Corporation of Marion County (Ind.) and as a director with the Association of State and Territorial Health Officials in Washington.
During her confirmation hearing, senators raised concerns about Ms. Verma’s past consulting agreements with states while working for Hewlett Packard, a company that had financial interests in the health programs she designed. But Ms. Verma argued that she never negotiated on behalf of Hewlett Packard, and that the work she conducted for the states did not overlap with work she completed for Hewlett Packard. Her company sought an ethics opinion to ensure the arrangement was not problematic, she said.
The Association for Community Affiliated Plans (ACAP) pledged to work with Ms. Verma as the Trump administration works toward changing how Medicaid is financed and administered. ACAP represents nonprofit safety net health plans in 28 states that serve patients enrolled in Medicaid, Medicare, the Children’s Health Insurance Program, marketplaces, and other publicly supported health programs.
“Flexibility is one of the great things about the Medicaid program today – this very flexibility is what has allowed the changes Ms. Verma helped to effect in Indiana,” ACAP CEO Margaret A. Murray said in a statement. “We look forward to working with Ms. Verma on pathways to refine the program while maintaining its guarantee of coverage for all eligible individuals, improving transparency and actuarial soundness in rate-setting, and assuring access to needed care and services.”
[email protected]
On Twitter @legal_med
The Senate confirmed Seema Verma as administrator of the Centers for Medicare & Medicaid Services on March 13 by a largely party line vote of 55-43.
Ms. Verma’s confirmation comes as Republicans begin their efforts to repeal and replace the Affordable Care Act. During the March 13 debate, Senate Finance Committee Chairman Orrin Hatch (R-Utah) reiterated his support for Ms. Verma, saying she will be a needed leader during the transition from the ACA.
Senate Finance Committee Ranking Member Ron Wyden (D-Ore.) continued to criticize Ms. Verma during the debate, stressing that she has presented no clear vision of her plans as the next CMS administrator.
“Ms. Verma gave the Finance Committee and the public virtually nothing to go by in terms of how she’d approach this job,” Sen. Wyden said during floor debate. “If confirmed, she’d be one of the top officials to implement Trumpcare, a bill that would raid Medicaid, slash Medicare, and kick millions of Americans off their health care... So I’m unable to support this nomination.”
A relative unknown before her nomination, Ms. Verma spent 20 years designing policy projects involving Medicaid, including HIP, the nation’s first consumer-directed Medicaid program under Indiana Governor Mitch Daniels and then-Gov. Mike Pence’s HIP 2.0 waiver proposal.
Prior to consulting, Ms. Verma served as vice president of planning for the Health and Hospital Corporation of Marion County (Ind.) and as a director with the Association of State and Territorial Health Officials in Washington.
During her confirmation hearing, senators raised concerns about Ms. Verma’s past consulting agreements with states while working for Hewlett Packard, a company that had financial interests in the health programs she designed. But Ms. Verma argued that she never negotiated on behalf of Hewlett Packard, and that the work she conducted for the states did not overlap with work she completed for Hewlett Packard. Her company sought an ethics opinion to ensure the arrangement was not problematic, she said.
The Association for Community Affiliated Plans (ACAP) pledged to work with Ms. Verma as the Trump administration works toward changing how Medicaid is financed and administered. ACAP represents nonprofit safety net health plans in 28 states that serve patients enrolled in Medicaid, Medicare, the Children’s Health Insurance Program, marketplaces, and other publicly supported health programs.
“Flexibility is one of the great things about the Medicaid program today – this very flexibility is what has allowed the changes Ms. Verma helped to effect in Indiana,” ACAP CEO Margaret A. Murray said in a statement. “We look forward to working with Ms. Verma on pathways to refine the program while maintaining its guarantee of coverage for all eligible individuals, improving transparency and actuarial soundness in rate-setting, and assuring access to needed care and services.”
[email protected]
On Twitter @legal_med