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Surgeons raise red flag on proposed 2017 physician fee schedule
The physician fee schedule for 2017 proposed by the Centers for Medicare & Medicaid Services has raised a red flag for the American College of Surgeons (ACS).
A proposal related to data collection on the transition of all 10- and 90- day global codes to 0-day codes in the proposed physician fee schedule 2017 is the area of greatest concern to the ACS. The provision would require all surgeons and other physicians who receive payment from these codes to devote many hours to collecting and reporting these data.
Two years ago, the CMS had pushed this exact transition through in regulation. However, Congress halted that transition in the Medicare Access and CHIP Reauthorization Act (MACRA), instead directing the CMS to study the effects of the transition by collecting data from a “representative sample” of physicians who receive payment from these codes.
For most surgical procedures, Medicare pays surgeons for either 10 or 90 days of care that include the procedure itself and postoperative care. Most global codes are 90-day codes. The CMS would have debundled the global payments 2 years ago had Congress not intervened.
However, in the proposed physician fee schedule update for 2017, the CMS would require all physicians to report data on these codes, something the ACS believes is overly burdensome.
“ACS believes that this proposal does not align with the MACRA requirement that CMS only collect data from a representative sample of physicians performing 10- or 90-day global codes,” ACS Regulatory Affairs Manager Vinita Ollapally told ACS Surgery News. “ACS is currently pursuing a legislative strategy that urges CMS to not finalize the proposal to collect data from all practitioners who perform 10- and 90-day global services, and instead revise the policy to collect data on 10- and 90-day global services from a ‘representative sample’ of practitioners.”
The college is developing a definition for what it believes that representative sample should include and expects to have that ready when the ACS files its comments on the physician fee schedule update proposal. Comments on the proposal are due Sept. 6.
The proposed update, published July 15 in the Federal Register, brings in several new policies aimed at improving physician payment for caring for patients with multiple chronic conditions; mental and behavioral health issues; and cognitive impairment or mobility-related issues.
Among the provisions in the 800+ page proposal are revised billing codes that would more accurately recognize the work of primary care and other cognitive specialties. The changes, according to the CMS, will help “better identify and value primary care, care management, and cognitive services.”
The agency is proposing several coding changes that “could improve health care delivery for all types of services holding the most promise for healthier people and smarter spending, and advance our health equity goals,” according to a CMS fact sheet.
The proposed fee schedule also would update how quality is measured and reported by accountable care organizations in the Medicare Shared Savings Program, align Accountable Care Organization reporting with the Physician Quality Reporting System, and change how beneficiaries are assigned to an ACO. Potentially misvalued services also would continue to be reviewed under the proposal.
The agency is also proposing a code to allow for the payment of advanced care planning services furnished via telehealth.
The physician fee schedule for 2017 proposed by the Centers for Medicare & Medicaid Services has raised a red flag for the American College of Surgeons (ACS).
A proposal related to data collection on the transition of all 10- and 90- day global codes to 0-day codes in the proposed physician fee schedule 2017 is the area of greatest concern to the ACS. The provision would require all surgeons and other physicians who receive payment from these codes to devote many hours to collecting and reporting these data.
Two years ago, the CMS had pushed this exact transition through in regulation. However, Congress halted that transition in the Medicare Access and CHIP Reauthorization Act (MACRA), instead directing the CMS to study the effects of the transition by collecting data from a “representative sample” of physicians who receive payment from these codes.
For most surgical procedures, Medicare pays surgeons for either 10 or 90 days of care that include the procedure itself and postoperative care. Most global codes are 90-day codes. The CMS would have debundled the global payments 2 years ago had Congress not intervened.
However, in the proposed physician fee schedule update for 2017, the CMS would require all physicians to report data on these codes, something the ACS believes is overly burdensome.
“ACS believes that this proposal does not align with the MACRA requirement that CMS only collect data from a representative sample of physicians performing 10- or 90-day global codes,” ACS Regulatory Affairs Manager Vinita Ollapally told ACS Surgery News. “ACS is currently pursuing a legislative strategy that urges CMS to not finalize the proposal to collect data from all practitioners who perform 10- and 90-day global services, and instead revise the policy to collect data on 10- and 90-day global services from a ‘representative sample’ of practitioners.”
The college is developing a definition for what it believes that representative sample should include and expects to have that ready when the ACS files its comments on the physician fee schedule update proposal. Comments on the proposal are due Sept. 6.
The proposed update, published July 15 in the Federal Register, brings in several new policies aimed at improving physician payment for caring for patients with multiple chronic conditions; mental and behavioral health issues; and cognitive impairment or mobility-related issues.
Among the provisions in the 800+ page proposal are revised billing codes that would more accurately recognize the work of primary care and other cognitive specialties. The changes, according to the CMS, will help “better identify and value primary care, care management, and cognitive services.”
The agency is proposing several coding changes that “could improve health care delivery for all types of services holding the most promise for healthier people and smarter spending, and advance our health equity goals,” according to a CMS fact sheet.
The proposed fee schedule also would update how quality is measured and reported by accountable care organizations in the Medicare Shared Savings Program, align Accountable Care Organization reporting with the Physician Quality Reporting System, and change how beneficiaries are assigned to an ACO. Potentially misvalued services also would continue to be reviewed under the proposal.
The agency is also proposing a code to allow for the payment of advanced care planning services furnished via telehealth.
The physician fee schedule for 2017 proposed by the Centers for Medicare & Medicaid Services has raised a red flag for the American College of Surgeons (ACS).
A proposal related to data collection on the transition of all 10- and 90- day global codes to 0-day codes in the proposed physician fee schedule 2017 is the area of greatest concern to the ACS. The provision would require all surgeons and other physicians who receive payment from these codes to devote many hours to collecting and reporting these data.
Two years ago, the CMS had pushed this exact transition through in regulation. However, Congress halted that transition in the Medicare Access and CHIP Reauthorization Act (MACRA), instead directing the CMS to study the effects of the transition by collecting data from a “representative sample” of physicians who receive payment from these codes.
For most surgical procedures, Medicare pays surgeons for either 10 or 90 days of care that include the procedure itself and postoperative care. Most global codes are 90-day codes. The CMS would have debundled the global payments 2 years ago had Congress not intervened.
However, in the proposed physician fee schedule update for 2017, the CMS would require all physicians to report data on these codes, something the ACS believes is overly burdensome.
“ACS believes that this proposal does not align with the MACRA requirement that CMS only collect data from a representative sample of physicians performing 10- or 90-day global codes,” ACS Regulatory Affairs Manager Vinita Ollapally told ACS Surgery News. “ACS is currently pursuing a legislative strategy that urges CMS to not finalize the proposal to collect data from all practitioners who perform 10- and 90-day global services, and instead revise the policy to collect data on 10- and 90-day global services from a ‘representative sample’ of practitioners.”
The college is developing a definition for what it believes that representative sample should include and expects to have that ready when the ACS files its comments on the physician fee schedule update proposal. Comments on the proposal are due Sept. 6.
The proposed update, published July 15 in the Federal Register, brings in several new policies aimed at improving physician payment for caring for patients with multiple chronic conditions; mental and behavioral health issues; and cognitive impairment or mobility-related issues.
Among the provisions in the 800+ page proposal are revised billing codes that would more accurately recognize the work of primary care and other cognitive specialties. The changes, according to the CMS, will help “better identify and value primary care, care management, and cognitive services.”
The agency is proposing several coding changes that “could improve health care delivery for all types of services holding the most promise for healthier people and smarter spending, and advance our health equity goals,” according to a CMS fact sheet.
The proposed fee schedule also would update how quality is measured and reported by accountable care organizations in the Medicare Shared Savings Program, align Accountable Care Organization reporting with the Physician Quality Reporting System, and change how beneficiaries are assigned to an ACO. Potentially misvalued services also would continue to be reviewed under the proposal.
The agency is also proposing a code to allow for the payment of advanced care planning services furnished via telehealth.
CPAP May Be Vasculoprotective in Stroke and TIA
DENVER—Long-term continuous positive airway pressure (CPAP) for treatment of sleep apnea in patients with a recent mild stroke or transient ischemic attack (TIA) resulted in improved cardiovascular and metabolic risk factors, better neurologic function, and a reduction in the recurrent vascular event rate, compared with usual care, in the SLEEP TIGHT study.
“Up to 25% of patients will have a stroke, cardiovascular event, or death within 90 days after a minor stroke or TIA despite current preventive strategies. And, importantly, patients with a TIA or stroke have a high prevalence of obstructive sleep apnea—on the order of 60% to 80%,” explained H. Klar Yaggi, MD, MPH, at the 30th Anniversary Meeting of the Associated Professional Sleep Societies.
H. Klar Yaggi, MD, MPH
SLEEP TIGHT’s findings support the hypothesis that diagnosis and treatment of sleep apnea in patients with a recent minor stroke or TIA will address a major unmet need for better methods of reducing the high vascular risk present in this population, said Dr. Yaggi, Associate Professor of Medicine and Director of the Program in Sleep Medicine at Yale University in New Haven, Connecticut.
A High-Risk Population
SLEEP TIGHT was a National Heart, Lung, and Blood Institute–sponsored phase II, 12-month, multicenter, single-blind, randomized, proof-of-concept study. It included 252 patients, 80% of whom had a recent minor stroke, and the rest had a TIA. Patients had high levels of cardiovascular risk factors; two-thirds had hypertension, half were hyperlipidemic, 40% had diabetes, 15% had a prior myocardial infarction, 10% had atrial fibrillation, and the group’s mean BMI was 30. Polysomnography revealed that 76% of subjects had sleep apnea, as defined by an apnea–hypopnea index of at least five events per hour. In fact, they averaged about 23 events per hour, putting them in the moderate-severity range. As is common among patients with stroke or TIA and sleep apnea, they experienced less daytime sleepiness than is typical in a sleep clinic population, with a mean baseline Epworth Sleepiness Scale score of 7.
Participants were randomized to one of three groups: a usual care control group, a CPAP arm, or an enhanced CPAP arm. The enhanced intervention protocol was designed to boost CPAP adherence; it included targeted education, a customized cognitive intervention, and additional CPAP support beyond the standard CPAP protocols used in sleep medicine clinics. Patients with sleep apnea in the two intervention arms were then placed on CPAP.
At one year of follow-up, the stroke rate was 8.7 per 100 patient-years in the usual care group, compared with 5.5 per 100 person-years in the combined intervention arms. The composite cardiovascular event rate, composed of all-cause mortality, acute myocardial infarction, stroke, hospitalization for unstable angina, or urgent coronary revascularization, was 13.1 per 100 person-years with usual care and 11.0 in the CPAP intervention arms. While these results are encouraging, SLEEP TIGHT wasn’t powered to show significant differences in these events.
Patient Adherence
Outcomes across the board didn’t differ significantly between the CPAP and enhanced CPAP groups. And since the mean number of hours of CPAP use per night was also similar in the two groups—3.9 hours with standard CPAP and 4.3 hours with enhanced CPAP—it’s likely that the phase III trial will rely upon the much simpler standard CPAP intervention, according to Dr. Yaggi.
He deemed CPAP adherence in this stroke or TIA population to be similar to the rates typically seen in routine sleep medicine practice. Roughly 40% of the patients with stroke or TIA were rated as having good adherence, 30% made some use of the therapy, and 30% had no or poor adherence.
Nonetheless, patients in the two intervention arms did significantly better than the usual care group, in terms of one-year changes in insulin resistance and glycosylated hemoglobin. They also had lower 24-hour mean systolic blood pressure and were more likely to convert to a favorable pattern of nocturnal blood pressure dipping. However, no differences between the intervention and usual care groups were seen in levels of high-sensitivity C-reactive protein and interleukin-6, the two markers of systemic inflammation analyzed. Nor did the CPAP intervention provide any benefit in terms of heart rate variability and other measures of autonomic function.
Fifty-eight percent of patients in the intervention arms had a desirable NIH Stroke Scale score of 0 to 1, compared with 38% of the usual care group. In addition, daytime sleepiness, as reflected in Epworth Sleepiness Scale scores, was reduced at last follow-up to a significantly greater extent in the CPAP groups, Dr. Yaggi noted.
Greater CPAP use was associated with a favorable trend for improvement in the modified Rankin score: a 0.3-point reduction with no or poor CPAP use, a 0.4-point reduction with some use, and a 0.9-point reduction with good use.
The encouraging results will be helpful in designing a larger, event-driven, definitive phase III trial, Dr. Yaggi said.
—Bruce Jancin
Suggested Reading
Yaggi HK, Mittleman MA, Bravata DM, et al. Reducing cardiovascular risk through treatment of obstructive sleep apnea: 2 methodological approaches. Am Heart J. 2016;172:135-143.
DENVER—Long-term continuous positive airway pressure (CPAP) for treatment of sleep apnea in patients with a recent mild stroke or transient ischemic attack (TIA) resulted in improved cardiovascular and metabolic risk factors, better neurologic function, and a reduction in the recurrent vascular event rate, compared with usual care, in the SLEEP TIGHT study.
“Up to 25% of patients will have a stroke, cardiovascular event, or death within 90 days after a minor stroke or TIA despite current preventive strategies. And, importantly, patients with a TIA or stroke have a high prevalence of obstructive sleep apnea—on the order of 60% to 80%,” explained H. Klar Yaggi, MD, MPH, at the 30th Anniversary Meeting of the Associated Professional Sleep Societies.
H. Klar Yaggi, MD, MPH
SLEEP TIGHT’s findings support the hypothesis that diagnosis and treatment of sleep apnea in patients with a recent minor stroke or TIA will address a major unmet need for better methods of reducing the high vascular risk present in this population, said Dr. Yaggi, Associate Professor of Medicine and Director of the Program in Sleep Medicine at Yale University in New Haven, Connecticut.
A High-Risk Population
SLEEP TIGHT was a National Heart, Lung, and Blood Institute–sponsored phase II, 12-month, multicenter, single-blind, randomized, proof-of-concept study. It included 252 patients, 80% of whom had a recent minor stroke, and the rest had a TIA. Patients had high levels of cardiovascular risk factors; two-thirds had hypertension, half were hyperlipidemic, 40% had diabetes, 15% had a prior myocardial infarction, 10% had atrial fibrillation, and the group’s mean BMI was 30. Polysomnography revealed that 76% of subjects had sleep apnea, as defined by an apnea–hypopnea index of at least five events per hour. In fact, they averaged about 23 events per hour, putting them in the moderate-severity range. As is common among patients with stroke or TIA and sleep apnea, they experienced less daytime sleepiness than is typical in a sleep clinic population, with a mean baseline Epworth Sleepiness Scale score of 7.
Participants were randomized to one of three groups: a usual care control group, a CPAP arm, or an enhanced CPAP arm. The enhanced intervention protocol was designed to boost CPAP adherence; it included targeted education, a customized cognitive intervention, and additional CPAP support beyond the standard CPAP protocols used in sleep medicine clinics. Patients with sleep apnea in the two intervention arms were then placed on CPAP.
At one year of follow-up, the stroke rate was 8.7 per 100 patient-years in the usual care group, compared with 5.5 per 100 person-years in the combined intervention arms. The composite cardiovascular event rate, composed of all-cause mortality, acute myocardial infarction, stroke, hospitalization for unstable angina, or urgent coronary revascularization, was 13.1 per 100 person-years with usual care and 11.0 in the CPAP intervention arms. While these results are encouraging, SLEEP TIGHT wasn’t powered to show significant differences in these events.
Patient Adherence
Outcomes across the board didn’t differ significantly between the CPAP and enhanced CPAP groups. And since the mean number of hours of CPAP use per night was also similar in the two groups—3.9 hours with standard CPAP and 4.3 hours with enhanced CPAP—it’s likely that the phase III trial will rely upon the much simpler standard CPAP intervention, according to Dr. Yaggi.
He deemed CPAP adherence in this stroke or TIA population to be similar to the rates typically seen in routine sleep medicine practice. Roughly 40% of the patients with stroke or TIA were rated as having good adherence, 30% made some use of the therapy, and 30% had no or poor adherence.
Nonetheless, patients in the two intervention arms did significantly better than the usual care group, in terms of one-year changes in insulin resistance and glycosylated hemoglobin. They also had lower 24-hour mean systolic blood pressure and were more likely to convert to a favorable pattern of nocturnal blood pressure dipping. However, no differences between the intervention and usual care groups were seen in levels of high-sensitivity C-reactive protein and interleukin-6, the two markers of systemic inflammation analyzed. Nor did the CPAP intervention provide any benefit in terms of heart rate variability and other measures of autonomic function.
Fifty-eight percent of patients in the intervention arms had a desirable NIH Stroke Scale score of 0 to 1, compared with 38% of the usual care group. In addition, daytime sleepiness, as reflected in Epworth Sleepiness Scale scores, was reduced at last follow-up to a significantly greater extent in the CPAP groups, Dr. Yaggi noted.
Greater CPAP use was associated with a favorable trend for improvement in the modified Rankin score: a 0.3-point reduction with no or poor CPAP use, a 0.4-point reduction with some use, and a 0.9-point reduction with good use.
The encouraging results will be helpful in designing a larger, event-driven, definitive phase III trial, Dr. Yaggi said.
—Bruce Jancin
DENVER—Long-term continuous positive airway pressure (CPAP) for treatment of sleep apnea in patients with a recent mild stroke or transient ischemic attack (TIA) resulted in improved cardiovascular and metabolic risk factors, better neurologic function, and a reduction in the recurrent vascular event rate, compared with usual care, in the SLEEP TIGHT study.
“Up to 25% of patients will have a stroke, cardiovascular event, or death within 90 days after a minor stroke or TIA despite current preventive strategies. And, importantly, patients with a TIA or stroke have a high prevalence of obstructive sleep apnea—on the order of 60% to 80%,” explained H. Klar Yaggi, MD, MPH, at the 30th Anniversary Meeting of the Associated Professional Sleep Societies.
H. Klar Yaggi, MD, MPH
SLEEP TIGHT’s findings support the hypothesis that diagnosis and treatment of sleep apnea in patients with a recent minor stroke or TIA will address a major unmet need for better methods of reducing the high vascular risk present in this population, said Dr. Yaggi, Associate Professor of Medicine and Director of the Program in Sleep Medicine at Yale University in New Haven, Connecticut.
A High-Risk Population
SLEEP TIGHT was a National Heart, Lung, and Blood Institute–sponsored phase II, 12-month, multicenter, single-blind, randomized, proof-of-concept study. It included 252 patients, 80% of whom had a recent minor stroke, and the rest had a TIA. Patients had high levels of cardiovascular risk factors; two-thirds had hypertension, half were hyperlipidemic, 40% had diabetes, 15% had a prior myocardial infarction, 10% had atrial fibrillation, and the group’s mean BMI was 30. Polysomnography revealed that 76% of subjects had sleep apnea, as defined by an apnea–hypopnea index of at least five events per hour. In fact, they averaged about 23 events per hour, putting them in the moderate-severity range. As is common among patients with stroke or TIA and sleep apnea, they experienced less daytime sleepiness than is typical in a sleep clinic population, with a mean baseline Epworth Sleepiness Scale score of 7.
Participants were randomized to one of three groups: a usual care control group, a CPAP arm, or an enhanced CPAP arm. The enhanced intervention protocol was designed to boost CPAP adherence; it included targeted education, a customized cognitive intervention, and additional CPAP support beyond the standard CPAP protocols used in sleep medicine clinics. Patients with sleep apnea in the two intervention arms were then placed on CPAP.
At one year of follow-up, the stroke rate was 8.7 per 100 patient-years in the usual care group, compared with 5.5 per 100 person-years in the combined intervention arms. The composite cardiovascular event rate, composed of all-cause mortality, acute myocardial infarction, stroke, hospitalization for unstable angina, or urgent coronary revascularization, was 13.1 per 100 person-years with usual care and 11.0 in the CPAP intervention arms. While these results are encouraging, SLEEP TIGHT wasn’t powered to show significant differences in these events.
Patient Adherence
Outcomes across the board didn’t differ significantly between the CPAP and enhanced CPAP groups. And since the mean number of hours of CPAP use per night was also similar in the two groups—3.9 hours with standard CPAP and 4.3 hours with enhanced CPAP—it’s likely that the phase III trial will rely upon the much simpler standard CPAP intervention, according to Dr. Yaggi.
He deemed CPAP adherence in this stroke or TIA population to be similar to the rates typically seen in routine sleep medicine practice. Roughly 40% of the patients with stroke or TIA were rated as having good adherence, 30% made some use of the therapy, and 30% had no or poor adherence.
Nonetheless, patients in the two intervention arms did significantly better than the usual care group, in terms of one-year changes in insulin resistance and glycosylated hemoglobin. They also had lower 24-hour mean systolic blood pressure and were more likely to convert to a favorable pattern of nocturnal blood pressure dipping. However, no differences between the intervention and usual care groups were seen in levels of high-sensitivity C-reactive protein and interleukin-6, the two markers of systemic inflammation analyzed. Nor did the CPAP intervention provide any benefit in terms of heart rate variability and other measures of autonomic function.
Fifty-eight percent of patients in the intervention arms had a desirable NIH Stroke Scale score of 0 to 1, compared with 38% of the usual care group. In addition, daytime sleepiness, as reflected in Epworth Sleepiness Scale scores, was reduced at last follow-up to a significantly greater extent in the CPAP groups, Dr. Yaggi noted.
Greater CPAP use was associated with a favorable trend for improvement in the modified Rankin score: a 0.3-point reduction with no or poor CPAP use, a 0.4-point reduction with some use, and a 0.9-point reduction with good use.
The encouraging results will be helpful in designing a larger, event-driven, definitive phase III trial, Dr. Yaggi said.
—Bruce Jancin
Suggested Reading
Yaggi HK, Mittleman MA, Bravata DM, et al. Reducing cardiovascular risk through treatment of obstructive sleep apnea: 2 methodological approaches. Am Heart J. 2016;172:135-143.
Suggested Reading
Yaggi HK, Mittleman MA, Bravata DM, et al. Reducing cardiovascular risk through treatment of obstructive sleep apnea: 2 methodological approaches. Am Heart J. 2016;172:135-143.
Skin rash in recent traveler? Think dengue fever
BOSTON – Maintain clinical suspicion for dengue fever among individuals with recent travel to endemic areas who present with a rash and other signs and symptoms of infection, an expert advised at the American Academy of Dermatology summer meeting.
Dengue fever accounts for nearly 10% of skin rashes among individuals returning from endemic areas, and related illness can range from mild to fatal, said Jose Dario Martinez, MD, chief of the Internal Medicine Clinic at University Hospital “J.E. Gonzalez,” UANL Monterrey, Mexico.
“This is the most prevalent arthropod-borne virus in the world at this time, and it is a resurgent disease in some countries, like Mexico, Brazil, and Colombia,” he noted.
Worldwide, more than 2.5 billion people are at risk of dengue infection, and between 50 million and 100 million cases occur each year, while about 250,000 to 500,000 cases of dengue hemorrhagic fever occur each year, and about 25,000 related deaths occur.
In 2005, there was a dengue outbreak in Texas, where 25 cases occurred; and in southern Florida, an outbreak of 90 cases was reported in 2009 and 2010. More recently, in 2015, there was an outbreak of 107 cases of locally-acquired dengue on the Big Island, Hawaii (MMWR). But in Mexico, 18,000 new cases occurred in 2015, Dr. Martinez said.
Of the RNA virus serotypes 1-4, type 1 (DENV1) is the most common, and DENV2 and 3 are the most severe, but up to 40% of cases are asymptomatic, he noted, adding that the virus has an incubation period of 2-8 days. When symptoms occur, they are representative of acute febrile illness, and may include headache, high fever, myalgia, arthralgia, retro-orbital pain, and fatigue. A faint, itchy, macular rash commonly occurs at 2-6 days into the illness. According to the World Health Organization, a probable dengue fever case includes acute febrile illness and at least two of either headache, retro-orbital pain, myalgia, arthralgia, rash, hemorrhagic manifestations, leukopenia, or supportive serology.
“Sometimes the nose bleeds, the gums bleed, and there is bruising in the patient,” Dr. Martinez said. “Most important are retro-orbital pain and hemorrhagic manifestations, but also supportive serology.”
About 1% of patients progress to dengue hemorrhagic fever or dengue shock syndrome during the critical phase (days 4-7) of illness. This is most likely in those with serotypes 2 and 3, but can occur with all serotypes. Warning signs of such severe disease include abdominal pain or tenderness, persistent vomiting, pleural effusion or ascites, and of particular importance – mucosal bleeding, Dr. Martinez said.
By the WHO definition, a diagnosis of dengue hemorrhagic fever requires the presence of fever for at least 2-7 days, hemorrhagic tendencies, thrombocytopenia, and evidence and signs of plasma leakage; dengue shock syndrome requires these, as well as evidence of circulatory failure, such as rapid and weak pulse, narrow pulse pressure, hypotension, and shock.
It is important to maintain clinical suspicion for dengue fever, particularly in anyone who has traveled to an endemic area in the 2 weeks before presentation. Serologic tests are important to detect anti-dengue antibodies. IgG is important, because its presence could suggest recurrent infection and thus the potential for severe disease, Dr. Martinez said. Polymerase chain reaction can be used for detection in the first 4-5 days of infection, and the NS1 rapid test can be positive on the first day, he noted.
The differential diagnosis for dengue fever is broad, and can include chikungunya fever, malaria, leptospirosis, meningococcemia, drug eruption, and Zika fever.
Management of dengue fever includes bed rest, liquids, and mosquito net isolation to prevent re-infection, as more severe disease can occur after re-infection. Acetaminophen can be used for pain relief; aspirin should be avoided due to risk of bleeding, Dr. Martinez said.
Hospitalization and supportive care are required for those with dengue hemorrhagic fever or dengue shock syndrome. Intensive care unit admission may be required.
Of note, a vaccine against dengue fever has shown promise in phase III trials. The vaccine has been approved in Mexico and Brazil, but not yet in the U.S.
Dr Martinez reported having no disclosures.
BOSTON – Maintain clinical suspicion for dengue fever among individuals with recent travel to endemic areas who present with a rash and other signs and symptoms of infection, an expert advised at the American Academy of Dermatology summer meeting.
Dengue fever accounts for nearly 10% of skin rashes among individuals returning from endemic areas, and related illness can range from mild to fatal, said Jose Dario Martinez, MD, chief of the Internal Medicine Clinic at University Hospital “J.E. Gonzalez,” UANL Monterrey, Mexico.
“This is the most prevalent arthropod-borne virus in the world at this time, and it is a resurgent disease in some countries, like Mexico, Brazil, and Colombia,” he noted.
Worldwide, more than 2.5 billion people are at risk of dengue infection, and between 50 million and 100 million cases occur each year, while about 250,000 to 500,000 cases of dengue hemorrhagic fever occur each year, and about 25,000 related deaths occur.
In 2005, there was a dengue outbreak in Texas, where 25 cases occurred; and in southern Florida, an outbreak of 90 cases was reported in 2009 and 2010. More recently, in 2015, there was an outbreak of 107 cases of locally-acquired dengue on the Big Island, Hawaii (MMWR). But in Mexico, 18,000 new cases occurred in 2015, Dr. Martinez said.
Of the RNA virus serotypes 1-4, type 1 (DENV1) is the most common, and DENV2 and 3 are the most severe, but up to 40% of cases are asymptomatic, he noted, adding that the virus has an incubation period of 2-8 days. When symptoms occur, they are representative of acute febrile illness, and may include headache, high fever, myalgia, arthralgia, retro-orbital pain, and fatigue. A faint, itchy, macular rash commonly occurs at 2-6 days into the illness. According to the World Health Organization, a probable dengue fever case includes acute febrile illness and at least two of either headache, retro-orbital pain, myalgia, arthralgia, rash, hemorrhagic manifestations, leukopenia, or supportive serology.
“Sometimes the nose bleeds, the gums bleed, and there is bruising in the patient,” Dr. Martinez said. “Most important are retro-orbital pain and hemorrhagic manifestations, but also supportive serology.”
About 1% of patients progress to dengue hemorrhagic fever or dengue shock syndrome during the critical phase (days 4-7) of illness. This is most likely in those with serotypes 2 and 3, but can occur with all serotypes. Warning signs of such severe disease include abdominal pain or tenderness, persistent vomiting, pleural effusion or ascites, and of particular importance – mucosal bleeding, Dr. Martinez said.
By the WHO definition, a diagnosis of dengue hemorrhagic fever requires the presence of fever for at least 2-7 days, hemorrhagic tendencies, thrombocytopenia, and evidence and signs of plasma leakage; dengue shock syndrome requires these, as well as evidence of circulatory failure, such as rapid and weak pulse, narrow pulse pressure, hypotension, and shock.
It is important to maintain clinical suspicion for dengue fever, particularly in anyone who has traveled to an endemic area in the 2 weeks before presentation. Serologic tests are important to detect anti-dengue antibodies. IgG is important, because its presence could suggest recurrent infection and thus the potential for severe disease, Dr. Martinez said. Polymerase chain reaction can be used for detection in the first 4-5 days of infection, and the NS1 rapid test can be positive on the first day, he noted.
The differential diagnosis for dengue fever is broad, and can include chikungunya fever, malaria, leptospirosis, meningococcemia, drug eruption, and Zika fever.
Management of dengue fever includes bed rest, liquids, and mosquito net isolation to prevent re-infection, as more severe disease can occur after re-infection. Acetaminophen can be used for pain relief; aspirin should be avoided due to risk of bleeding, Dr. Martinez said.
Hospitalization and supportive care are required for those with dengue hemorrhagic fever or dengue shock syndrome. Intensive care unit admission may be required.
Of note, a vaccine against dengue fever has shown promise in phase III trials. The vaccine has been approved in Mexico and Brazil, but not yet in the U.S.
Dr Martinez reported having no disclosures.
BOSTON – Maintain clinical suspicion for dengue fever among individuals with recent travel to endemic areas who present with a rash and other signs and symptoms of infection, an expert advised at the American Academy of Dermatology summer meeting.
Dengue fever accounts for nearly 10% of skin rashes among individuals returning from endemic areas, and related illness can range from mild to fatal, said Jose Dario Martinez, MD, chief of the Internal Medicine Clinic at University Hospital “J.E. Gonzalez,” UANL Monterrey, Mexico.
“This is the most prevalent arthropod-borne virus in the world at this time, and it is a resurgent disease in some countries, like Mexico, Brazil, and Colombia,” he noted.
Worldwide, more than 2.5 billion people are at risk of dengue infection, and between 50 million and 100 million cases occur each year, while about 250,000 to 500,000 cases of dengue hemorrhagic fever occur each year, and about 25,000 related deaths occur.
In 2005, there was a dengue outbreak in Texas, where 25 cases occurred; and in southern Florida, an outbreak of 90 cases was reported in 2009 and 2010. More recently, in 2015, there was an outbreak of 107 cases of locally-acquired dengue on the Big Island, Hawaii (MMWR). But in Mexico, 18,000 new cases occurred in 2015, Dr. Martinez said.
Of the RNA virus serotypes 1-4, type 1 (DENV1) is the most common, and DENV2 and 3 are the most severe, but up to 40% of cases are asymptomatic, he noted, adding that the virus has an incubation period of 2-8 days. When symptoms occur, they are representative of acute febrile illness, and may include headache, high fever, myalgia, arthralgia, retro-orbital pain, and fatigue. A faint, itchy, macular rash commonly occurs at 2-6 days into the illness. According to the World Health Organization, a probable dengue fever case includes acute febrile illness and at least two of either headache, retro-orbital pain, myalgia, arthralgia, rash, hemorrhagic manifestations, leukopenia, or supportive serology.
“Sometimes the nose bleeds, the gums bleed, and there is bruising in the patient,” Dr. Martinez said. “Most important are retro-orbital pain and hemorrhagic manifestations, but also supportive serology.”
About 1% of patients progress to dengue hemorrhagic fever or dengue shock syndrome during the critical phase (days 4-7) of illness. This is most likely in those with serotypes 2 and 3, but can occur with all serotypes. Warning signs of such severe disease include abdominal pain or tenderness, persistent vomiting, pleural effusion or ascites, and of particular importance – mucosal bleeding, Dr. Martinez said.
By the WHO definition, a diagnosis of dengue hemorrhagic fever requires the presence of fever for at least 2-7 days, hemorrhagic tendencies, thrombocytopenia, and evidence and signs of plasma leakage; dengue shock syndrome requires these, as well as evidence of circulatory failure, such as rapid and weak pulse, narrow pulse pressure, hypotension, and shock.
It is important to maintain clinical suspicion for dengue fever, particularly in anyone who has traveled to an endemic area in the 2 weeks before presentation. Serologic tests are important to detect anti-dengue antibodies. IgG is important, because its presence could suggest recurrent infection and thus the potential for severe disease, Dr. Martinez said. Polymerase chain reaction can be used for detection in the first 4-5 days of infection, and the NS1 rapid test can be positive on the first day, he noted.
The differential diagnosis for dengue fever is broad, and can include chikungunya fever, malaria, leptospirosis, meningococcemia, drug eruption, and Zika fever.
Management of dengue fever includes bed rest, liquids, and mosquito net isolation to prevent re-infection, as more severe disease can occur after re-infection. Acetaminophen can be used for pain relief; aspirin should be avoided due to risk of bleeding, Dr. Martinez said.
Hospitalization and supportive care are required for those with dengue hemorrhagic fever or dengue shock syndrome. Intensive care unit admission may be required.
Of note, a vaccine against dengue fever has shown promise in phase III trials. The vaccine has been approved in Mexico and Brazil, but not yet in the U.S.
Dr Martinez reported having no disclosures.
EXPERT ANALYSIS FROM THE AAD SUMMER ACADEMY 2016
Transfers to tertiary acute care surgery service point to shortage of rural general surgeons
Nearly half of all transfer patients admitted to a tertiary facility’s acute care surgery service over a 12-month period underwent only basic surgical procedures or required no intervention after the transfer, according to a retrospective chart review.
The 161 patients transferred through the acute care surgery system during the 2014 study period were in need of the services for which they were transferred; thus, the findings highlight a “concerning lack of general surgery resources” in the community, Brittany Misercola, MD, and her colleagues at Maine Medical Center, Portland, reported in the Journal of Surgical Research.
Acute care surgery (ACS) is a relatively new paradigm – borne in part out of a heavy call burden for trauma and general surgeons – for managing patients in need of non–trauma-related emergency surgery, the investigators explained.
“At the same time as the ACS paradigm has developed, rural areas are suffering worsening shortages of physicians, especially specialists like surgeons. Another change has been regionalization of sick, complex, and resource-intensive patients to larger hospitals with more specialized care.
However, no one has yet examined the effect of an ACS service in a predominantly rural area, given these changes in health care,” they wrote (J Surg Res. 2016. [doi:10.106/j.jss.2016.06.090]).
Patients included all adults aged 18 and older admitted between Jan. 1 and Dec. 31, 2014, excluding elective surgical and trauma patients. Transfer patients were admitted from 29 different institutions. The hospital is the largest in Maine, with a wide and rural catchment area. Transfer patients came from every county in the state, with a few from outside the state; 18% were transferred from a Maine Critical Access Hospital.
Compared with 611 local patients admitted through the emergency department or from local long-term care facilities, the transfer patients were older (61.2 years vs. 54.7 years), had more comorbidities (Charlson Comorbidity Index, or CCI, of 4 vs. 3.1), and required more resources (length of stay, 8.2 vs. 3.4 days; intensive care unit admission, 24% vs. 6%), the investigators reported.
Stratification by CCI showed that the difference in length of stay between transfer and local patients was largest in those with a low CCI (0-3), compared with those with a higher CCI.
The admission diagnosis was similar in the transferred and local patients, with pancreaticobiliary and small bowel complaints being the most common (29% and 30%, and 25% and 23%, respectively, for the two diagnoses). The most common interventions were laparoscopic cholecystectomy in both groups (29% and 25%, respectively). Subspecialty interventions were also similar in the groups, and were performed in 10% and 8%, respectively.
However, the transfer patients were more likely than the local patients to not require any intervention, including subspecialty care (32% vs. 23%), they said, noting that the most common reason for admission without operative intervention was “small bowel obstruction, followed by diverticulitis without drainable abscess and mesenteric ischemia.”
The transfer patients also were more likely to have Medicare (55% vs. 24%) and less likely to be privately insured (26% vs. 45%).
The discharge destination differed significantly between the groups, with local patients being more likely to be discharged directly to home (76% vs. 46%), and transfer patients more often discharged home with services (46% vs. 12%) or to acute rehabilitation or skilled nursing facilities (12% vs. 9%). In-hospital mortality and discharge to hospice care also were more likely among transfer patients (6% vs. 2%).
“If changes are not made to support rural hospitals in caring for these patients, tertiary centers in larger cities will see increasing volume of basic surgical emergencies. As such, investing in community hospitals is important to improve patient outcomes not only locally but also after transfer to tertiary referral centers,” they wrote, adding that additional research on the populations most affected is needed.
The authors reported having no relevant financial disclosures.
Nearly half of all transfer patients admitted to a tertiary facility’s acute care surgery service over a 12-month period underwent only basic surgical procedures or required no intervention after the transfer, according to a retrospective chart review.
The 161 patients transferred through the acute care surgery system during the 2014 study period were in need of the services for which they were transferred; thus, the findings highlight a “concerning lack of general surgery resources” in the community, Brittany Misercola, MD, and her colleagues at Maine Medical Center, Portland, reported in the Journal of Surgical Research.
Acute care surgery (ACS) is a relatively new paradigm – borne in part out of a heavy call burden for trauma and general surgeons – for managing patients in need of non–trauma-related emergency surgery, the investigators explained.
“At the same time as the ACS paradigm has developed, rural areas are suffering worsening shortages of physicians, especially specialists like surgeons. Another change has been regionalization of sick, complex, and resource-intensive patients to larger hospitals with more specialized care.
However, no one has yet examined the effect of an ACS service in a predominantly rural area, given these changes in health care,” they wrote (J Surg Res. 2016. [doi:10.106/j.jss.2016.06.090]).
Patients included all adults aged 18 and older admitted between Jan. 1 and Dec. 31, 2014, excluding elective surgical and trauma patients. Transfer patients were admitted from 29 different institutions. The hospital is the largest in Maine, with a wide and rural catchment area. Transfer patients came from every county in the state, with a few from outside the state; 18% were transferred from a Maine Critical Access Hospital.
Compared with 611 local patients admitted through the emergency department or from local long-term care facilities, the transfer patients were older (61.2 years vs. 54.7 years), had more comorbidities (Charlson Comorbidity Index, or CCI, of 4 vs. 3.1), and required more resources (length of stay, 8.2 vs. 3.4 days; intensive care unit admission, 24% vs. 6%), the investigators reported.
Stratification by CCI showed that the difference in length of stay between transfer and local patients was largest in those with a low CCI (0-3), compared with those with a higher CCI.
The admission diagnosis was similar in the transferred and local patients, with pancreaticobiliary and small bowel complaints being the most common (29% and 30%, and 25% and 23%, respectively, for the two diagnoses). The most common interventions were laparoscopic cholecystectomy in both groups (29% and 25%, respectively). Subspecialty interventions were also similar in the groups, and were performed in 10% and 8%, respectively.
However, the transfer patients were more likely than the local patients to not require any intervention, including subspecialty care (32% vs. 23%), they said, noting that the most common reason for admission without operative intervention was “small bowel obstruction, followed by diverticulitis without drainable abscess and mesenteric ischemia.”
The transfer patients also were more likely to have Medicare (55% vs. 24%) and less likely to be privately insured (26% vs. 45%).
The discharge destination differed significantly between the groups, with local patients being more likely to be discharged directly to home (76% vs. 46%), and transfer patients more often discharged home with services (46% vs. 12%) or to acute rehabilitation or skilled nursing facilities (12% vs. 9%). In-hospital mortality and discharge to hospice care also were more likely among transfer patients (6% vs. 2%).
“If changes are not made to support rural hospitals in caring for these patients, tertiary centers in larger cities will see increasing volume of basic surgical emergencies. As such, investing in community hospitals is important to improve patient outcomes not only locally but also after transfer to tertiary referral centers,” they wrote, adding that additional research on the populations most affected is needed.
The authors reported having no relevant financial disclosures.
Nearly half of all transfer patients admitted to a tertiary facility’s acute care surgery service over a 12-month period underwent only basic surgical procedures or required no intervention after the transfer, according to a retrospective chart review.
The 161 patients transferred through the acute care surgery system during the 2014 study period were in need of the services for which they were transferred; thus, the findings highlight a “concerning lack of general surgery resources” in the community, Brittany Misercola, MD, and her colleagues at Maine Medical Center, Portland, reported in the Journal of Surgical Research.
Acute care surgery (ACS) is a relatively new paradigm – borne in part out of a heavy call burden for trauma and general surgeons – for managing patients in need of non–trauma-related emergency surgery, the investigators explained.
“At the same time as the ACS paradigm has developed, rural areas are suffering worsening shortages of physicians, especially specialists like surgeons. Another change has been regionalization of sick, complex, and resource-intensive patients to larger hospitals with more specialized care.
However, no one has yet examined the effect of an ACS service in a predominantly rural area, given these changes in health care,” they wrote (J Surg Res. 2016. [doi:10.106/j.jss.2016.06.090]).
Patients included all adults aged 18 and older admitted between Jan. 1 and Dec. 31, 2014, excluding elective surgical and trauma patients. Transfer patients were admitted from 29 different institutions. The hospital is the largest in Maine, with a wide and rural catchment area. Transfer patients came from every county in the state, with a few from outside the state; 18% were transferred from a Maine Critical Access Hospital.
Compared with 611 local patients admitted through the emergency department or from local long-term care facilities, the transfer patients were older (61.2 years vs. 54.7 years), had more comorbidities (Charlson Comorbidity Index, or CCI, of 4 vs. 3.1), and required more resources (length of stay, 8.2 vs. 3.4 days; intensive care unit admission, 24% vs. 6%), the investigators reported.
Stratification by CCI showed that the difference in length of stay between transfer and local patients was largest in those with a low CCI (0-3), compared with those with a higher CCI.
The admission diagnosis was similar in the transferred and local patients, with pancreaticobiliary and small bowel complaints being the most common (29% and 30%, and 25% and 23%, respectively, for the two diagnoses). The most common interventions were laparoscopic cholecystectomy in both groups (29% and 25%, respectively). Subspecialty interventions were also similar in the groups, and were performed in 10% and 8%, respectively.
However, the transfer patients were more likely than the local patients to not require any intervention, including subspecialty care (32% vs. 23%), they said, noting that the most common reason for admission without operative intervention was “small bowel obstruction, followed by diverticulitis without drainable abscess and mesenteric ischemia.”
The transfer patients also were more likely to have Medicare (55% vs. 24%) and less likely to be privately insured (26% vs. 45%).
The discharge destination differed significantly between the groups, with local patients being more likely to be discharged directly to home (76% vs. 46%), and transfer patients more often discharged home with services (46% vs. 12%) or to acute rehabilitation or skilled nursing facilities (12% vs. 9%). In-hospital mortality and discharge to hospice care also were more likely among transfer patients (6% vs. 2%).
“If changes are not made to support rural hospitals in caring for these patients, tertiary centers in larger cities will see increasing volume of basic surgical emergencies. As such, investing in community hospitals is important to improve patient outcomes not only locally but also after transfer to tertiary referral centers,” they wrote, adding that additional research on the populations most affected is needed.
The authors reported having no relevant financial disclosures.
FROM THE JOURNAL OF SURGICAL RESEARCH
Key clinical point: Transfer of patients to a tertiary facility and acute care surgery service who require basic surgical procedures or no intervention points to a shortage of general surgery capability in the rural areas.
Major finding: Transfer patients were more likely than local patients to not require any intervention, including subspecialty care (32% vs. 23%).
Data source: A retrospective review of 772 patient charts.
Disclosures: The authors reported having no relevant financial disclosures.
ED Visits Rise With Age in Children, Young Adults With Diabetes
The rate of diabetes-related emergency department visits was 464.5 per 100,000 U.S. population among Americans under age 30 in 2012, with young adults heading to the ED far more often than children, according to the Agency for Healthcare Research and Quality.
Young adults aged 18-29 years made diabetes-related ED visits at a rate of 905 per 100,000 in 2012, compared with 149 per 100,000 for children 17 and under. Narrowing down the age groups shows even greater differences: The rate was 47 per 100,000 for children aged 5 years and under, 95 for children aged 6-9, 193 for 10- to 13-year-olds, 316.5 for those aged 14-17, 607 for 18- to 21-year-olds, 889 for 22- to 25-year-olds, and 1,236 for those aged 26-29 years, the AHRQ reported.
Patients aged 5 years and under were, however, the most likely to be admitted to the hospital in 2012: 29% of their diabetes-related ED visits resulted in admission, compared with 26% for those aged 26-29. Those aged 22-25 years were the least likely to be admitted, with 18% staying after their ED visit, and the overall admission rate for those aged 0-29 years was 23.5%, the report noted.
The ED visit rate for diabetes was higher for females than for males aged 0-29 years – 569 per 100,000 vs. 355 – but males were more likely to be admitted – 27% vs. 21% for females, according to data from the Nationwide Emergency Department Sample.
The rate of diabetes-related emergency department visits was 464.5 per 100,000 U.S. population among Americans under age 30 in 2012, with young adults heading to the ED far more often than children, according to the Agency for Healthcare Research and Quality.
Young adults aged 18-29 years made diabetes-related ED visits at a rate of 905 per 100,000 in 2012, compared with 149 per 100,000 for children 17 and under. Narrowing down the age groups shows even greater differences: The rate was 47 per 100,000 for children aged 5 years and under, 95 for children aged 6-9, 193 for 10- to 13-year-olds, 316.5 for those aged 14-17, 607 for 18- to 21-year-olds, 889 for 22- to 25-year-olds, and 1,236 for those aged 26-29 years, the AHRQ reported.
Patients aged 5 years and under were, however, the most likely to be admitted to the hospital in 2012: 29% of their diabetes-related ED visits resulted in admission, compared with 26% for those aged 26-29. Those aged 22-25 years were the least likely to be admitted, with 18% staying after their ED visit, and the overall admission rate for those aged 0-29 years was 23.5%, the report noted.
The ED visit rate for diabetes was higher for females than for males aged 0-29 years – 569 per 100,000 vs. 355 – but males were more likely to be admitted – 27% vs. 21% for females, according to data from the Nationwide Emergency Department Sample.
The rate of diabetes-related emergency department visits was 464.5 per 100,000 U.S. population among Americans under age 30 in 2012, with young adults heading to the ED far more often than children, according to the Agency for Healthcare Research and Quality.
Young adults aged 18-29 years made diabetes-related ED visits at a rate of 905 per 100,000 in 2012, compared with 149 per 100,000 for children 17 and under. Narrowing down the age groups shows even greater differences: The rate was 47 per 100,000 for children aged 5 years and under, 95 for children aged 6-9, 193 for 10- to 13-year-olds, 316.5 for those aged 14-17, 607 for 18- to 21-year-olds, 889 for 22- to 25-year-olds, and 1,236 for those aged 26-29 years, the AHRQ reported.
Patients aged 5 years and under were, however, the most likely to be admitted to the hospital in 2012: 29% of their diabetes-related ED visits resulted in admission, compared with 26% for those aged 26-29. Those aged 22-25 years were the least likely to be admitted, with 18% staying after their ED visit, and the overall admission rate for those aged 0-29 years was 23.5%, the report noted.
The ED visit rate for diabetes was higher for females than for males aged 0-29 years – 569 per 100,000 vs. 355 – but males were more likely to be admitted – 27% vs. 21% for females, according to data from the Nationwide Emergency Department Sample.
ED visits rise with age in children, young adults with diabetes
The rate of diabetes-related emergency department visits was 464.5 per 100,000 U.S. population among Americans under age 30 in 2012, with young adults heading to the ED far more often than children, according to the Agency for Healthcare Research and Quality.
Young adults aged 18-29 years made diabetes-related ED visits at a rate of 905 per 100,000 in 2012, compared with 149 per 100,000 for children 17 and under. Narrowing down the age groups shows even greater differences: The rate was 47 per 100,000 for children aged 5 years and under, 95 for children aged 6-9, 193 for 10- to 13-year-olds, 316.5 for those aged 14-17, 607 for 18- to 21-year-olds, 889 for 22- to 25-year-olds, and 1,236 for those aged 26-29 years, the AHRQ reported.
Patients aged 5 years and under were, however, the most likely to be admitted to the hospital in 2012: 29% of their diabetes-related ED visits resulted in admission, compared with 26% for those aged 26-29. Those aged 22-25 years were the least likely to be admitted, with 18% staying after their ED visit, and the overall admission rate for those aged 0-29 years was 23.5%, the report noted.
The ED visit rate for diabetes was higher for females than for males aged 0-29 years – 569 per 100,000 vs. 355 – but males were more likely to be admitted – 27% vs. 21% for females, according to data from the Nationwide Emergency Department Sample.
The rate of diabetes-related emergency department visits was 464.5 per 100,000 U.S. population among Americans under age 30 in 2012, with young adults heading to the ED far more often than children, according to the Agency for Healthcare Research and Quality.
Young adults aged 18-29 years made diabetes-related ED visits at a rate of 905 per 100,000 in 2012, compared with 149 per 100,000 for children 17 and under. Narrowing down the age groups shows even greater differences: The rate was 47 per 100,000 for children aged 5 years and under, 95 for children aged 6-9, 193 for 10- to 13-year-olds, 316.5 for those aged 14-17, 607 for 18- to 21-year-olds, 889 for 22- to 25-year-olds, and 1,236 for those aged 26-29 years, the AHRQ reported.
Patients aged 5 years and under were, however, the most likely to be admitted to the hospital in 2012: 29% of their diabetes-related ED visits resulted in admission, compared with 26% for those aged 26-29. Those aged 22-25 years were the least likely to be admitted, with 18% staying after their ED visit, and the overall admission rate for those aged 0-29 years was 23.5%, the report noted.
The ED visit rate for diabetes was higher for females than for males aged 0-29 years – 569 per 100,000 vs. 355 – but males were more likely to be admitted – 27% vs. 21% for females, according to data from the Nationwide Emergency Department Sample.
The rate of diabetes-related emergency department visits was 464.5 per 100,000 U.S. population among Americans under age 30 in 2012, with young adults heading to the ED far more often than children, according to the Agency for Healthcare Research and Quality.
Young adults aged 18-29 years made diabetes-related ED visits at a rate of 905 per 100,000 in 2012, compared with 149 per 100,000 for children 17 and under. Narrowing down the age groups shows even greater differences: The rate was 47 per 100,000 for children aged 5 years and under, 95 for children aged 6-9, 193 for 10- to 13-year-olds, 316.5 for those aged 14-17, 607 for 18- to 21-year-olds, 889 for 22- to 25-year-olds, and 1,236 for those aged 26-29 years, the AHRQ reported.
Patients aged 5 years and under were, however, the most likely to be admitted to the hospital in 2012: 29% of their diabetes-related ED visits resulted in admission, compared with 26% for those aged 26-29. Those aged 22-25 years were the least likely to be admitted, with 18% staying after their ED visit, and the overall admission rate for those aged 0-29 years was 23.5%, the report noted.
The ED visit rate for diabetes was higher for females than for males aged 0-29 years – 569 per 100,000 vs. 355 – but males were more likely to be admitted – 27% vs. 21% for females, according to data from the Nationwide Emergency Department Sample.
GLP-1 receptor agonist lixisenatide approved for type 2 diabetes
The Food and Drug Administration has approved the once-daily injectable lixisenatide, a glucagonlike peptide-1 (GLP-1) receptor agonist, as an adjunct to diet and exercise for improved glycemic control in adults with type 2 diabetes.
The safety and effectiveness of lixisenatide (Adlyxin, Sanofi) were evaluated either as a standalone therapy or in combination with other FDA-approved treatments in a series of clinical trials that enrolled 5,400 adults with poorly controlled type 2 diabetes. The combinations tested in the GetGoal Duo2 studies included lixisenatide with metformin, sulfonylureas, pioglitazone, or basal insulin. Lixisenatide successfully met the primary endpoint of improved hemoglobin A1c levels.
Sanofi, the drug’s manufacturer, withdrew its original 2013 application for lixisenatide’s approval pending evaluation of its cardiovascular safety profile using data from the randomized, controlled Evaluation of Lixisenatide in Acute Coronary Syndrome ELIXA trial. In that study of more than 6,000 adults with type 2 diabetes at risk for atherosclerotic cardiovascular disease, lixisenatide did not increase the risk of cardiovascular adverse events, which occurred in 13.2% of placebo patients and 13.4% of treatment group patients (N Engl J Med. 2015;373:2247-57).
The drug’s most common side effects are nausea, vomiting, headache, diarrhea, dizziness, and hypoglycemia. Severe hypersensitivity reactions, including anaphylaxis, also were reported in the clinical trials.
Lixisenatide should not be used to treat people with type 1 diabetes or patients with diabetic ketoacidosis.
The drug will be marketed in disposable, 20-mcg single-dose pens to be injected postprandially, once daily, following initial treatment with a once-daily dose of 10 mcg for 14 days.
Lixisenatide is approved in more than 60 countries and marketed as Lyxumia in over 40, according to information on the manufacturer’s website.
Postmarketing studies for lixisenatide will be required to evaluate dosing, efficacy, and safety in pediatric patients, and to evaluate the drug’s immunogenicity, according to an FDA statement.
“The FDA continues to support the development of new drug therapies for diabetes management,” said Mary Thanh Hai Parks, MD, deputy director, Office of Drug Evaluation II in the FDA’s Center for Drug Evaluation and Research. “Adlyxin will add to the available treatment options to control blood sugar levels for those with type 2.”
On Twitter @whitneymcknight
The Food and Drug Administration has approved the once-daily injectable lixisenatide, a glucagonlike peptide-1 (GLP-1) receptor agonist, as an adjunct to diet and exercise for improved glycemic control in adults with type 2 diabetes.
The safety and effectiveness of lixisenatide (Adlyxin, Sanofi) were evaluated either as a standalone therapy or in combination with other FDA-approved treatments in a series of clinical trials that enrolled 5,400 adults with poorly controlled type 2 diabetes. The combinations tested in the GetGoal Duo2 studies included lixisenatide with metformin, sulfonylureas, pioglitazone, or basal insulin. Lixisenatide successfully met the primary endpoint of improved hemoglobin A1c levels.
Sanofi, the drug’s manufacturer, withdrew its original 2013 application for lixisenatide’s approval pending evaluation of its cardiovascular safety profile using data from the randomized, controlled Evaluation of Lixisenatide in Acute Coronary Syndrome ELIXA trial. In that study of more than 6,000 adults with type 2 diabetes at risk for atherosclerotic cardiovascular disease, lixisenatide did not increase the risk of cardiovascular adverse events, which occurred in 13.2% of placebo patients and 13.4% of treatment group patients (N Engl J Med. 2015;373:2247-57).
The drug’s most common side effects are nausea, vomiting, headache, diarrhea, dizziness, and hypoglycemia. Severe hypersensitivity reactions, including anaphylaxis, also were reported in the clinical trials.
Lixisenatide should not be used to treat people with type 1 diabetes or patients with diabetic ketoacidosis.
The drug will be marketed in disposable, 20-mcg single-dose pens to be injected postprandially, once daily, following initial treatment with a once-daily dose of 10 mcg for 14 days.
Lixisenatide is approved in more than 60 countries and marketed as Lyxumia in over 40, according to information on the manufacturer’s website.
Postmarketing studies for lixisenatide will be required to evaluate dosing, efficacy, and safety in pediatric patients, and to evaluate the drug’s immunogenicity, according to an FDA statement.
“The FDA continues to support the development of new drug therapies for diabetes management,” said Mary Thanh Hai Parks, MD, deputy director, Office of Drug Evaluation II in the FDA’s Center for Drug Evaluation and Research. “Adlyxin will add to the available treatment options to control blood sugar levels for those with type 2.”
On Twitter @whitneymcknight
The Food and Drug Administration has approved the once-daily injectable lixisenatide, a glucagonlike peptide-1 (GLP-1) receptor agonist, as an adjunct to diet and exercise for improved glycemic control in adults with type 2 diabetes.
The safety and effectiveness of lixisenatide (Adlyxin, Sanofi) were evaluated either as a standalone therapy or in combination with other FDA-approved treatments in a series of clinical trials that enrolled 5,400 adults with poorly controlled type 2 diabetes. The combinations tested in the GetGoal Duo2 studies included lixisenatide with metformin, sulfonylureas, pioglitazone, or basal insulin. Lixisenatide successfully met the primary endpoint of improved hemoglobin A1c levels.
Sanofi, the drug’s manufacturer, withdrew its original 2013 application for lixisenatide’s approval pending evaluation of its cardiovascular safety profile using data from the randomized, controlled Evaluation of Lixisenatide in Acute Coronary Syndrome ELIXA trial. In that study of more than 6,000 adults with type 2 diabetes at risk for atherosclerotic cardiovascular disease, lixisenatide did not increase the risk of cardiovascular adverse events, which occurred in 13.2% of placebo patients and 13.4% of treatment group patients (N Engl J Med. 2015;373:2247-57).
The drug’s most common side effects are nausea, vomiting, headache, diarrhea, dizziness, and hypoglycemia. Severe hypersensitivity reactions, including anaphylaxis, also were reported in the clinical trials.
Lixisenatide should not be used to treat people with type 1 diabetes or patients with diabetic ketoacidosis.
The drug will be marketed in disposable, 20-mcg single-dose pens to be injected postprandially, once daily, following initial treatment with a once-daily dose of 10 mcg for 14 days.
Lixisenatide is approved in more than 60 countries and marketed as Lyxumia in over 40, according to information on the manufacturer’s website.
Postmarketing studies for lixisenatide will be required to evaluate dosing, efficacy, and safety in pediatric patients, and to evaluate the drug’s immunogenicity, according to an FDA statement.
“The FDA continues to support the development of new drug therapies for diabetes management,” said Mary Thanh Hai Parks, MD, deputy director, Office of Drug Evaluation II in the FDA’s Center for Drug Evaluation and Research. “Adlyxin will add to the available treatment options to control blood sugar levels for those with type 2.”
On Twitter @whitneymcknight
United States up to 855 cases of Zika in pregnant women
There was one live-born infant with Zika virus–related birth defects and 77 new cases of Zika among pregnant women reported during the week ending July 21, 2016, in the United States, but no additional Zika-related pregnancy losses, according to the Centers for Disease Control and Prevention.
The new cases bring the totals to 13 infants born with birth defects and 855 pregnant women with any laboratory evidence of Zika virus infection. All of the infants with birth defects so far were born in the 50 states and the District of Columbia, which is where six of the seven Zika-related pregnancy losses occurred. There has been only one pregnancy loss in the U.S. territories, but the territories account for almost half (422) of the 855 pregnant women with Zika infection. Of the 77 new infections in pregnant women for the week, 44 occurred in the territories and 33 were in the states, the CDC reported July 28.
The figures for states, territories, and the District of Columbia reflect reporting to the U.S. Zika Pregnancy Registry; data for Puerto Rico are reported to the U.S. Zika Active Pregnancy Surveillance System.
Zika-related birth defects recorded by the CDC could include microcephaly, calcium deposits in the brain indicating possible brain damage, excess fluid in the brain cavities and surrounding the brain, absent or poorly formed brain structures, abnormal eye development, or other problems resulting from brain damage that affect nerves, muscles, and bones. The pregnancy losses encompass any miscarriage, stillbirth, and termination with evidence of birth defects.
There was one live-born infant with Zika virus–related birth defects and 77 new cases of Zika among pregnant women reported during the week ending July 21, 2016, in the United States, but no additional Zika-related pregnancy losses, according to the Centers for Disease Control and Prevention.
The new cases bring the totals to 13 infants born with birth defects and 855 pregnant women with any laboratory evidence of Zika virus infection. All of the infants with birth defects so far were born in the 50 states and the District of Columbia, which is where six of the seven Zika-related pregnancy losses occurred. There has been only one pregnancy loss in the U.S. territories, but the territories account for almost half (422) of the 855 pregnant women with Zika infection. Of the 77 new infections in pregnant women for the week, 44 occurred in the territories and 33 were in the states, the CDC reported July 28.
The figures for states, territories, and the District of Columbia reflect reporting to the U.S. Zika Pregnancy Registry; data for Puerto Rico are reported to the U.S. Zika Active Pregnancy Surveillance System.
Zika-related birth defects recorded by the CDC could include microcephaly, calcium deposits in the brain indicating possible brain damage, excess fluid in the brain cavities and surrounding the brain, absent or poorly formed brain structures, abnormal eye development, or other problems resulting from brain damage that affect nerves, muscles, and bones. The pregnancy losses encompass any miscarriage, stillbirth, and termination with evidence of birth defects.
There was one live-born infant with Zika virus–related birth defects and 77 new cases of Zika among pregnant women reported during the week ending July 21, 2016, in the United States, but no additional Zika-related pregnancy losses, according to the Centers for Disease Control and Prevention.
The new cases bring the totals to 13 infants born with birth defects and 855 pregnant women with any laboratory evidence of Zika virus infection. All of the infants with birth defects so far were born in the 50 states and the District of Columbia, which is where six of the seven Zika-related pregnancy losses occurred. There has been only one pregnancy loss in the U.S. territories, but the territories account for almost half (422) of the 855 pregnant women with Zika infection. Of the 77 new infections in pregnant women for the week, 44 occurred in the territories and 33 were in the states, the CDC reported July 28.
The figures for states, territories, and the District of Columbia reflect reporting to the U.S. Zika Pregnancy Registry; data for Puerto Rico are reported to the U.S. Zika Active Pregnancy Surveillance System.
Zika-related birth defects recorded by the CDC could include microcephaly, calcium deposits in the brain indicating possible brain damage, excess fluid in the brain cavities and surrounding the brain, absent or poorly formed brain structures, abnormal eye development, or other problems resulting from brain damage that affect nerves, muscles, and bones. The pregnancy losses encompass any miscarriage, stillbirth, and termination with evidence of birth defects.
Aluminum chloride still helps control hyperhidrosis
BOSTON – Aluminum chloride, a chemical found in rocks and as ancient as the earth itself, still can control hyperhidrosis for many people when used correctly. It is the active ingredient in over-the-counter antiperspirants as well as prescription products.
At the American Academy of Dermatology summer meeting, Louis Kuchnir, MD, who is a physical chemist by training as well as a dermatologist, described the chemical properties of aluminum chloride and how it works, based on those properties.
Just as no dermatologist would prescribe isotretinoin for acne without understanding its mechanism of action, so should physicians know how aluminum chloride works to be able to use it effectively, he said. Each aluminum chloride molecule can covalently bind six water molecules and tightly bind another shell or two of 12-20 molecules, with a further third shell, all “making the water very viscous such that the weak muscles that push sweat out of our sweat glands are unable to move the sweat to the surface of our skin,” he said.
“When aluminum chloride gets close to water, it soaks it up and thickens it,” said Dr. Kuchnir, who is in private practice in Marlborough, Mass. “By spreading it over the areas that perspire, it thickens the water in the top of the duct where the sweat’s coming out, and that thickening, like a gel, will block it.” Most people get satisfactory results for a full day from one application of an antiperspirant containing aluminum chloride. A failure to control sweating results from such excessive sweat gland activity that the moisture pushes the gel away from the top of the sweat gland.
Diagnosis of hyperhidrosis
A diagnosis of primary hyperhidrosis requires focal, visible sweating present for at least 6 months with no apparent secondary causes and at least two of the following criteria:
• It is bilateral and symmetric.
• It impairs activities of daily life.
• There is at least one episode per week.
• The age of onset is less than 25 years.
• There is a positive family history.
• There is cessation during sleep.
Patients whose sweating is not controlled with regular antiperspirant deodorants may find relief using an aluminum chloride–containing liquid that is not a classic deodorant. These products are available over the counter. Beyond that, primary care doctors often prescribe a 20% aluminum chloride liquid, which can be very effective.
If a patient still has hyperhidrosis, often of the axillae or the palms of the hand, a dermatologist may recommend injections of botulinum toxin A “to disable sweat glands up to 10 months at a time ... which is a costly procedure that has been heavily marketed over the past 5-10 years,” Dr. Kuchnir said. By asking patients what they have been using and what the problem is, and understanding why aluminum chloride failed them in the past, he has found that he could get “four out of five of these patients to be happy and not perspiring with topical antiperspirants, often prescription strength, even though virtually all of them are ready to go for neurotoxins when I first meet them.” The remaining 20% will need botulinum toxin A to block nerve endings from communicating with the smooth muscle in the eccrine gland, which is required to push sweat out of the gland.
Botulinum toxin for hyperhidrosis is covered by prescription drug benefit plans, and prior authorization is routine. Patients should obtain the drug at the best price they can find and then bring it to the physician for injection. The duration of action is often 8-10 months, so dosing can be done yearly in the springtime. Aluminum chloride preparations can be retried once botulinum toxin wears off.
Countering common problems with aluminum chloride preparations
The two most common complaints about topical aluminum chloride preparations are that they sting or do not work. Stinging is often from alcohol in the liquids, so letting it evaporate from the armpits before patients put their arms down can solve this problem. As for the problem of not controlling sweating, Dr. Kuchnir said the most common reason is that patients apply the products while they are actively sweating, “so the aluminum chloride doesn’t have time to gel in the eccrine gland.” Another reason is that the preparation has too much moisture in it and will fail to block sweating.
To be able to apply an antiperspirant to dry skin, patients should minimize the causes of sweating by being in a cool, calm environment. The temporary use of anticholinergic drugs may help. Once control of sweating is achieved, the aluminum chloride–containing preparation should be reapplied before it wears off.
Dr. Kuchnir says he encourages dermatologists to bring the same level of care, understanding, and communication to patients suffering from hyperhidrosis that they do to patients whom they see for acne. Just as clinicians do not always use the strongest medicines but choose the safest ones, especially ones that can be self-administered and self-guided, teaching patients how to use antiperspirants when they will work “is as important as being able to effectively and safely inject neurotoxins,” Dr. Kuchnir advised.
While many patients have heard reports of an association between the use of aluminum chloride–containing antiperspirants and a risk of breast cancer or of aluminum in general being associated with Alzheimer’s disease, he says he tells his patients that “aluminum chloride is completely safe, and I don’t say that about a lot of prescription medicines.”
Dr. Kuchnir reported having no financial disclosures.
BOSTON – Aluminum chloride, a chemical found in rocks and as ancient as the earth itself, still can control hyperhidrosis for many people when used correctly. It is the active ingredient in over-the-counter antiperspirants as well as prescription products.
At the American Academy of Dermatology summer meeting, Louis Kuchnir, MD, who is a physical chemist by training as well as a dermatologist, described the chemical properties of aluminum chloride and how it works, based on those properties.
Just as no dermatologist would prescribe isotretinoin for acne without understanding its mechanism of action, so should physicians know how aluminum chloride works to be able to use it effectively, he said. Each aluminum chloride molecule can covalently bind six water molecules and tightly bind another shell or two of 12-20 molecules, with a further third shell, all “making the water very viscous such that the weak muscles that push sweat out of our sweat glands are unable to move the sweat to the surface of our skin,” he said.
“When aluminum chloride gets close to water, it soaks it up and thickens it,” said Dr. Kuchnir, who is in private practice in Marlborough, Mass. “By spreading it over the areas that perspire, it thickens the water in the top of the duct where the sweat’s coming out, and that thickening, like a gel, will block it.” Most people get satisfactory results for a full day from one application of an antiperspirant containing aluminum chloride. A failure to control sweating results from such excessive sweat gland activity that the moisture pushes the gel away from the top of the sweat gland.
Diagnosis of hyperhidrosis
A diagnosis of primary hyperhidrosis requires focal, visible sweating present for at least 6 months with no apparent secondary causes and at least two of the following criteria:
• It is bilateral and symmetric.
• It impairs activities of daily life.
• There is at least one episode per week.
• The age of onset is less than 25 years.
• There is a positive family history.
• There is cessation during sleep.
Patients whose sweating is not controlled with regular antiperspirant deodorants may find relief using an aluminum chloride–containing liquid that is not a classic deodorant. These products are available over the counter. Beyond that, primary care doctors often prescribe a 20% aluminum chloride liquid, which can be very effective.
If a patient still has hyperhidrosis, often of the axillae or the palms of the hand, a dermatologist may recommend injections of botulinum toxin A “to disable sweat glands up to 10 months at a time ... which is a costly procedure that has been heavily marketed over the past 5-10 years,” Dr. Kuchnir said. By asking patients what they have been using and what the problem is, and understanding why aluminum chloride failed them in the past, he has found that he could get “four out of five of these patients to be happy and not perspiring with topical antiperspirants, often prescription strength, even though virtually all of them are ready to go for neurotoxins when I first meet them.” The remaining 20% will need botulinum toxin A to block nerve endings from communicating with the smooth muscle in the eccrine gland, which is required to push sweat out of the gland.
Botulinum toxin for hyperhidrosis is covered by prescription drug benefit plans, and prior authorization is routine. Patients should obtain the drug at the best price they can find and then bring it to the physician for injection. The duration of action is often 8-10 months, so dosing can be done yearly in the springtime. Aluminum chloride preparations can be retried once botulinum toxin wears off.
Countering common problems with aluminum chloride preparations
The two most common complaints about topical aluminum chloride preparations are that they sting or do not work. Stinging is often from alcohol in the liquids, so letting it evaporate from the armpits before patients put their arms down can solve this problem. As for the problem of not controlling sweating, Dr. Kuchnir said the most common reason is that patients apply the products while they are actively sweating, “so the aluminum chloride doesn’t have time to gel in the eccrine gland.” Another reason is that the preparation has too much moisture in it and will fail to block sweating.
To be able to apply an antiperspirant to dry skin, patients should minimize the causes of sweating by being in a cool, calm environment. The temporary use of anticholinergic drugs may help. Once control of sweating is achieved, the aluminum chloride–containing preparation should be reapplied before it wears off.
Dr. Kuchnir says he encourages dermatologists to bring the same level of care, understanding, and communication to patients suffering from hyperhidrosis that they do to patients whom they see for acne. Just as clinicians do not always use the strongest medicines but choose the safest ones, especially ones that can be self-administered and self-guided, teaching patients how to use antiperspirants when they will work “is as important as being able to effectively and safely inject neurotoxins,” Dr. Kuchnir advised.
While many patients have heard reports of an association between the use of aluminum chloride–containing antiperspirants and a risk of breast cancer or of aluminum in general being associated with Alzheimer’s disease, he says he tells his patients that “aluminum chloride is completely safe, and I don’t say that about a lot of prescription medicines.”
Dr. Kuchnir reported having no financial disclosures.
BOSTON – Aluminum chloride, a chemical found in rocks and as ancient as the earth itself, still can control hyperhidrosis for many people when used correctly. It is the active ingredient in over-the-counter antiperspirants as well as prescription products.
At the American Academy of Dermatology summer meeting, Louis Kuchnir, MD, who is a physical chemist by training as well as a dermatologist, described the chemical properties of aluminum chloride and how it works, based on those properties.
Just as no dermatologist would prescribe isotretinoin for acne without understanding its mechanism of action, so should physicians know how aluminum chloride works to be able to use it effectively, he said. Each aluminum chloride molecule can covalently bind six water molecules and tightly bind another shell or two of 12-20 molecules, with a further third shell, all “making the water very viscous such that the weak muscles that push sweat out of our sweat glands are unable to move the sweat to the surface of our skin,” he said.
“When aluminum chloride gets close to water, it soaks it up and thickens it,” said Dr. Kuchnir, who is in private practice in Marlborough, Mass. “By spreading it over the areas that perspire, it thickens the water in the top of the duct where the sweat’s coming out, and that thickening, like a gel, will block it.” Most people get satisfactory results for a full day from one application of an antiperspirant containing aluminum chloride. A failure to control sweating results from such excessive sweat gland activity that the moisture pushes the gel away from the top of the sweat gland.
Diagnosis of hyperhidrosis
A diagnosis of primary hyperhidrosis requires focal, visible sweating present for at least 6 months with no apparent secondary causes and at least two of the following criteria:
• It is bilateral and symmetric.
• It impairs activities of daily life.
• There is at least one episode per week.
• The age of onset is less than 25 years.
• There is a positive family history.
• There is cessation during sleep.
Patients whose sweating is not controlled with regular antiperspirant deodorants may find relief using an aluminum chloride–containing liquid that is not a classic deodorant. These products are available over the counter. Beyond that, primary care doctors often prescribe a 20% aluminum chloride liquid, which can be very effective.
If a patient still has hyperhidrosis, often of the axillae or the palms of the hand, a dermatologist may recommend injections of botulinum toxin A “to disable sweat glands up to 10 months at a time ... which is a costly procedure that has been heavily marketed over the past 5-10 years,” Dr. Kuchnir said. By asking patients what they have been using and what the problem is, and understanding why aluminum chloride failed them in the past, he has found that he could get “four out of five of these patients to be happy and not perspiring with topical antiperspirants, often prescription strength, even though virtually all of them are ready to go for neurotoxins when I first meet them.” The remaining 20% will need botulinum toxin A to block nerve endings from communicating with the smooth muscle in the eccrine gland, which is required to push sweat out of the gland.
Botulinum toxin for hyperhidrosis is covered by prescription drug benefit plans, and prior authorization is routine. Patients should obtain the drug at the best price they can find and then bring it to the physician for injection. The duration of action is often 8-10 months, so dosing can be done yearly in the springtime. Aluminum chloride preparations can be retried once botulinum toxin wears off.
Countering common problems with aluminum chloride preparations
The two most common complaints about topical aluminum chloride preparations are that they sting or do not work. Stinging is often from alcohol in the liquids, so letting it evaporate from the armpits before patients put their arms down can solve this problem. As for the problem of not controlling sweating, Dr. Kuchnir said the most common reason is that patients apply the products while they are actively sweating, “so the aluminum chloride doesn’t have time to gel in the eccrine gland.” Another reason is that the preparation has too much moisture in it and will fail to block sweating.
To be able to apply an antiperspirant to dry skin, patients should minimize the causes of sweating by being in a cool, calm environment. The temporary use of anticholinergic drugs may help. Once control of sweating is achieved, the aluminum chloride–containing preparation should be reapplied before it wears off.
Dr. Kuchnir says he encourages dermatologists to bring the same level of care, understanding, and communication to patients suffering from hyperhidrosis that they do to patients whom they see for acne. Just as clinicians do not always use the strongest medicines but choose the safest ones, especially ones that can be self-administered and self-guided, teaching patients how to use antiperspirants when they will work “is as important as being able to effectively and safely inject neurotoxins,” Dr. Kuchnir advised.
While many patients have heard reports of an association between the use of aluminum chloride–containing antiperspirants and a risk of breast cancer or of aluminum in general being associated with Alzheimer’s disease, he says he tells his patients that “aluminum chloride is completely safe, and I don’t say that about a lot of prescription medicines.”
Dr. Kuchnir reported having no financial disclosures.
EXPERT ANALYSIS FROM THE AAD SUMMER ACADEMY 2016
The EHR Report: The vortex that sucks you in
Recently, a colleague of ours described the office electronic health record as “the vortex that sucks you in.” This statement occurred during a departmental meeting focused on physician burnout. When members of the department were asked about what things they felt contributed to a feeling of dissatisfaction with work, the electronic health record quickly emerged as a common denominator of dissatisfaction. There were certainly other contributors – the changing and challenging medical environment, fighting with insurance companies, decreased autonomy over practice decisions – but far and away the most cited contributor to dissatisfaction among members of the department was the EHR.
The reasons that EHRs have led to dissatisfaction seem to have changed over the last few years. Initially, physicians found it difficult to suddenly adapt practice styles developed over many years to the new world of electronic documentation. Suddenly they needed to type (or in the case of many, hunt and peck) notes into the history of present illness and fit patient histories into templates seemingly developed by engineers rather than physicians. Now, while most of us have adapted to the logistics of the EHR, there is no escaping the increasing demands for more and more information. There is also ongoing frustration with the lack of control in deciding whether information is relevant for the patient, as well as disparity between the promise and expectation of what electronic records should deliver and what we experience each day in front of us.
Given the degree to which EHRs are contributing to physician dissatisfaction and burnout, it is incumbent upon us to figure out ways to make the EHR work better for clinicians. The literature describes burnout as “a syndrome characterized by a loss of enthusiasm for work (emotional exhaustion), feelings of cynicism (depersonalization), and a low sense of personal accomplishment.” In a recent study, almost half of all physicians described at least one symptom of burnout. Interestingly, physician burnout is greatest in primary care specialties. Surprisingly, compared with other working adults in the United States, physicians are more likely to have symptoms of burnout (38% vs 28%) as well as express dissatisfaction with their work-life balance (40% vs. 23%).1 This issue is important because burnout – in addition to its negative effects on physicians’ experience and quality of life – can erode the quality of the care they give, increase the risk of medical errors, and lead to early ending of lifelong careers.2 The literature suggests that the high prevalence of burnout among U.S. physicians means that “the problem lies more with the system and environment in which physicians work rather than being due to innate vulnerabilities in a few susceptible individuals.” Not surprisingly, we have received letters from readers of our column over many years discussing how the entry of EHRs into their practice was a critical influence in their decisions to retire early.
In our discussion after the department meeting, several physicians described the need to do charting at night from home in order to have their work accomplished for the next day. This is not surprising to any of us who work in primary care and use EHRs. The ability to have access to the EHR anytime and from anywhere is a classic double-edged sword. It is certainly convenient to be able to complete our charting from home without having to stay late in the office on nights and weekends. Unfortunately, bringing work home also erodes into time that could otherwise be spent with family and pursuing other interests.
This is just one of many frustrations. Another common issue is superfluous documentation on the part of specialists. Often, the information is entered by physician extenders or using canned macros to “pad” the note. Sifting through paragraphs of this irrelevant – and sometimes inaccurate – information in consultant notes devalues the integrity of the interaction. It also minimizes the time that was actually spent in the office doing the real hard work of medicine instead of the rudimentary work of documenting things that were either never said or mentioned briefly in passing.
The week after our department meeting was the first week of work for our new interns. Rounding in one of our nursing homes, I handed the intern a patient’s chart and began to explain how the chart was organized – where the orders, progress notes, and labs were located in the chart. The intern had an odd smile on her face. I asked her what was wrong. She replied, “I didn’t know anyone still had paper charts; how do you enter a note there?”
So we come full circle. You can’t miss what you never had. Younger physicians do not resent the EHR, nor can they perceive the EHR to be contributing to discontent. That is not to say that it does not contribute; it is just difficult to identify problems when the way things are is what you have always known. The issue of EHRs contributing to physician burnout is real, and we need to learn more about its causes. Please email us with your thoughts about the aspects of EHRs that you find most frustrating or challenging. Our goal in hearing from you is that it is only by knowing the challenges that we face that we can begin to formulate solutions to overcome those challenges and together make tomorrow’s practice better than today’s.
References
1. Shanafelt TD et al. Burnout and satisfaction with work-life balance among U.S. physicians relative to the general U.S. population. Arch Intern Med. 2012;172(18):1377-85.
2. Shanafelt TD, Balch CM, Bechamps G et al. Burnout and medical errors among American surgeons. Ann Surg. 2010;251(6):995-1000.
Dr. Skolnik is associate director of the family medicine residency program at Abington (Pa.) Memorial Hospital and professor of family and community medicine at Temple University, Philadelphia. Dr. Notte is a family physician and clinical informaticist for Abington (Pa.) Memorial Hospital. He is also a partner in EHR Practice Consultants, a firm that aids physicians in adopting electronic health records.
Recently, a colleague of ours described the office electronic health record as “the vortex that sucks you in.” This statement occurred during a departmental meeting focused on physician burnout. When members of the department were asked about what things they felt contributed to a feeling of dissatisfaction with work, the electronic health record quickly emerged as a common denominator of dissatisfaction. There were certainly other contributors – the changing and challenging medical environment, fighting with insurance companies, decreased autonomy over practice decisions – but far and away the most cited contributor to dissatisfaction among members of the department was the EHR.
The reasons that EHRs have led to dissatisfaction seem to have changed over the last few years. Initially, physicians found it difficult to suddenly adapt practice styles developed over many years to the new world of electronic documentation. Suddenly they needed to type (or in the case of many, hunt and peck) notes into the history of present illness and fit patient histories into templates seemingly developed by engineers rather than physicians. Now, while most of us have adapted to the logistics of the EHR, there is no escaping the increasing demands for more and more information. There is also ongoing frustration with the lack of control in deciding whether information is relevant for the patient, as well as disparity between the promise and expectation of what electronic records should deliver and what we experience each day in front of us.
Given the degree to which EHRs are contributing to physician dissatisfaction and burnout, it is incumbent upon us to figure out ways to make the EHR work better for clinicians. The literature describes burnout as “a syndrome characterized by a loss of enthusiasm for work (emotional exhaustion), feelings of cynicism (depersonalization), and a low sense of personal accomplishment.” In a recent study, almost half of all physicians described at least one symptom of burnout. Interestingly, physician burnout is greatest in primary care specialties. Surprisingly, compared with other working adults in the United States, physicians are more likely to have symptoms of burnout (38% vs 28%) as well as express dissatisfaction with their work-life balance (40% vs. 23%).1 This issue is important because burnout – in addition to its negative effects on physicians’ experience and quality of life – can erode the quality of the care they give, increase the risk of medical errors, and lead to early ending of lifelong careers.2 The literature suggests that the high prevalence of burnout among U.S. physicians means that “the problem lies more with the system and environment in which physicians work rather than being due to innate vulnerabilities in a few susceptible individuals.” Not surprisingly, we have received letters from readers of our column over many years discussing how the entry of EHRs into their practice was a critical influence in their decisions to retire early.
In our discussion after the department meeting, several physicians described the need to do charting at night from home in order to have their work accomplished for the next day. This is not surprising to any of us who work in primary care and use EHRs. The ability to have access to the EHR anytime and from anywhere is a classic double-edged sword. It is certainly convenient to be able to complete our charting from home without having to stay late in the office on nights and weekends. Unfortunately, bringing work home also erodes into time that could otherwise be spent with family and pursuing other interests.
This is just one of many frustrations. Another common issue is superfluous documentation on the part of specialists. Often, the information is entered by physician extenders or using canned macros to “pad” the note. Sifting through paragraphs of this irrelevant – and sometimes inaccurate – information in consultant notes devalues the integrity of the interaction. It also minimizes the time that was actually spent in the office doing the real hard work of medicine instead of the rudimentary work of documenting things that were either never said or mentioned briefly in passing.
The week after our department meeting was the first week of work for our new interns. Rounding in one of our nursing homes, I handed the intern a patient’s chart and began to explain how the chart was organized – where the orders, progress notes, and labs were located in the chart. The intern had an odd smile on her face. I asked her what was wrong. She replied, “I didn’t know anyone still had paper charts; how do you enter a note there?”
So we come full circle. You can’t miss what you never had. Younger physicians do not resent the EHR, nor can they perceive the EHR to be contributing to discontent. That is not to say that it does not contribute; it is just difficult to identify problems when the way things are is what you have always known. The issue of EHRs contributing to physician burnout is real, and we need to learn more about its causes. Please email us with your thoughts about the aspects of EHRs that you find most frustrating or challenging. Our goal in hearing from you is that it is only by knowing the challenges that we face that we can begin to formulate solutions to overcome those challenges and together make tomorrow’s practice better than today’s.
References
1. Shanafelt TD et al. Burnout and satisfaction with work-life balance among U.S. physicians relative to the general U.S. population. Arch Intern Med. 2012;172(18):1377-85.
2. Shanafelt TD, Balch CM, Bechamps G et al. Burnout and medical errors among American surgeons. Ann Surg. 2010;251(6):995-1000.
Dr. Skolnik is associate director of the family medicine residency program at Abington (Pa.) Memorial Hospital and professor of family and community medicine at Temple University, Philadelphia. Dr. Notte is a family physician and clinical informaticist for Abington (Pa.) Memorial Hospital. He is also a partner in EHR Practice Consultants, a firm that aids physicians in adopting electronic health records.
Recently, a colleague of ours described the office electronic health record as “the vortex that sucks you in.” This statement occurred during a departmental meeting focused on physician burnout. When members of the department were asked about what things they felt contributed to a feeling of dissatisfaction with work, the electronic health record quickly emerged as a common denominator of dissatisfaction. There were certainly other contributors – the changing and challenging medical environment, fighting with insurance companies, decreased autonomy over practice decisions – but far and away the most cited contributor to dissatisfaction among members of the department was the EHR.
The reasons that EHRs have led to dissatisfaction seem to have changed over the last few years. Initially, physicians found it difficult to suddenly adapt practice styles developed over many years to the new world of electronic documentation. Suddenly they needed to type (or in the case of many, hunt and peck) notes into the history of present illness and fit patient histories into templates seemingly developed by engineers rather than physicians. Now, while most of us have adapted to the logistics of the EHR, there is no escaping the increasing demands for more and more information. There is also ongoing frustration with the lack of control in deciding whether information is relevant for the patient, as well as disparity between the promise and expectation of what electronic records should deliver and what we experience each day in front of us.
Given the degree to which EHRs are contributing to physician dissatisfaction and burnout, it is incumbent upon us to figure out ways to make the EHR work better for clinicians. The literature describes burnout as “a syndrome characterized by a loss of enthusiasm for work (emotional exhaustion), feelings of cynicism (depersonalization), and a low sense of personal accomplishment.” In a recent study, almost half of all physicians described at least one symptom of burnout. Interestingly, physician burnout is greatest in primary care specialties. Surprisingly, compared with other working adults in the United States, physicians are more likely to have symptoms of burnout (38% vs 28%) as well as express dissatisfaction with their work-life balance (40% vs. 23%).1 This issue is important because burnout – in addition to its negative effects on physicians’ experience and quality of life – can erode the quality of the care they give, increase the risk of medical errors, and lead to early ending of lifelong careers.2 The literature suggests that the high prevalence of burnout among U.S. physicians means that “the problem lies more with the system and environment in which physicians work rather than being due to innate vulnerabilities in a few susceptible individuals.” Not surprisingly, we have received letters from readers of our column over many years discussing how the entry of EHRs into their practice was a critical influence in their decisions to retire early.
In our discussion after the department meeting, several physicians described the need to do charting at night from home in order to have their work accomplished for the next day. This is not surprising to any of us who work in primary care and use EHRs. The ability to have access to the EHR anytime and from anywhere is a classic double-edged sword. It is certainly convenient to be able to complete our charting from home without having to stay late in the office on nights and weekends. Unfortunately, bringing work home also erodes into time that could otherwise be spent with family and pursuing other interests.
This is just one of many frustrations. Another common issue is superfluous documentation on the part of specialists. Often, the information is entered by physician extenders or using canned macros to “pad” the note. Sifting through paragraphs of this irrelevant – and sometimes inaccurate – information in consultant notes devalues the integrity of the interaction. It also minimizes the time that was actually spent in the office doing the real hard work of medicine instead of the rudimentary work of documenting things that were either never said or mentioned briefly in passing.
The week after our department meeting was the first week of work for our new interns. Rounding in one of our nursing homes, I handed the intern a patient’s chart and began to explain how the chart was organized – where the orders, progress notes, and labs were located in the chart. The intern had an odd smile on her face. I asked her what was wrong. She replied, “I didn’t know anyone still had paper charts; how do you enter a note there?”
So we come full circle. You can’t miss what you never had. Younger physicians do not resent the EHR, nor can they perceive the EHR to be contributing to discontent. That is not to say that it does not contribute; it is just difficult to identify problems when the way things are is what you have always known. The issue of EHRs contributing to physician burnout is real, and we need to learn more about its causes. Please email us with your thoughts about the aspects of EHRs that you find most frustrating or challenging. Our goal in hearing from you is that it is only by knowing the challenges that we face that we can begin to formulate solutions to overcome those challenges and together make tomorrow’s practice better than today’s.
References
1. Shanafelt TD et al. Burnout and satisfaction with work-life balance among U.S. physicians relative to the general U.S. population. Arch Intern Med. 2012;172(18):1377-85.
2. Shanafelt TD, Balch CM, Bechamps G et al. Burnout and medical errors among American surgeons. Ann Surg. 2010;251(6):995-1000.
Dr. Skolnik is associate director of the family medicine residency program at Abington (Pa.) Memorial Hospital and professor of family and community medicine at Temple University, Philadelphia. Dr. Notte is a family physician and clinical informaticist for Abington (Pa.) Memorial Hospital. He is also a partner in EHR Practice Consultants, a firm that aids physicians in adopting electronic health records.
