Two deals involving hospitalist management firms were announced in the past week, further consolidating the ranks of staffing companies in the specialty.

In the bigger deal, TeamHealth Holdings, Inc., last week agreed to acquire IPC Healthcare Inc. of North Hollywood, Calif., for $1.6 billion. The deal announcement highlighted IPC's stake in both hospital and post-acute care settings as a motivational factor for the acquisition.

"Combining emergency department staffing with hospitalist presence creates the opportunity to effectively manage patients from the emergency department through the inpatient discharge and beyond," the deal announcement notes. "This will allow TeamHealth to lower costs and increase quality, and, as a result, drive better patient experiences."

TeamHealth’s acquisition of IPC Healthcare is the latest deal to combine large hospital management groups, perpetuating a consolidation trend among companies seeking cost efficiencies.

Also last week, private equity firm Onex Corporation announced an agreement to acquire Hospital Physician Partners (HPP) of Hollywood, Fla., which bills itself as the fourth-largest provider of emergency and hospitalist clinical staffing services. Financial terms were not released.

Both deals are expected to close by year's end. They follow 2014's acquisition by Sound Physicians of Cogent Healthcare. The combined entity, which retained the Sound name, created the largest hospital management group in the country.

John Nelson, MD, MHM, a principal in Nelson Flores Hospital Medicine Consultants and regular practice management columnist for The Hospitalist, says consolidation is a double-edged sword.

"They may have the scale to come up with new valuable ways to organize care that can be adopted … by others," Dr. Nelson writes in an email to The Hospitalist. "But a marketplace that moves from multiple competing companies to a few very large ones faces the usual negatives of fewer competitors in the marketplace."

Dr. Nelson compares such deals to the airline industry, where consolidation has shrunk the playing field to a handful of major carriers. While larger HM firms may carry more weight in contract negotiations with institutions, individual practitioners need not worry that consolidation as a trend will negatively impact their daily rounds, he notes.

"Any efficiencies large companies have will likely have little effect on the work life of rank-and-file hospitalists, at least for foreseeable future," he adds. TH

Visit our website for more information on consolidation in hospital medicine.

Two deals involving hospitalist management firms were announced in the past week, further consolidating the ranks of staffing companies in the specialty.

In the bigger deal, TeamHealth Holdings, Inc., last week agreed to acquire IPC Healthcare Inc. of North Hollywood, Calif., for $1.6 billion. The deal announcement highlighted IPC's stake in both hospital and post-acute care settings as a motivational factor for the acquisition.

"Combining emergency department staffing with hospitalist presence creates the opportunity to effectively manage patients from the emergency department through the inpatient discharge and beyond," the deal announcement notes. "This will allow TeamHealth to lower costs and increase quality, and, as a result, drive better patient experiences."

TeamHealth’s acquisition of IPC Healthcare is the latest deal to combine large hospital management groups, perpetuating a consolidation trend among companies seeking cost efficiencies.

Also last week, private equity firm Onex Corporation announced an agreement to acquire Hospital Physician Partners (HPP) of Hollywood, Fla., which bills itself as the fourth-largest provider of emergency and hospitalist clinical staffing services. Financial terms were not released.

Both deals are expected to close by year's end. They follow 2014's acquisition by Sound Physicians of Cogent Healthcare. The combined entity, which retained the Sound name, created the largest hospital management group in the country.

John Nelson, MD, MHM, a principal in Nelson Flores Hospital Medicine Consultants and regular practice management columnist for The Hospitalist, says consolidation is a double-edged sword.

"They may have the scale to come up with new valuable ways to organize care that can be adopted … by others," Dr. Nelson writes in an email to The Hospitalist. "But a marketplace that moves from multiple competing companies to a few very large ones faces the usual negatives of fewer competitors in the marketplace."

Dr. Nelson compares such deals to the airline industry, where consolidation has shrunk the playing field to a handful of major carriers. While larger HM firms may carry more weight in contract negotiations with institutions, individual practitioners need not worry that consolidation as a trend will negatively impact their daily rounds, he notes.

"Any efficiencies large companies have will likely have little effect on the work life of rank-and-file hospitalists, at least for foreseeable future," he adds. TH

Visit our website for more information on consolidation in hospital medicine.

Two deals involving hospitalist management firms were announced in the past week, further consolidating the ranks of staffing companies in the specialty.

In the bigger deal, TeamHealth Holdings, Inc., last week agreed to acquire IPC Healthcare Inc. of North Hollywood, Calif., for $1.6 billion. The deal announcement highlighted IPC's stake in both hospital and post-acute care settings as a motivational factor for the acquisition.

"Combining emergency department staffing with hospitalist presence creates the opportunity to effectively manage patients from the emergency department through the inpatient discharge and beyond," the deal announcement notes. "This will allow TeamHealth to lower costs and increase quality, and, as a result, drive better patient experiences."

TeamHealth’s acquisition of IPC Healthcare is the latest deal to combine large hospital management groups, perpetuating a consolidation trend among companies seeking cost efficiencies.

Also last week, private equity firm Onex Corporation announced an agreement to acquire Hospital Physician Partners (HPP) of Hollywood, Fla., which bills itself as the fourth-largest provider of emergency and hospitalist clinical staffing services. Financial terms were not released.

Both deals are expected to close by year's end. They follow 2014's acquisition by Sound Physicians of Cogent Healthcare. The combined entity, which retained the Sound name, created the largest hospital management group in the country.

John Nelson, MD, MHM, a principal in Nelson Flores Hospital Medicine Consultants and regular practice management columnist for The Hospitalist, says consolidation is a double-edged sword.

"They may have the scale to come up with new valuable ways to organize care that can be adopted … by others," Dr. Nelson writes in an email to The Hospitalist. "But a marketplace that moves from multiple competing companies to a few very large ones faces the usual negatives of fewer competitors in the marketplace."

Dr. Nelson compares such deals to the airline industry, where consolidation has shrunk the playing field to a handful of major carriers. While larger HM firms may carry more weight in contract negotiations with institutions, individual practitioners need not worry that consolidation as a trend will negatively impact their daily rounds, he notes.

"Any efficiencies large companies have will likely have little effect on the work life of rank-and-file hospitalists, at least for foreseeable future," he adds. TH

Visit our website for more information on consolidation in hospital medicine.

NEW YORK (Reuters Health) - The American Board of Internal Medicine (ABIM) maintenance-of-certification (MOC) program could cost $5.7 billion in physicians' time and fees over the next decade, according to a new model study.

"We estimate that physicians will spend 33 million hours over 10 years to fulfill MOC requirements," Dr. Dhruv S. Kazi from the University of California, San Francisco, told Reuters Health by email.

"This is approximately equivalent to the total clinical work load of 1785 physicians over 10 years," Dr. Kazi said. "This demand on physician time comes during a period of expanding insurance coverage and anticipated physician workforce shortfalls; it may therefore adversely affect access to care, particularly elective care."

The ABIM's substantial expansion in 2014 of its MOC requirements for the more than 250,000 board-certified internists, hospitalists and internal medicine subspecialists ignited an intense debate about the societal value of the program, resulting in temporary suspension of some of the new requirements.

Dr. Kazi's team sought to quantify the costs of the 2015 version of the MOC program and compare them with the costs that would have been incurred had the 2013 version remained unchanged.

The new MOC requirements would cost board-certified internal medicine physicians an average of $23,607 over 10 years, including $2,349 in fees to the ABIM and $21,259 in time costs, the researchers report in Annals of Internal Medicine, online July 28.

Average costs would range from $16,725 for general internists to $40,495 for hematologists-oncologists.

The overall program would cost $5.7 billion ($561 million in fees to ABIM and $5.1 billion in time costs) over the next 10 years, an increase of $1.2 billion over the previous MOC program.

"The ABIM has previously suggested that participation in MOC will cost $200 to $400 per year," the researchers note. "This is a substantial underestimate precisely because it overlooks time costs."

"While we had anticipated that physician time would be an important driver of costs of the program, we were surprised to see that 9 out of every 10 dollars in MOC costs were related to the program's demands on physician time," Dr. Kazi said. "In fact, every additional hour spent by physicians on MOC increased the costs of the program by approximately 13 million dollars."

"The internal medicine community has embraced the principle of evidence-based medicine in clinical practice; expensive policy interventions such as MOC should be held to the same evidentiary standards," Dr. Kazi concluded.

"Instead of piecemeal evaluations, the entire MOC program should be compared head-to-head with other policy interventions or health systems interventions that improve healthcare quality, thus providing an empirical basis for choosing MOC over alternative strategies for quality improvement," Dr. Kazi said.

"We hope that the high costs of MOC catalyze future studies examining the impact of MOC on the quality and economics of care delivered by board-certified physicians in the United States," Dr. Kazi added.

Dr. Robert B. Baron from the American Board of Internal Medicine told Reuters Health by email, "Their analysis is less about time and cost of doing MOC than it is about the time physicians take staying up-to-date. They estimate that it is about an hour a month, and about 40 hours to prepare for the exam every decade. While the researchers attribute that time to MOC, I suspect most physicians would be spending this time staying abreast of the latest developments in their field, with or without MOC. What MOC offers them is a structured framework to keep up and a marker for the public that they are."

"Our MOC program already recognizes so much of what physicians are doing in practice to stay up to date," said Dr. Baron, also of the University of California, San Francisco. "We can and should do more in that area. We are getting a lot of feedback from physicians about how we can improve MOC, and this feedback will help us shape what we know will be an evolving program."

"In conversations we have already had with the community, one thing physicians have shared loud and clear is that they deeply value staying current in their field," he added. "They believe they should spend time staying abreast of the latest updates in their discipline. We are talking with the community to assure that MOC gives them a structured way to stay current, and we all agree it is an important marker for patients that they have done so."

"The researchers make some claims about overall costs to the health care system," Dr. Baron said. "If you accept their methodology, which is a stretch, other research that appeared in JAMA in December showed greater overall savings - 30 times as much as the costs reported here - just in Medicare costs for physicians who participated in MOC. So maybe all those hours spent keeping up are worth it, not just for the physicians and the patients we take care of but for our entire health care system."

NEW YORK (Reuters Health) - The American Board of Internal Medicine (ABIM) maintenance-of-certification (MOC) program could cost $5.7 billion in physicians' time and fees over the next decade, according to a new model study.

"We estimate that physicians will spend 33 million hours over 10 years to fulfill MOC requirements," Dr. Dhruv S. Kazi from the University of California, San Francisco, told Reuters Health by email.

"This is approximately equivalent to the total clinical work load of 1785 physicians over 10 years," Dr. Kazi said. "This demand on physician time comes during a period of expanding insurance coverage and anticipated physician workforce shortfalls; it may therefore adversely affect access to care, particularly elective care."

The ABIM's substantial expansion in 2014 of its MOC requirements for the more than 250,000 board-certified internists, hospitalists and internal medicine subspecialists ignited an intense debate about the societal value of the program, resulting in temporary suspension of some of the new requirements.

Dr. Kazi's team sought to quantify the costs of the 2015 version of the MOC program and compare them with the costs that would have been incurred had the 2013 version remained unchanged.

The new MOC requirements would cost board-certified internal medicine physicians an average of $23,607 over 10 years, including $2,349 in fees to the ABIM and $21,259 in time costs, the researchers report in Annals of Internal Medicine, online July 28.

Average costs would range from $16,725 for general internists to $40,495 for hematologists-oncologists.

The overall program would cost $5.7 billion ($561 million in fees to ABIM and $5.1 billion in time costs) over the next 10 years, an increase of $1.2 billion over the previous MOC program.

"The ABIM has previously suggested that participation in MOC will cost $200 to $400 per year," the researchers note. "This is a substantial underestimate precisely because it overlooks time costs."

"While we had anticipated that physician time would be an important driver of costs of the program, we were surprised to see that 9 out of every 10 dollars in MOC costs were related to the program's demands on physician time," Dr. Kazi said. "In fact, every additional hour spent by physicians on MOC increased the costs of the program by approximately 13 million dollars."

"The internal medicine community has embraced the principle of evidence-based medicine in clinical practice; expensive policy interventions such as MOC should be held to the same evidentiary standards," Dr. Kazi concluded.

"Instead of piecemeal evaluations, the entire MOC program should be compared head-to-head with other policy interventions or health systems interventions that improve healthcare quality, thus providing an empirical basis for choosing MOC over alternative strategies for quality improvement," Dr. Kazi said.

"We hope that the high costs of MOC catalyze future studies examining the impact of MOC on the quality and economics of care delivered by board-certified physicians in the United States," Dr. Kazi added.

Dr. Robert B. Baron from the American Board of Internal Medicine told Reuters Health by email, "Their analysis is less about time and cost of doing MOC than it is about the time physicians take staying up-to-date. They estimate that it is about an hour a month, and about 40 hours to prepare for the exam every decade. While the researchers attribute that time to MOC, I suspect most physicians would be spending this time staying abreast of the latest developments in their field, with or without MOC. What MOC offers them is a structured framework to keep up and a marker for the public that they are."

"Our MOC program already recognizes so much of what physicians are doing in practice to stay up to date," said Dr. Baron, also of the University of California, San Francisco. "We can and should do more in that area. We are getting a lot of feedback from physicians about how we can improve MOC, and this feedback will help us shape what we know will be an evolving program."

"In conversations we have already had with the community, one thing physicians have shared loud and clear is that they deeply value staying current in their field," he added. "They believe they should spend time staying abreast of the latest updates in their discipline. We are talking with the community to assure that MOC gives them a structured way to stay current, and we all agree it is an important marker for patients that they have done so."

"The researchers make some claims about overall costs to the health care system," Dr. Baron said. "If you accept their methodology, which is a stretch, other research that appeared in JAMA in December showed greater overall savings - 30 times as much as the costs reported here - just in Medicare costs for physicians who participated in MOC. So maybe all those hours spent keeping up are worth it, not just for the physicians and the patients we take care of but for our entire health care system."

NEW YORK (Reuters Health) - The American Board of Internal Medicine (ABIM) maintenance-of-certification (MOC) program could cost $5.7 billion in physicians' time and fees over the next decade, according to a new model study.

"We estimate that physicians will spend 33 million hours over 10 years to fulfill MOC requirements," Dr. Dhruv S. Kazi from the University of California, San Francisco, told Reuters Health by email.

"This is approximately equivalent to the total clinical work load of 1785 physicians over 10 years," Dr. Kazi said. "This demand on physician time comes during a period of expanding insurance coverage and anticipated physician workforce shortfalls; it may therefore adversely affect access to care, particularly elective care."

The ABIM's substantial expansion in 2014 of its MOC requirements for the more than 250,000 board-certified internists, hospitalists and internal medicine subspecialists ignited an intense debate about the societal value of the program, resulting in temporary suspension of some of the new requirements.

Dr. Kazi's team sought to quantify the costs of the 2015 version of the MOC program and compare them with the costs that would have been incurred had the 2013 version remained unchanged.

The new MOC requirements would cost board-certified internal medicine physicians an average of $23,607 over 10 years, including $2,349 in fees to the ABIM and $21,259 in time costs, the researchers report in Annals of Internal Medicine, online July 28.

Average costs would range from $16,725 for general internists to $40,495 for hematologists-oncologists.

The overall program would cost $5.7 billion ($561 million in fees to ABIM and $5.1 billion in time costs) over the next 10 years, an increase of $1.2 billion over the previous MOC program.

"The ABIM has previously suggested that participation in MOC will cost $200 to $400 per year," the researchers note. "This is a substantial underestimate precisely because it overlooks time costs."

"While we had anticipated that physician time would be an important driver of costs of the program, we were surprised to see that 9 out of every 10 dollars in MOC costs were related to the program's demands on physician time," Dr. Kazi said. "In fact, every additional hour spent by physicians on MOC increased the costs of the program by approximately 13 million dollars."

"The internal medicine community has embraced the principle of evidence-based medicine in clinical practice; expensive policy interventions such as MOC should be held to the same evidentiary standards," Dr. Kazi concluded.

"Instead of piecemeal evaluations, the entire MOC program should be compared head-to-head with other policy interventions or health systems interventions that improve healthcare quality, thus providing an empirical basis for choosing MOC over alternative strategies for quality improvement," Dr. Kazi said.

"We hope that the high costs of MOC catalyze future studies examining the impact of MOC on the quality and economics of care delivered by board-certified physicians in the United States," Dr. Kazi added.

Dr. Robert B. Baron from the American Board of Internal Medicine told Reuters Health by email, "Their analysis is less about time and cost of doing MOC than it is about the time physicians take staying up-to-date. They estimate that it is about an hour a month, and about 40 hours to prepare for the exam every decade. While the researchers attribute that time to MOC, I suspect most physicians would be spending this time staying abreast of the latest developments in their field, with or without MOC. What MOC offers them is a structured framework to keep up and a marker for the public that they are."

"Our MOC program already recognizes so much of what physicians are doing in practice to stay up to date," said Dr. Baron, also of the University of California, San Francisco. "We can and should do more in that area. We are getting a lot of feedback from physicians about how we can improve MOC, and this feedback will help us shape what we know will be an evolving program."

"In conversations we have already had with the community, one thing physicians have shared loud and clear is that they deeply value staying current in their field," he added. "They believe they should spend time staying abreast of the latest updates in their discipline. We are talking with the community to assure that MOC gives them a structured way to stay current, and we all agree it is an important marker for patients that they have done so."

"The researchers make some claims about overall costs to the health care system," Dr. Baron said. "If you accept their methodology, which is a stretch, other research that appeared in JAMA in December showed greater overall savings - 30 times as much as the costs reported here - just in Medicare costs for physicians who participated in MOC. So maybe all those hours spent keeping up are worth it, not just for the physicians and the patients we take care of but for our entire health care system."

(Reuters Health) - Most older adults who are hospitalized for acute myocardial infarction do not attend even one of the recommended cardiac rehabilitation sessions, according to a new study.

Cardiac rehab increases physical and cardiovascular fitness through structured exercise and education sessions, said lead author Dr. Jacob A. Doll, of Duke Clinical Research Institute in Durham, North Carolina.

Patients may attend individual or group sessions to improve medication adherence, help them quit smoking, lose weight, improve their diet and manage chronic diseases, while also focusing on psychological and social wellbeing, he said.

"Some people will be too sick after a heart attack to exercise safely, but this should be a fairly low percentage," Doll told Reuters Health by email. "Most other people can benefit, especially older adults."

Researchers used data on 58,269 patients 65 years or older who had acute MI between 2007 and 2010.

The researchers found that 36,376 patients, or 62%, were referred to cardiac rehab - but only 11,862 attended at least one rehab session over the year following hospital discharge.

Of those who had not been referred, 1,795 attended at least one session.

Half of those who went to the rehab program attended less than 26 sessions, though insurance usually covers 36 sessions - or two to three sessions per week, as reported August 3 in JAMA Internal Medicine.

Less than a quarter of the total group of MI patients attended at least one rehab session, and only 5% completed 36 sessions.

Younger white male nonsmokers with few other health problems were most likely to attend cardiac rehab.

"Not all (heart attack) patients are referred, some for valid reasons such as inability to exercise, difficulty in scheduling due to their job, lack of transportation, need to care for a sick spouse, etc," said Dr. Jerome L. Fleg of the National Heart, Lung and Blood Institute in Bethesda, Maryland.

Rehab sessions typically involve five to 10 minutes of warm-up, 30 to 40 minutes of walking, stationary cycling, or elliptical machine exercise, followed by five to 10 minutes of cool down, said Fleg, who was not part of the new study.

Hospitals should improve referral rates, and should encourage enrolled patients to actually complete the rehab programs, Doll said.

"Many people might feel that cardiac rehab is not for them, potentially because they feel they are not able to exercise or are too sick," he said.

Medicare recipients, like those in this study, generally have all costs covered for cardiac rehab, Fleg told Reuters Health by email.

Most other insurances cover cardiac rehab, but copayments may be cost-prohibitive for some people, and those living in rural areas may have to drive long distances to find a center, Doll said.

"Health systems and insurers should consider reducing copayments in order to improve access, since cardiac rehabilitation has been shown (to) improve survival and functioning after a heart attack," he said. "For people that cannot attend a traditional program, we may need new ways to deliver rehab services, such as home-based programs."

(Reuters Health) - Most older adults who are hospitalized for acute myocardial infarction do not attend even one of the recommended cardiac rehabilitation sessions, according to a new study.

Cardiac rehab increases physical and cardiovascular fitness through structured exercise and education sessions, said lead author Dr. Jacob A. Doll, of Duke Clinical Research Institute in Durham, North Carolina.

Patients may attend individual or group sessions to improve medication adherence, help them quit smoking, lose weight, improve their diet and manage chronic diseases, while also focusing on psychological and social wellbeing, he said.

"Some people will be too sick after a heart attack to exercise safely, but this should be a fairly low percentage," Doll told Reuters Health by email. "Most other people can benefit, especially older adults."

Researchers used data on 58,269 patients 65 years or older who had acute MI between 2007 and 2010.

The researchers found that 36,376 patients, or 62%, were referred to cardiac rehab - but only 11,862 attended at least one rehab session over the year following hospital discharge.

Of those who had not been referred, 1,795 attended at least one session.

Half of those who went to the rehab program attended less than 26 sessions, though insurance usually covers 36 sessions - or two to three sessions per week, as reported August 3 in JAMA Internal Medicine.

Less than a quarter of the total group of MI patients attended at least one rehab session, and only 5% completed 36 sessions.

Younger white male nonsmokers with few other health problems were most likely to attend cardiac rehab.

"Not all (heart attack) patients are referred, some for valid reasons such as inability to exercise, difficulty in scheduling due to their job, lack of transportation, need to care for a sick spouse, etc," said Dr. Jerome L. Fleg of the National Heart, Lung and Blood Institute in Bethesda, Maryland.

Rehab sessions typically involve five to 10 minutes of warm-up, 30 to 40 minutes of walking, stationary cycling, or elliptical machine exercise, followed by five to 10 minutes of cool down, said Fleg, who was not part of the new study.

Hospitals should improve referral rates, and should encourage enrolled patients to actually complete the rehab programs, Doll said.

"Many people might feel that cardiac rehab is not for them, potentially because they feel they are not able to exercise or are too sick," he said.

Medicare recipients, like those in this study, generally have all costs covered for cardiac rehab, Fleg told Reuters Health by email.

Most other insurances cover cardiac rehab, but copayments may be cost-prohibitive for some people, and those living in rural areas may have to drive long distances to find a center, Doll said.

"Health systems and insurers should consider reducing copayments in order to improve access, since cardiac rehabilitation has been shown (to) improve survival and functioning after a heart attack," he said. "For people that cannot attend a traditional program, we may need new ways to deliver rehab services, such as home-based programs."

(Reuters Health) - Most older adults who are hospitalized for acute myocardial infarction do not attend even one of the recommended cardiac rehabilitation sessions, according to a new study.

Cardiac rehab increases physical and cardiovascular fitness through structured exercise and education sessions, said lead author Dr. Jacob A. Doll, of Duke Clinical Research Institute in Durham, North Carolina.

Patients may attend individual or group sessions to improve medication adherence, help them quit smoking, lose weight, improve their diet and manage chronic diseases, while also focusing on psychological and social wellbeing, he said.

"Some people will be too sick after a heart attack to exercise safely, but this should be a fairly low percentage," Doll told Reuters Health by email. "Most other people can benefit, especially older adults."

Researchers used data on 58,269 patients 65 years or older who had acute MI between 2007 and 2010.

The researchers found that 36,376 patients, or 62%, were referred to cardiac rehab - but only 11,862 attended at least one rehab session over the year following hospital discharge.

Of those who had not been referred, 1,795 attended at least one session.

Half of those who went to the rehab program attended less than 26 sessions, though insurance usually covers 36 sessions - or two to three sessions per week, as reported August 3 in JAMA Internal Medicine.

Less than a quarter of the total group of MI patients attended at least one rehab session, and only 5% completed 36 sessions.

Younger white male nonsmokers with few other health problems were most likely to attend cardiac rehab.

"Not all (heart attack) patients are referred, some for valid reasons such as inability to exercise, difficulty in scheduling due to their job, lack of transportation, need to care for a sick spouse, etc," said Dr. Jerome L. Fleg of the National Heart, Lung and Blood Institute in Bethesda, Maryland.

Rehab sessions typically involve five to 10 minutes of warm-up, 30 to 40 minutes of walking, stationary cycling, or elliptical machine exercise, followed by five to 10 minutes of cool down, said Fleg, who was not part of the new study.

Hospitals should improve referral rates, and should encourage enrolled patients to actually complete the rehab programs, Doll said.

"Many people might feel that cardiac rehab is not for them, potentially because they feel they are not able to exercise or are too sick," he said.

Medicare recipients, like those in this study, generally have all costs covered for cardiac rehab, Fleg told Reuters Health by email.

Most other insurances cover cardiac rehab, but copayments may be cost-prohibitive for some people, and those living in rural areas may have to drive long distances to find a center, Doll said.

"Health systems and insurers should consider reducing copayments in order to improve access, since cardiac rehabilitation has been shown (to) improve survival and functioning after a heart attack," he said. "For people that cannot attend a traditional program, we may need new ways to deliver rehab services, such as home-based programs."

VANCOUVER – Achieving effective local anesthesia is the critical first step in successful nail surgery, Dr. Chris G. Adigun said at the World Congress of Dermatology.

“Always remember: Nail surgery hurts. Your patients will applaud you enthusiastically when they’re back home for your having used a long-acting anesthetic,” said Dr. Adigun, a dermatologist in group practice in Chapel Hill, N.C.

The three most widely used anesthetic agents in nail surgery are lidocaine (Xylocaine), bupivacaine (Marcaine), and ropivacaine (Naropin). Dr. Adigun said she strongly prefers ropivacaine. It combines the best features of the other two: lidocaine’s rapid onset along with a duration of action that’s even longer than bupivacaine’s, she noted. Ropivacaine’s duration of action is 8-12 hours – and it comes without bupivacaine’s potential for cardiotoxicity. Moreover, ropivacaine has a vasoconstrictive effect, which improves hemostasis and enhances visualization during the surgery.

She provided numerous additional tips on how to predictably achieve effective anesthesia for nail surgery:

• Buffer with sodium bicarbonate. The idea is to bring the anesthetic solution close to physiologic pH, which makes for a far less painful experience than injecting the acidic unbuffered solution.

• Warm it. Investigators have shown that warming anesthetic fluid reduces pain upon injection of both nonbuffered and buffered local anesthetics (Ann Emerg Med. 2011 Jul;58(1):86-98).

• Stick to a small-gauge needle. Dr. Adigan said she favors 30 gauge. It makes for a smaller, less painful puncture and limits the rate of flow of anesthetic fluid into the digital space.

• Inject in a perpendicular plane. This will disrupt fewer nerve endings than when going in at an angle.

“I think this is something that’s not frequently taught to residents in dermatology. I think we almost always go in at an angle, but if you go in at a perpendicular plane, you’re going to cause less pain,” according to Dr. Adigun.

• Inject just below the dermis. The dermis is nociceptor rich, and stretching those tissues by injecting a volume of fluid there will cause intense, continuous pain until the local anesthetic has time to take effect.

• Use distraction techniques liberally. Dr. Adigun said she likes to tell stories and jokes, which she calls “talkesthesia.” She also utilizes a battery-powered massager.

“Put the massager as close to your surgical field as you’re comfortable with. Under the gate theory of pain, you want to create as much sensory ‘noise’ as possible with your distraction techniques so that gate is filled with your sensory noise rather than pain,” the dermatologist explained.

There are three solid, time-tested completely acceptable techniques for getting the target digit numb: the wing block, the traditional digital block, and the transthecal digital block.

Dr. Adigun said she generally relies upon the wing block unless she is concerned that the associated blanching might cause her to lose her digital landmarks during surgery addressing a subtle abnormality. In that situation she turns mainly to the traditional digital block, which doesn’t interfere with digital landmarks and effectively anesthetizes both the paired digital and volar nerves.

The downside of the traditional digital block is it entails a 15- to 20-minute wait for the anesthetic to diffuse. So does the transthecal digital block, which has the additional shortcoming of achieving predictable results only when applied for surgery on the second, third, or fourth digits.

The wing block is an efficient infiltrative technique targeting the distal digit. It offers immediate anesthesia of the total nail unit. To achieve an excellent wing block, initially inject just 0.1-0.2 mL of anesthetic fluid subcutaneously into the proximal nail fold midway between the cuticle and the distal interphalangeal joint. Wait for a wheal to form; then wait an additional 45-60 seconds. At that point, inject obliquely along the lateral edge of the nail fold in the direction of the digital tip. The needle should be advanced while maintaining a gentle fluid bolus ahead of the needle tip in order to minimize the patient’s sensation of the moving needle. The process is then repeated on the opposite side of the digit.

“You want to keep that needle in the dermal plane and avoid filling the pulp with anesthetic fluid. If you do this correctly, only one prick is felt by the patient. I very rarely have to use a full cc of anesthetic fluid when I use a wing block,” Dr. Adigun said.

If any additional needle insertions are needed, make sure they’re placed into tissue that’s already been anesthetized, she added.

Dr. Adigun reported having no financial conflicts of interest.

[email protected]

VANCOUVER – Achieving effective local anesthesia is the critical first step in successful nail surgery, Dr. Chris G. Adigun said at the World Congress of Dermatology.

“Always remember: Nail surgery hurts. Your patients will applaud you enthusiastically when they’re back home for your having used a long-acting anesthetic,” said Dr. Adigun, a dermatologist in group practice in Chapel Hill, N.C.

The three most widely used anesthetic agents in nail surgery are lidocaine (Xylocaine), bupivacaine (Marcaine), and ropivacaine (Naropin). Dr. Adigun said she strongly prefers ropivacaine. It combines the best features of the other two: lidocaine’s rapid onset along with a duration of action that’s even longer than bupivacaine’s, she noted. Ropivacaine’s duration of action is 8-12 hours – and it comes without bupivacaine’s potential for cardiotoxicity. Moreover, ropivacaine has a vasoconstrictive effect, which improves hemostasis and enhances visualization during the surgery.

She provided numerous additional tips on how to predictably achieve effective anesthesia for nail surgery:

• Buffer with sodium bicarbonate. The idea is to bring the anesthetic solution close to physiologic pH, which makes for a far less painful experience than injecting the acidic unbuffered solution.

• Warm it. Investigators have shown that warming anesthetic fluid reduces pain upon injection of both nonbuffered and buffered local anesthetics (Ann Emerg Med. 2011 Jul;58(1):86-98).

• Stick to a small-gauge needle. Dr. Adigan said she favors 30 gauge. It makes for a smaller, less painful puncture and limits the rate of flow of anesthetic fluid into the digital space.

• Inject in a perpendicular plane. This will disrupt fewer nerve endings than when going in at an angle.

“I think this is something that’s not frequently taught to residents in dermatology. I think we almost always go in at an angle, but if you go in at a perpendicular plane, you’re going to cause less pain,” according to Dr. Adigun.

• Inject just below the dermis. The dermis is nociceptor rich, and stretching those tissues by injecting a volume of fluid there will cause intense, continuous pain until the local anesthetic has time to take effect.

• Use distraction techniques liberally. Dr. Adigun said she likes to tell stories and jokes, which she calls “talkesthesia.” She also utilizes a battery-powered massager.

“Put the massager as close to your surgical field as you’re comfortable with. Under the gate theory of pain, you want to create as much sensory ‘noise’ as possible with your distraction techniques so that gate is filled with your sensory noise rather than pain,” the dermatologist explained.

There are three solid, time-tested completely acceptable techniques for getting the target digit numb: the wing block, the traditional digital block, and the transthecal digital block.

Dr. Adigun said she generally relies upon the wing block unless she is concerned that the associated blanching might cause her to lose her digital landmarks during surgery addressing a subtle abnormality. In that situation she turns mainly to the traditional digital block, which doesn’t interfere with digital landmarks and effectively anesthetizes both the paired digital and volar nerves.

The downside of the traditional digital block is it entails a 15- to 20-minute wait for the anesthetic to diffuse. So does the transthecal digital block, which has the additional shortcoming of achieving predictable results only when applied for surgery on the second, third, or fourth digits.

The wing block is an efficient infiltrative technique targeting the distal digit. It offers immediate anesthesia of the total nail unit. To achieve an excellent wing block, initially inject just 0.1-0.2 mL of anesthetic fluid subcutaneously into the proximal nail fold midway between the cuticle and the distal interphalangeal joint. Wait for a wheal to form; then wait an additional 45-60 seconds. At that point, inject obliquely along the lateral edge of the nail fold in the direction of the digital tip. The needle should be advanced while maintaining a gentle fluid bolus ahead of the needle tip in order to minimize the patient’s sensation of the moving needle. The process is then repeated on the opposite side of the digit.

“You want to keep that needle in the dermal plane and avoid filling the pulp with anesthetic fluid. If you do this correctly, only one prick is felt by the patient. I very rarely have to use a full cc of anesthetic fluid when I use a wing block,” Dr. Adigun said.

If any additional needle insertions are needed, make sure they’re placed into tissue that’s already been anesthetized, she added.

Dr. Adigun reported having no financial conflicts of interest.

[email protected]

VANCOUVER – Achieving effective local anesthesia is the critical first step in successful nail surgery, Dr. Chris G. Adigun said at the World Congress of Dermatology.

“Always remember: Nail surgery hurts. Your patients will applaud you enthusiastically when they’re back home for your having used a long-acting anesthetic,” said Dr. Adigun, a dermatologist in group practice in Chapel Hill, N.C.

The three most widely used anesthetic agents in nail surgery are lidocaine (Xylocaine), bupivacaine (Marcaine), and ropivacaine (Naropin). Dr. Adigun said she strongly prefers ropivacaine. It combines the best features of the other two: lidocaine’s rapid onset along with a duration of action that’s even longer than bupivacaine’s, she noted. Ropivacaine’s duration of action is 8-12 hours – and it comes without bupivacaine’s potential for cardiotoxicity. Moreover, ropivacaine has a vasoconstrictive effect, which improves hemostasis and enhances visualization during the surgery.

She provided numerous additional tips on how to predictably achieve effective anesthesia for nail surgery:

• Buffer with sodium bicarbonate. The idea is to bring the anesthetic solution close to physiologic pH, which makes for a far less painful experience than injecting the acidic unbuffered solution.

• Warm it. Investigators have shown that warming anesthetic fluid reduces pain upon injection of both nonbuffered and buffered local anesthetics (Ann Emerg Med. 2011 Jul;58(1):86-98).

• Stick to a small-gauge needle. Dr. Adigan said she favors 30 gauge. It makes for a smaller, less painful puncture and limits the rate of flow of anesthetic fluid into the digital space.

• Inject in a perpendicular plane. This will disrupt fewer nerve endings than when going in at an angle.

“I think this is something that’s not frequently taught to residents in dermatology. I think we almost always go in at an angle, but if you go in at a perpendicular plane, you’re going to cause less pain,” according to Dr. Adigun.

• Inject just below the dermis. The dermis is nociceptor rich, and stretching those tissues by injecting a volume of fluid there will cause intense, continuous pain until the local anesthetic has time to take effect.

• Use distraction techniques liberally. Dr. Adigun said she likes to tell stories and jokes, which she calls “talkesthesia.” She also utilizes a battery-powered massager.

“Put the massager as close to your surgical field as you’re comfortable with. Under the gate theory of pain, you want to create as much sensory ‘noise’ as possible with your distraction techniques so that gate is filled with your sensory noise rather than pain,” the dermatologist explained.

There are three solid, time-tested completely acceptable techniques for getting the target digit numb: the wing block, the traditional digital block, and the transthecal digital block.

Dr. Adigun said she generally relies upon the wing block unless she is concerned that the associated blanching might cause her to lose her digital landmarks during surgery addressing a subtle abnormality. In that situation she turns mainly to the traditional digital block, which doesn’t interfere with digital landmarks and effectively anesthetizes both the paired digital and volar nerves.

The downside of the traditional digital block is it entails a 15- to 20-minute wait for the anesthetic to diffuse. So does the transthecal digital block, which has the additional shortcoming of achieving predictable results only when applied for surgery on the second, third, or fourth digits.

The wing block is an efficient infiltrative technique targeting the distal digit. It offers immediate anesthesia of the total nail unit. To achieve an excellent wing block, initially inject just 0.1-0.2 mL of anesthetic fluid subcutaneously into the proximal nail fold midway between the cuticle and the distal interphalangeal joint. Wait for a wheal to form; then wait an additional 45-60 seconds. At that point, inject obliquely along the lateral edge of the nail fold in the direction of the digital tip. The needle should be advanced while maintaining a gentle fluid bolus ahead of the needle tip in order to minimize the patient’s sensation of the moving needle. The process is then repeated on the opposite side of the digit.

“You want to keep that needle in the dermal plane and avoid filling the pulp with anesthetic fluid. If you do this correctly, only one prick is felt by the patient. I very rarely have to use a full cc of anesthetic fluid when I use a wing block,” Dr. Adigun said.

If any additional needle insertions are needed, make sure they’re placed into tissue that’s already been anesthetized, she added.

Dr. Adigun reported having no financial conflicts of interest.

[email protected]

For patients with chronic primary immune thrombocytopenia, a three-drug regimen was associated with a high response rate and relapse-free survival, according to the results of a single-arm, phase IIb trial published online in Blood.

Twenty patients with primary immune thrombocytopenia (ITP) received an investigative triple therapy of oral dexamethasone 40 mg (days 1-4), oral cyclosporine 2.5-3.0 mg/kg daily (days 1-28), and intravenous rituximab 100 mg (day 7, 14, 21, and 28), and of this group, 12 patients responded. The median time to response was 7.4 days, and all patients maintained their response for at least 7 months, Dr. Philip Young-Ill Choi, of St. George Clinical School, University of New South Wales, Kogarah, Australia, and his colleagues reported (Blood 2015;126[4]:500-3).

Complete response was 30% at 6 months, and only two patients relapsed during a median follow-up period of 17.5 months (range, 7-47 months). Among patients who responded, relapse-free survival at 12 and 24 months was 92% and 76%, respectively (95% confidence intervals, 53%-98% and 30%-93%, respectively).

Peripheral T cells declined for all patients, irrespective of response, but responders had lower CD4+ T cells than did nonresponders for 6 months after treatment (median, 0.62 vs. 0.91 x 10⁹/L; P less than .0001). Peripheral CD19+ B cells became undetectable for all patients by day 28, but recovery was earlier for patients younger than 50 years (median, 6.5 months vs. not reached; P = .0105).

The regimen was generally well tolerated, without any deaths, treatment-related serious adverse events, serum sickness, interruptions, or delays caused by toxicity.

A major advantage of this regimen is its short duration of therapy, and yet 12 of 20 patients enjoyed a prolonged remission of 7 months or longer without needing further treatment. However, interpretation of the data was limited by the small sample size, the investigators noted.

“Although our study shows encouraging results, the incremental benefit of cyclosporine to rituximab and dexamethasone remains unresolved, and randomized controlled trials are required,” they wrote.

No funding source for the study was given. One author reported receiving speaker’s fees from Roche, and another is on the speakers bureau and receives research funding from GlaxoSmithKline and Amgen. The remaining authors declared no competing financial interests.

For patients with chronic primary immune thrombocytopenia, a three-drug regimen was associated with a high response rate and relapse-free survival, according to the results of a single-arm, phase IIb trial published online in Blood.

Twenty patients with primary immune thrombocytopenia (ITP) received an investigative triple therapy of oral dexamethasone 40 mg (days 1-4), oral cyclosporine 2.5-3.0 mg/kg daily (days 1-28), and intravenous rituximab 100 mg (day 7, 14, 21, and 28), and of this group, 12 patients responded. The median time to response was 7.4 days, and all patients maintained their response for at least 7 months, Dr. Philip Young-Ill Choi, of St. George Clinical School, University of New South Wales, Kogarah, Australia, and his colleagues reported (Blood 2015;126[4]:500-3).

Complete response was 30% at 6 months, and only two patients relapsed during a median follow-up period of 17.5 months (range, 7-47 months). Among patients who responded, relapse-free survival at 12 and 24 months was 92% and 76%, respectively (95% confidence intervals, 53%-98% and 30%-93%, respectively).

Peripheral T cells declined for all patients, irrespective of response, but responders had lower CD4+ T cells than did nonresponders for 6 months after treatment (median, 0.62 vs. 0.91 x 10⁹/L; P less than .0001). Peripheral CD19+ B cells became undetectable for all patients by day 28, but recovery was earlier for patients younger than 50 years (median, 6.5 months vs. not reached; P = .0105).

The regimen was generally well tolerated, without any deaths, treatment-related serious adverse events, serum sickness, interruptions, or delays caused by toxicity.

A major advantage of this regimen is its short duration of therapy, and yet 12 of 20 patients enjoyed a prolonged remission of 7 months or longer without needing further treatment. However, interpretation of the data was limited by the small sample size, the investigators noted.

“Although our study shows encouraging results, the incremental benefit of cyclosporine to rituximab and dexamethasone remains unresolved, and randomized controlled trials are required,” they wrote.

No funding source for the study was given. One author reported receiving speaker’s fees from Roche, and another is on the speakers bureau and receives research funding from GlaxoSmithKline and Amgen. The remaining authors declared no competing financial interests.

For patients with chronic primary immune thrombocytopenia, a three-drug regimen was associated with a high response rate and relapse-free survival, according to the results of a single-arm, phase IIb trial published online in Blood.

Twenty patients with primary immune thrombocytopenia (ITP) received an investigative triple therapy of oral dexamethasone 40 mg (days 1-4), oral cyclosporine 2.5-3.0 mg/kg daily (days 1-28), and intravenous rituximab 100 mg (day 7, 14, 21, and 28), and of this group, 12 patients responded. The median time to response was 7.4 days, and all patients maintained their response for at least 7 months, Dr. Philip Young-Ill Choi, of St. George Clinical School, University of New South Wales, Kogarah, Australia, and his colleagues reported (Blood 2015;126[4]:500-3).

Complete response was 30% at 6 months, and only two patients relapsed during a median follow-up period of 17.5 months (range, 7-47 months). Among patients who responded, relapse-free survival at 12 and 24 months was 92% and 76%, respectively (95% confidence intervals, 53%-98% and 30%-93%, respectively).

Peripheral T cells declined for all patients, irrespective of response, but responders had lower CD4+ T cells than did nonresponders for 6 months after treatment (median, 0.62 vs. 0.91 x 10⁹/L; P less than .0001). Peripheral CD19+ B cells became undetectable for all patients by day 28, but recovery was earlier for patients younger than 50 years (median, 6.5 months vs. not reached; P = .0105).

The regimen was generally well tolerated, without any deaths, treatment-related serious adverse events, serum sickness, interruptions, or delays caused by toxicity.

A major advantage of this regimen is its short duration of therapy, and yet 12 of 20 patients enjoyed a prolonged remission of 7 months or longer without needing further treatment. However, interpretation of the data was limited by the small sample size, the investigators noted.

“Although our study shows encouraging results, the incremental benefit of cyclosporine to rituximab and dexamethasone remains unresolved, and randomized controlled trials are required,” they wrote.

No funding source for the study was given. One author reported receiving speaker’s fees from Roche, and another is on the speakers bureau and receives research funding from GlaxoSmithKline and Amgen. The remaining authors declared no competing financial interests.

As readers of this column know, the move to value-based payment for population health management can lead to a golden era for proactive primary care physicians. This conclusion is only strengthened by recent legislation mandating value incentives and penalties: the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), sometimes called the “SGR fix.”

This radical change, tellingly supported by both parties and both houses of Congress, would have been unthinkable just a few years ago. Under MACRA’s new Merit-Based Incentive Payment System (MIPS), you are looking at fee increases or reductions ranging from an upside of 4%-9% over time and an equal potential for reduction.

But, if you participate in a Medicare ACO or similar entity under the new alternative payment model, you get a 5% bump and are excluded from any MIPS and meaningful use requirements or penalties.

This merely adds to the growing list of incentives for primary care physician–led coordinated care. There is an extra compensation for wellness exams and chronic care management amounting to potentially more than $100,000 per primary care physician per year. Do not forget the $840 million the Centers for Medicare & Medicaid Services is designating to the Transforming Clinical Practice Initiative limited to training clinicians, and the $800 million for rural accountable care organizations (ACO) operations costs limited to physicians, critical access hospitals, and small hospitals.

Oh, by the way, all of the high-value opportunities for ACOs are in the primary care physician’s wheelhouse. Success stories of primary care–led ACOs are impressive.

A no-brainer, right? Well, apparently not for most primary care physicians. Why? This all will require change. It can be a very beneficial change of your status – measured by professional and financial reward – but it is big-time change.

As Mark Twain is quoted as saying, “I’m all for progress; it’s change I object to.”

You have not been in such a position of influence before, you don’t have teams of advisors like others in health care, and you don’t have the experience for this. You do not have spare intellectual bandwidth to deal with this and everything else. You are accustomed to things being run by the big health systems and managed care companies.

It is human nature to deal with stress with the survivalist instincts of fight, flight, or freeze. You may be feeling an almost irresistible urge to hunker down and do nothing. It’s natural. It is your “default future.”

But being unprepared is not an option. This shift is coming inexorably and rapidly. You can either stay sitting on the tracks or drive the train. It’s up to you.

Your default future is one controlled by others. It is one of the missed opportunity of a lifetime for primary care. The government is paying you for training, ACO start-up and operations, and incentivizing your leadership through both coding- and value-based financial inducements.

The bottom line is that America is asking you to run the new health care system and wants to pay you to do it, on top of your fee-for-service payments.

Think of the impact on your patients. Isn’t this why you went to medical school? Failure to do anything means you actually have made a bigger choice for your default future – guaranteeing even greater change being imposed on you by others. Control your agenda; do not wait to become part of someone else’s.

In closing, a recent email comment by one of your fellow readers sums it up best: “The default future (or the ostrich option) is a destiny of marginalization and consumption by the beast, an outcome not in our patients’ best interest.”

Mr. Bobbitt is a senior partner and head of the health law group at the Smith Anderson law firm in Raleigh, N.C. He has many years’ experience assisting physicians form integrated delivery systems. He has spoken and written nationally to primary care physicians on the strategies and practicalities of forming or joining ACOs. This article is meant to be educational and does not constitute legal advice. For additional information, readers may contact the author at [email protected] or 919-821-6612.

As readers of this column know, the move to value-based payment for population health management can lead to a golden era for proactive primary care physicians. This conclusion is only strengthened by recent legislation mandating value incentives and penalties: the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), sometimes called the “SGR fix.”

This radical change, tellingly supported by both parties and both houses of Congress, would have been unthinkable just a few years ago. Under MACRA’s new Merit-Based Incentive Payment System (MIPS), you are looking at fee increases or reductions ranging from an upside of 4%-9% over time and an equal potential for reduction.

But, if you participate in a Medicare ACO or similar entity under the new alternative payment model, you get a 5% bump and are excluded from any MIPS and meaningful use requirements or penalties.

This merely adds to the growing list of incentives for primary care physician–led coordinated care. There is an extra compensation for wellness exams and chronic care management amounting to potentially more than $100,000 per primary care physician per year. Do not forget the $840 million the Centers for Medicare & Medicaid Services is designating to the Transforming Clinical Practice Initiative limited to training clinicians, and the $800 million for rural accountable care organizations (ACO) operations costs limited to physicians, critical access hospitals, and small hospitals.

Oh, by the way, all of the high-value opportunities for ACOs are in the primary care physician’s wheelhouse. Success stories of primary care–led ACOs are impressive.

A no-brainer, right? Well, apparently not for most primary care physicians. Why? This all will require change. It can be a very beneficial change of your status – measured by professional and financial reward – but it is big-time change.

As Mark Twain is quoted as saying, “I’m all for progress; it’s change I object to.”

You have not been in such a position of influence before, you don’t have teams of advisors like others in health care, and you don’t have the experience for this. You do not have spare intellectual bandwidth to deal with this and everything else. You are accustomed to things being run by the big health systems and managed care companies.

It is human nature to deal with stress with the survivalist instincts of fight, flight, or freeze. You may be feeling an almost irresistible urge to hunker down and do nothing. It’s natural. It is your “default future.”

But being unprepared is not an option. This shift is coming inexorably and rapidly. You can either stay sitting on the tracks or drive the train. It’s up to you.

Your default future is one controlled by others. It is one of the missed opportunity of a lifetime for primary care. The government is paying you for training, ACO start-up and operations, and incentivizing your leadership through both coding- and value-based financial inducements.

The bottom line is that America is asking you to run the new health care system and wants to pay you to do it, on top of your fee-for-service payments.

Think of the impact on your patients. Isn’t this why you went to medical school? Failure to do anything means you actually have made a bigger choice for your default future – guaranteeing even greater change being imposed on you by others. Control your agenda; do not wait to become part of someone else’s.

In closing, a recent email comment by one of your fellow readers sums it up best: “The default future (or the ostrich option) is a destiny of marginalization and consumption by the beast, an outcome not in our patients’ best interest.”

Mr. Bobbitt is a senior partner and head of the health law group at the Smith Anderson law firm in Raleigh, N.C. He has many years’ experience assisting physicians form integrated delivery systems. He has spoken and written nationally to primary care physicians on the strategies and practicalities of forming or joining ACOs. This article is meant to be educational and does not constitute legal advice. For additional information, readers may contact the author at [email protected] or 919-821-6612.

As readers of this column know, the move to value-based payment for population health management can lead to a golden era for proactive primary care physicians. This conclusion is only strengthened by recent legislation mandating value incentives and penalties: the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), sometimes called the “SGR fix.”

This radical change, tellingly supported by both parties and both houses of Congress, would have been unthinkable just a few years ago. Under MACRA’s new Merit-Based Incentive Payment System (MIPS), you are looking at fee increases or reductions ranging from an upside of 4%-9% over time and an equal potential for reduction.

But, if you participate in a Medicare ACO or similar entity under the new alternative payment model, you get a 5% bump and are excluded from any MIPS and meaningful use requirements or penalties.

This merely adds to the growing list of incentives for primary care physician–led coordinated care. There is an extra compensation for wellness exams and chronic care management amounting to potentially more than $100,000 per primary care physician per year. Do not forget the $840 million the Centers for Medicare & Medicaid Services is designating to the Transforming Clinical Practice Initiative limited to training clinicians, and the $800 million for rural accountable care organizations (ACO) operations costs limited to physicians, critical access hospitals, and small hospitals.

Oh, by the way, all of the high-value opportunities for ACOs are in the primary care physician’s wheelhouse. Success stories of primary care–led ACOs are impressive.

A no-brainer, right? Well, apparently not for most primary care physicians. Why? This all will require change. It can be a very beneficial change of your status – measured by professional and financial reward – but it is big-time change.

As Mark Twain is quoted as saying, “I’m all for progress; it’s change I object to.”

You have not been in such a position of influence before, you don’t have teams of advisors like others in health care, and you don’t have the experience for this. You do not have spare intellectual bandwidth to deal with this and everything else. You are accustomed to things being run by the big health systems and managed care companies.

It is human nature to deal with stress with the survivalist instincts of fight, flight, or freeze. You may be feeling an almost irresistible urge to hunker down and do nothing. It’s natural. It is your “default future.”

But being unprepared is not an option. This shift is coming inexorably and rapidly. You can either stay sitting on the tracks or drive the train. It’s up to you.

Your default future is one controlled by others. It is one of the missed opportunity of a lifetime for primary care. The government is paying you for training, ACO start-up and operations, and incentivizing your leadership through both coding- and value-based financial inducements.

The bottom line is that America is asking you to run the new health care system and wants to pay you to do it, on top of your fee-for-service payments.

Think of the impact on your patients. Isn’t this why you went to medical school? Failure to do anything means you actually have made a bigger choice for your default future – guaranteeing even greater change being imposed on you by others. Control your agenda; do not wait to become part of someone else’s.

In closing, a recent email comment by one of your fellow readers sums it up best: “The default future (or the ostrich option) is a destiny of marginalization and consumption by the beast, an outcome not in our patients’ best interest.”

Mr. Bobbitt is a senior partner and head of the health law group at the Smith Anderson law firm in Raleigh, N.C. He has many years’ experience assisting physicians form integrated delivery systems. He has spoken and written nationally to primary care physicians on the strategies and practicalities of forming or joining ACOs. This article is meant to be educational and does not constitute legal advice. For additional information, readers may contact the author at [email protected] or 919-821-6612.

At one time or another, insomnia afflicts nearly one-half of U.S. adults, half of whom have a clinically diagnosable disorder. This presents perpetual challenges in the face of patient populations that have been told to “ask your doctor about” sleeping medications or have received them already.

We know that the Z-drugs (zolpidem, zaleplon, and eszopiclone), some of the most widely used pharmacologics for insomnia, are benzodiazepine receptor agonists. As such, tolerance develops, and this tolerance leads to escalating doses, increased side effects, and sleepier patients.

Cognitive-behavioral therapy has been shown to be effective for insomnia, but this clinical service is not widely available. For busy clinicians trying to help these patients, we need a simple tool that can be easily explained to patients, giving them a project on which to work.

This tool is sleep restriction. The goal of sleep restriction is to consolidate fragmented sleep to increase the intrinsic sleep drive.

You might have heard your patients describe their bedroom as a “torture chamber.” Some of this torture relates to sleepless staring at the ceiling for hours on end. Sleep restriction gets them out of the chamber.

Karen Falloon, Ph.D., of the University of Auckland (New Zealand), and her colleagues conducted a randomized trial in New Zealand investigating the impact of simplified sleep restriction (SSR) for patients with primary insomnia (Br J Gen Pract. 2015 Aug;65(637):e508-15).

A total of 97 patients were randomized. All patients received sleep hygiene advice, including avoiding caffeine and developing a consistent bedtime routine. Patients in the SSR arm received a verbal and written sleep prescription establishing bedtime and wake-up times informed by a baseline 2-week daily sleep diary.

The sleep prescription was average total sleep duration plus 50% of the total time spent awake in bed. The minimum time in bed was 5 hours. If participants were sleeping less than 85% of the time in bed, the time allowed in bed was reduced to total sleep time plus 30 minutes. Sleepy patients could spend 30 more minutes in bed. All changes were made at bedtime, with wake-up time held constant.

At 6 months, the SSR group had improved perceived sleep quality and fatigue, and improved sleep efficiency as measured by actigraphy. A total of 67% of patients responded to SSR, compared with 41% of controls (number needed to treat = 4).

The efficacy of this intervention is extremely impressive. Importantly, it was delivered by a general practitioner without specialized training during two “slightly extended” visits.

Potential participants were excluded if they were on a sleeping medication, which does not imply that this would not work in a population already on Z-drugs. Consideration should to be given to possible risks when implementing sleep restriction with patients taking Z-drugs with longer half-lives (for example, eszopiclone is 6 hours, zolpidem is 3 hours, and zaleplon is 1 hour), because of higher serum concentrations upon waking.

But when these medications fail, or you have Z-drug–naive patients with insomnia, have this intervention ready.

Dr. Ebbert is professor of medicine, a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author and do not necessarily represent the views and opinions of the Mayo Clinic. The opinions expressed in this article should not be used to diagnose or treat any medical condition, nor should they be used as a substitute for medical advice from a qualified, board-certified practicing clinician. Dr. Ebbert has no relevant financial disclosures about this article. Follow him on Twitter @jonebbert.

At one time or another, insomnia afflicts nearly one-half of U.S. adults, half of whom have a clinically diagnosable disorder. This presents perpetual challenges in the face of patient populations that have been told to “ask your doctor about” sleeping medications or have received them already.

We know that the Z-drugs (zolpidem, zaleplon, and eszopiclone), some of the most widely used pharmacologics for insomnia, are benzodiazepine receptor agonists. As such, tolerance develops, and this tolerance leads to escalating doses, increased side effects, and sleepier patients.

Cognitive-behavioral therapy has been shown to be effective for insomnia, but this clinical service is not widely available. For busy clinicians trying to help these patients, we need a simple tool that can be easily explained to patients, giving them a project on which to work.

This tool is sleep restriction. The goal of sleep restriction is to consolidate fragmented sleep to increase the intrinsic sleep drive.

You might have heard your patients describe their bedroom as a “torture chamber.” Some of this torture relates to sleepless staring at the ceiling for hours on end. Sleep restriction gets them out of the chamber.

Karen Falloon, Ph.D., of the University of Auckland (New Zealand), and her colleagues conducted a randomized trial in New Zealand investigating the impact of simplified sleep restriction (SSR) for patients with primary insomnia (Br J Gen Pract. 2015 Aug;65(637):e508-15).

A total of 97 patients were randomized. All patients received sleep hygiene advice, including avoiding caffeine and developing a consistent bedtime routine. Patients in the SSR arm received a verbal and written sleep prescription establishing bedtime and wake-up times informed by a baseline 2-week daily sleep diary.

The sleep prescription was average total sleep duration plus 50% of the total time spent awake in bed. The minimum time in bed was 5 hours. If participants were sleeping less than 85% of the time in bed, the time allowed in bed was reduced to total sleep time plus 30 minutes. Sleepy patients could spend 30 more minutes in bed. All changes were made at bedtime, with wake-up time held constant.

At 6 months, the SSR group had improved perceived sleep quality and fatigue, and improved sleep efficiency as measured by actigraphy. A total of 67% of patients responded to SSR, compared with 41% of controls (number needed to treat = 4).

The efficacy of this intervention is extremely impressive. Importantly, it was delivered by a general practitioner without specialized training during two “slightly extended” visits.

Potential participants were excluded if they were on a sleeping medication, which does not imply that this would not work in a population already on Z-drugs. Consideration should to be given to possible risks when implementing sleep restriction with patients taking Z-drugs with longer half-lives (for example, eszopiclone is 6 hours, zolpidem is 3 hours, and zaleplon is 1 hour), because of higher serum concentrations upon waking.

But when these medications fail, or you have Z-drug–naive patients with insomnia, have this intervention ready.

Dr. Ebbert is professor of medicine, a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author and do not necessarily represent the views and opinions of the Mayo Clinic. The opinions expressed in this article should not be used to diagnose or treat any medical condition, nor should they be used as a substitute for medical advice from a qualified, board-certified practicing clinician. Dr. Ebbert has no relevant financial disclosures about this article. Follow him on Twitter @jonebbert.

At one time or another, insomnia afflicts nearly one-half of U.S. adults, half of whom have a clinically diagnosable disorder. This presents perpetual challenges in the face of patient populations that have been told to “ask your doctor about” sleeping medications or have received them already.

We know that the Z-drugs (zolpidem, zaleplon, and eszopiclone), some of the most widely used pharmacologics for insomnia, are benzodiazepine receptor agonists. As such, tolerance develops, and this tolerance leads to escalating doses, increased side effects, and sleepier patients.

Cognitive-behavioral therapy has been shown to be effective for insomnia, but this clinical service is not widely available. For busy clinicians trying to help these patients, we need a simple tool that can be easily explained to patients, giving them a project on which to work.

This tool is sleep restriction. The goal of sleep restriction is to consolidate fragmented sleep to increase the intrinsic sleep drive.

You might have heard your patients describe their bedroom as a “torture chamber.” Some of this torture relates to sleepless staring at the ceiling for hours on end. Sleep restriction gets them out of the chamber.

Karen Falloon, Ph.D., of the University of Auckland (New Zealand), and her colleagues conducted a randomized trial in New Zealand investigating the impact of simplified sleep restriction (SSR) for patients with primary insomnia (Br J Gen Pract. 2015 Aug;65(637):e508-15).

A total of 97 patients were randomized. All patients received sleep hygiene advice, including avoiding caffeine and developing a consistent bedtime routine. Patients in the SSR arm received a verbal and written sleep prescription establishing bedtime and wake-up times informed by a baseline 2-week daily sleep diary.

The sleep prescription was average total sleep duration plus 50% of the total time spent awake in bed. The minimum time in bed was 5 hours. If participants were sleeping less than 85% of the time in bed, the time allowed in bed was reduced to total sleep time plus 30 minutes. Sleepy patients could spend 30 more minutes in bed. All changes were made at bedtime, with wake-up time held constant.

At 6 months, the SSR group had improved perceived sleep quality and fatigue, and improved sleep efficiency as measured by actigraphy. A total of 67% of patients responded to SSR, compared with 41% of controls (number needed to treat = 4).

The efficacy of this intervention is extremely impressive. Importantly, it was delivered by a general practitioner without specialized training during two “slightly extended” visits.

Potential participants were excluded if they were on a sleeping medication, which does not imply that this would not work in a population already on Z-drugs. Consideration should to be given to possible risks when implementing sleep restriction with patients taking Z-drugs with longer half-lives (for example, eszopiclone is 6 hours, zolpidem is 3 hours, and zaleplon is 1 hour), because of higher serum concentrations upon waking.

But when these medications fail, or you have Z-drug–naive patients with insomnia, have this intervention ready.

Dr. Ebbert is professor of medicine, a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author and do not necessarily represent the views and opinions of the Mayo Clinic. The opinions expressed in this article should not be used to diagnose or treat any medical condition, nor should they be used as a substitute for medical advice from a qualified, board-certified practicing clinician. Dr. Ebbert has no relevant financial disclosures about this article. Follow him on Twitter @jonebbert.

Interim results of the ASPIRE trial suggest extended treatment or prophylaxis with a recombinant factor VIII Fc fusion protein (rFVIIIFc/efmoroctocog alfa, Eloctate/Elocta) can be safe and effective for hemophilia A patients of all ages.

Patients could enroll in the phase 3 ASPIRE trial after completing the A-LONG and Kids A-LONG studies.

At the time of the interim analysis, most patients had at least 100 days of cumulative exposure to rFVIIIFc.

None of the patients developed inhibitors, and the investigators said adverse events (AEs) were generally consistent with those expected in the general hemophilia A population.

Furthermore, the median annualized bleeding rates (ABRs) were low among patients receiving prophylaxis, and most patients had no change in prophylactic infusion frequency or total weekly prophylactic dose.

These results appear in Haemophilia. The trial is sponsored by Biogen, the company developing rFVIIIFc.

Trial design

ASPIRE has enrolled 211 males with hemophilia A, including 150 (98%) of those who completed A-LONG and 61 (91%) of those who completed Kids A-LONG.

ASPIRE has an on-demand treatment group and 3 prophylactic treatment groups: individualized, weekly, and modified prophylaxis. In the on-demand group, dosing is based on the type and severity of bleeding episodes.

Subjects in the individualized prophylaxis group receive rFVIIIFc at 25-65 IU kg⁻¹ every 3 to 5 days or twice-weekly rFVIIIFc at 20–65 IU kg⁻¹ on day 1 and 40–65 IU kg⁻¹ on day 4. In subjects younger than 12, the investigators can make dose adjustments.

The weekly prophylaxis group receives rFVIIIFc at 65 IU kg⁻¹ every 7 days. Patients who cannot receive optimal treatment in either the individualized or weekly prophylaxis groups can be placed in the modified prophylaxis group.

Patients can change their treatment group at any time during the study. However, subjects younger than 12 can only participate in the individualized and modified prophylaxis groups.

“The design of the ASPIRE study provides physicians a high degree of dosing flexibility, with the goal of reflecting their real-world treatment practices,” said Guy Young, MD, of Children’s Hospital of Los Angeles in California.

Treatment

As of the interim analysis, the median time in the ASPIRE study was 80.9 weeks for adults and adolescents completing the A-LONG study and 23.9 weeks for children completing the Kids A-LONG study. The median cumulative duration of treatment was 117.7 weeks for adults and adolescents and 51.5 weeks for children.

Nearly all Kids A-LONG subjects (96.7%) continued on individualized prophylaxis. Two subjects switched to the modified prophylaxis group upon enrollment in ASPIRE, but none of the subjects changed their treatment group during ASPIRE.

Of the A-LONG subjects, 16.7% changed treatment groups at enrollment in ASPIRE, and 11.3% made a change to their treatment group during ASPIRE. None of the subjects changed treatment groups more than once.

Most patients who were previously on a prophylactic regimen in A-LONG had either no change to their infusion interval (71.9%) or had a longer infusion interval (21.9%) during ASPIRE. Most patients on Kids A-LONG (95.1%) had no change to their prophylactic infusion interval on ASPIRE.

Safety

Overall, 65.4% of subjects had at least 1 AE, and 10.9% had at least 1 serious AE. All of the serious AEs were considered unrelated to rFVIIIFc, and all had resolved by the time of the interim data cut. There were no serious allergic reactions, serious vascular thrombotic events, or deaths.

The most common AEs (incidence of 5% or greater) were nasopharyngitis (12.8%), upper respiratory infection (7.6%), and arthralgia (5.2%). Three adults (1.4%) experienced 4 mild AEs that were thought to be related to rFVIIIFc—chromaturia, elevated blood creatinine, and headache/hot flashes.

Efficacy

For adults and adolescents, the overall ABR was 0.66 in the individualized prophylaxis arm, 2.03 in the weekly prophylaxis arm, 1.97 in the modified prophylaxis arm, and 18.36 in the on-demand treatment arm.

For children in the individualized prophylaxis arm, the overall ABR was 0.00 in children younger than 6 and 1.56 in those ages 6 to 11. For children in the modified prophylaxis arm, the overall ABR was 6.55 in those younger than 6 and 0.00 for children 6 to 11.

A total of 566 bleeding episodes occurred in adults and adolescents who were treated prophylactically. Patients in the on-demand treatment arm experienced 262 bleeding episodes.

Overall, 90.8% of these bleeding episodes were controlled with a single infusion of rFVIIIFc, and 96.9% of the episodes were controlled with 1 or 2 infusions.

Children had a total of 51 bleeding episodes—23 among children younger than 6 and 28 among children 6 to 11.

Most of these episodes were controlled with a single infusion of rFVIIIFc—82.6% among children younger than 6 and 82.1% among children 6 to 11. And 95.7% and 89.3%, respectively, were controlled with 1 to 2 infusions.

“The results suggest prophylaxis with Eloctate shows efficacy and safety for the long-term treatment of hemophilia A,” Dr Young concluded.

Interim results of the ASPIRE trial suggest extended treatment or prophylaxis with a recombinant factor VIII Fc fusion protein (rFVIIIFc/efmoroctocog alfa, Eloctate/Elocta) can be safe and effective for hemophilia A patients of all ages.

Patients could enroll in the phase 3 ASPIRE trial after completing the A-LONG and Kids A-LONG studies.

At the time of the interim analysis, most patients had at least 100 days of cumulative exposure to rFVIIIFc.

None of the patients developed inhibitors, and the investigators said adverse events (AEs) were generally consistent with those expected in the general hemophilia A population.

Furthermore, the median annualized bleeding rates (ABRs) were low among patients receiving prophylaxis, and most patients had no change in prophylactic infusion frequency or total weekly prophylactic dose.

These results appear in Haemophilia. The trial is sponsored by Biogen, the company developing rFVIIIFc.

Trial design

ASPIRE has enrolled 211 males with hemophilia A, including 150 (98%) of those who completed A-LONG and 61 (91%) of those who completed Kids A-LONG.

ASPIRE has an on-demand treatment group and 3 prophylactic treatment groups: individualized, weekly, and modified prophylaxis. In the on-demand group, dosing is based on the type and severity of bleeding episodes.

Subjects in the individualized prophylaxis group receive rFVIIIFc at 25-65 IU kg⁻¹ every 3 to 5 days or twice-weekly rFVIIIFc at 20–65 IU kg⁻¹ on day 1 and 40–65 IU kg⁻¹ on day 4. In subjects younger than 12, the investigators can make dose adjustments.

The weekly prophylaxis group receives rFVIIIFc at 65 IU kg⁻¹ every 7 days. Patients who cannot receive optimal treatment in either the individualized or weekly prophylaxis groups can be placed in the modified prophylaxis group.

Patients can change their treatment group at any time during the study. However, subjects younger than 12 can only participate in the individualized and modified prophylaxis groups.

“The design of the ASPIRE study provides physicians a high degree of dosing flexibility, with the goal of reflecting their real-world treatment practices,” said Guy Young, MD, of Children’s Hospital of Los Angeles in California.

Treatment

As of the interim analysis, the median time in the ASPIRE study was 80.9 weeks for adults and adolescents completing the A-LONG study and 23.9 weeks for children completing the Kids A-LONG study. The median cumulative duration of treatment was 117.7 weeks for adults and adolescents and 51.5 weeks for children.

Nearly all Kids A-LONG subjects (96.7%) continued on individualized prophylaxis. Two subjects switched to the modified prophylaxis group upon enrollment in ASPIRE, but none of the subjects changed their treatment group during ASPIRE.

Of the A-LONG subjects, 16.7% changed treatment groups at enrollment in ASPIRE, and 11.3% made a change to their treatment group during ASPIRE. None of the subjects changed treatment groups more than once.

Most patients who were previously on a prophylactic regimen in A-LONG had either no change to their infusion interval (71.9%) or had a longer infusion interval (21.9%) during ASPIRE. Most patients on Kids A-LONG (95.1%) had no change to their prophylactic infusion interval on ASPIRE.

Safety

Overall, 65.4% of subjects had at least 1 AE, and 10.9% had at least 1 serious AE. All of the serious AEs were considered unrelated to rFVIIIFc, and all had resolved by the time of the interim data cut. There were no serious allergic reactions, serious vascular thrombotic events, or deaths.

The most common AEs (incidence of 5% or greater) were nasopharyngitis (12.8%), upper respiratory infection (7.6%), and arthralgia (5.2%). Three adults (1.4%) experienced 4 mild AEs that were thought to be related to rFVIIIFc—chromaturia, elevated blood creatinine, and headache/hot flashes.

Efficacy

For adults and adolescents, the overall ABR was 0.66 in the individualized prophylaxis arm, 2.03 in the weekly prophylaxis arm, 1.97 in the modified prophylaxis arm, and 18.36 in the on-demand treatment arm.

For children in the individualized prophylaxis arm, the overall ABR was 0.00 in children younger than 6 and 1.56 in those ages 6 to 11. For children in the modified prophylaxis arm, the overall ABR was 6.55 in those younger than 6 and 0.00 for children 6 to 11.

A total of 566 bleeding episodes occurred in adults and adolescents who were treated prophylactically. Patients in the on-demand treatment arm experienced 262 bleeding episodes.

Overall, 90.8% of these bleeding episodes were controlled with a single infusion of rFVIIIFc, and 96.9% of the episodes were controlled with 1 or 2 infusions.

Children had a total of 51 bleeding episodes—23 among children younger than 6 and 28 among children 6 to 11.

Most of these episodes were controlled with a single infusion of rFVIIIFc—82.6% among children younger than 6 and 82.1% among children 6 to 11. And 95.7% and 89.3%, respectively, were controlled with 1 to 2 infusions.

“The results suggest prophylaxis with Eloctate shows efficacy and safety for the long-term treatment of hemophilia A,” Dr Young concluded.

Interim results of the ASPIRE trial suggest extended treatment or prophylaxis with a recombinant factor VIII Fc fusion protein (rFVIIIFc/efmoroctocog alfa, Eloctate/Elocta) can be safe and effective for hemophilia A patients of all ages.

Patients could enroll in the phase 3 ASPIRE trial after completing the A-LONG and Kids A-LONG studies.

At the time of the interim analysis, most patients had at least 100 days of cumulative exposure to rFVIIIFc.

None of the patients developed inhibitors, and the investigators said adverse events (AEs) were generally consistent with those expected in the general hemophilia A population.

Furthermore, the median annualized bleeding rates (ABRs) were low among patients receiving prophylaxis, and most patients had no change in prophylactic infusion frequency or total weekly prophylactic dose.

These results appear in Haemophilia. The trial is sponsored by Biogen, the company developing rFVIIIFc.

Trial design

ASPIRE has enrolled 211 males with hemophilia A, including 150 (98%) of those who completed A-LONG and 61 (91%) of those who completed Kids A-LONG.

ASPIRE has an on-demand treatment group and 3 prophylactic treatment groups: individualized, weekly, and modified prophylaxis. In the on-demand group, dosing is based on the type and severity of bleeding episodes.

Subjects in the individualized prophylaxis group receive rFVIIIFc at 25-65 IU kg⁻¹ every 3 to 5 days or twice-weekly rFVIIIFc at 20–65 IU kg⁻¹ on day 1 and 40–65 IU kg⁻¹ on day 4. In subjects younger than 12, the investigators can make dose adjustments.

The weekly prophylaxis group receives rFVIIIFc at 65 IU kg⁻¹ every 7 days. Patients who cannot receive optimal treatment in either the individualized or weekly prophylaxis groups can be placed in the modified prophylaxis group.

Patients can change their treatment group at any time during the study. However, subjects younger than 12 can only participate in the individualized and modified prophylaxis groups.

“The design of the ASPIRE study provides physicians a high degree of dosing flexibility, with the goal of reflecting their real-world treatment practices,” said Guy Young, MD, of Children’s Hospital of Los Angeles in California.

Treatment

As of the interim analysis, the median time in the ASPIRE study was 80.9 weeks for adults and adolescents completing the A-LONG study and 23.9 weeks for children completing the Kids A-LONG study. The median cumulative duration of treatment was 117.7 weeks for adults and adolescents and 51.5 weeks for children.

Nearly all Kids A-LONG subjects (96.7%) continued on individualized prophylaxis. Two subjects switched to the modified prophylaxis group upon enrollment in ASPIRE, but none of the subjects changed their treatment group during ASPIRE.

Of the A-LONG subjects, 16.7% changed treatment groups at enrollment in ASPIRE, and 11.3% made a change to their treatment group during ASPIRE. None of the subjects changed treatment groups more than once.

Most patients who were previously on a prophylactic regimen in A-LONG had either no change to their infusion interval (71.9%) or had a longer infusion interval (21.9%) during ASPIRE. Most patients on Kids A-LONG (95.1%) had no change to their prophylactic infusion interval on ASPIRE.

Safety

Overall, 65.4% of subjects had at least 1 AE, and 10.9% had at least 1 serious AE. All of the serious AEs were considered unrelated to rFVIIIFc, and all had resolved by the time of the interim data cut. There were no serious allergic reactions, serious vascular thrombotic events, or deaths.

The most common AEs (incidence of 5% or greater) were nasopharyngitis (12.8%), upper respiratory infection (7.6%), and arthralgia (5.2%). Three adults (1.4%) experienced 4 mild AEs that were thought to be related to rFVIIIFc—chromaturia, elevated blood creatinine, and headache/hot flashes.

Efficacy

For adults and adolescents, the overall ABR was 0.66 in the individualized prophylaxis arm, 2.03 in the weekly prophylaxis arm, 1.97 in the modified prophylaxis arm, and 18.36 in the on-demand treatment arm.

For children in the individualized prophylaxis arm, the overall ABR was 0.00 in children younger than 6 and 1.56 in those ages 6 to 11. For children in the modified prophylaxis arm, the overall ABR was 6.55 in those younger than 6 and 0.00 for children 6 to 11.

A total of 566 bleeding episodes occurred in adults and adolescents who were treated prophylactically. Patients in the on-demand treatment arm experienced 262 bleeding episodes.

Overall, 90.8% of these bleeding episodes were controlled with a single infusion of rFVIIIFc, and 96.9% of the episodes were controlled with 1 or 2 infusions.

Children had a total of 51 bleeding episodes—23 among children younger than 6 and 28 among children 6 to 11.

Most of these episodes were controlled with a single infusion of rFVIIIFc—82.6% among children younger than 6 and 82.1% among children 6 to 11. And 95.7% and 89.3%, respectively, were controlled with 1 to 2 infusions.

“The results suggest prophylaxis with Eloctate shows efficacy and safety for the long-term treatment of hemophilia A,” Dr Young concluded.

Doctor evaluating patient

Photo courtesy of the CDC

The American Society of Hematology (ASH) and the College of American Pathologists (CAP) have opened a public comment period for a draft guideline that addresses the initial work-up of acute leukemia.

The guideline details the information required for the diagnosis of acute leukemias, as well as recommended testing and how test results and diagnosis should be correlated.

The document will be available for comment through August 31.

The guideline authors examined evidence from more than 170 articles to devise the draft guidelines. The resulting document answers the following questions:

• What clinical and laboratory information should be available during the initial diagnostic evaluation of a patient with acute leukemia?
• What specimens and sample types should be evaluated during the initial work-up of a patient with acute leukemia?
• At the time of diagnosis, what tests are required for all patients for the initial evaluation of an acute leukemia?
• What tests should be performed only on a subset of patients, including in response to results of initial tests and morphology?
• Where should testing be performed?
• How should test results and the diagnosis be correlated and reported?

“Evidence-based guidelines like these are increasingly vital to the continued improvement and continuity of patient care,” said ASH guideline co-chair James W. Vardiman, MD, of the University of Chicago in Illinois.

He and Daniel A. Arber, MD, of Stanford School of Medicine in California, (the CAP representative co-chair) are leading an interdisciplinary team of 8 physicians representing sub-specialties that include hematopathology and oncology.

“Our work on these guidelines aims at integrating the very best practices to improve outcomes for [acute leukemia] patients and their families,” Dr Arber said.

At the close of the comment period, the CAP/ASH team will review any comments and make final recommendations, which are targeted for publication in the first quarter of 2016.

Doctor evaluating patient

Photo courtesy of the CDC

The American Society of Hematology (ASH) and the College of American Pathologists (CAP) have opened a public comment period for a draft guideline that addresses the initial work-up of acute leukemia.

The guideline details the information required for the diagnosis of acute leukemias, as well as recommended testing and how test results and diagnosis should be correlated.

The document will be available for comment through August 31.

The guideline authors examined evidence from more than 170 articles to devise the draft guidelines. The resulting document answers the following questions:

• What clinical and laboratory information should be available during the initial diagnostic evaluation of a patient with acute leukemia?
• What specimens and sample types should be evaluated during the initial work-up of a patient with acute leukemia?
• At the time of diagnosis, what tests are required for all patients for the initial evaluation of an acute leukemia?
• What tests should be performed only on a subset of patients, including in response to results of initial tests and morphology?
• Where should testing be performed?
• How should test results and the diagnosis be correlated and reported?

“Evidence-based guidelines like these are increasingly vital to the continued improvement and continuity of patient care,” said ASH guideline co-chair James W. Vardiman, MD, of the University of Chicago in Illinois.

He and Daniel A. Arber, MD, of Stanford School of Medicine in California, (the CAP representative co-chair) are leading an interdisciplinary team of 8 physicians representing sub-specialties that include hematopathology and oncology.

“Our work on these guidelines aims at integrating the very best practices to improve outcomes for [acute leukemia] patients and their families,” Dr Arber said.

At the close of the comment period, the CAP/ASH team will review any comments and make final recommendations, which are targeted for publication in the first quarter of 2016.

Doctor evaluating patient

Photo courtesy of the CDC

The American Society of Hematology (ASH) and the College of American Pathologists (CAP) have opened a public comment period for a draft guideline that addresses the initial work-up of acute leukemia.

The guideline details the information required for the diagnosis of acute leukemias, as well as recommended testing and how test results and diagnosis should be correlated.

The document will be available for comment through August 31.

The guideline authors examined evidence from more than 170 articles to devise the draft guidelines. The resulting document answers the following questions:

• What clinical and laboratory information should be available during the initial diagnostic evaluation of a patient with acute leukemia?
• What specimens and sample types should be evaluated during the initial work-up of a patient with acute leukemia?
• At the time of diagnosis, what tests are required for all patients for the initial evaluation of an acute leukemia?
• What tests should be performed only on a subset of patients, including in response to results of initial tests and morphology?
• Where should testing be performed?
• How should test results and the diagnosis be correlated and reported?

“Evidence-based guidelines like these are increasingly vital to the continued improvement and continuity of patient care,” said ASH guideline co-chair James W. Vardiman, MD, of the University of Chicago in Illinois.

He and Daniel A. Arber, MD, of Stanford School of Medicine in California, (the CAP representative co-chair) are leading an interdisciplinary team of 8 physicians representing sub-specialties that include hematopathology and oncology.

“Our work on these guidelines aims at integrating the very best practices to improve outcomes for [acute leukemia] patients and their families,” Dr Arber said.

At the close of the comment period, the CAP/ASH team will review any comments and make final recommendations, which are targeted for publication in the first quarter of 2016.

Micrograph showing

mycosis fungoides

Researchers have identified 15 mutations that may drive cutaneous T-cell lymphoma (CTCL).

The team sequenced normal and cancerous samples from 73 patients with mycosis fungoides or Sézary syndrome.

This revealed recurrent alterations in the TNFR2 pathway, as well as mutations in phosphoinositide 3-kinase (PI3K)-related genes, NF-κB pathway genes, and other genes that regulate T-cell survival and proliferation.

Specifically, the researchers identified TNFRSF1B point mutations, TNFRSF1B gains, CTLA4-CD28 fusions, a TRAF3 deletion, and mutations in NFAT5, TEC, PIK3CD, PIK3R6, PIK3CG, PIK3R5, PIK3R4, VAV1, MALT1, CD28, and ITK.

Paul Khavari, MD, PhD, of Stanford University in California, and his colleagues conducted this research and described their findings in a letter to Nature Genetics.

TNFR2 mutations

The researchers noted that the most frequent recurrent point mutation they identified occurred at codon 377 of TNFRSF1B (5%; 4/73), resulting in a recurrent TNFR2 Thr377Ile mutant.

TNFR2 is a receptor that regulates T-cell signaling pathways, and the mutation locked the receptor into an always-on state, preventing the T-cell-survival pathway from shutting down.

Previous studies showed that patients with increased TNFR2 in their bloodstream had more aggressive forms of CTCL that were more likely to return quickly after treatment.

This led Dr Khavari and his colleagues to look at the other patients’ DNA to see if duplications could account for both the elevated levels in the blood and increased signaling to activate the T-cell-survival pathway. The team found that 10 of the patients had TNFRSF1B gains.

In total, TNFRSF1B was altered in 18% of patients (13/73), by point mutation or gain (both in 1 patient). The researchers said this suggests a potential role of oncogenic TNFR2 signaling in the development of CTCL.

The team uncovered evidence to support this role by growing cells in the lab with either the point mutation or the gain. Their experiment showed the T-cell-survival pathway was more active in these cells than in normal cells.

Now, the researchers are working to incorporate the mutations they identified into the DNA of mice to study the mutated genes’ effects and the actions of drugs on those genes.

Micrograph showing

mycosis fungoides

Researchers have identified 15 mutations that may drive cutaneous T-cell lymphoma (CTCL).

The team sequenced normal and cancerous samples from 73 patients with mycosis fungoides or Sézary syndrome.

This revealed recurrent alterations in the TNFR2 pathway, as well as mutations in phosphoinositide 3-kinase (PI3K)-related genes, NF-κB pathway genes, and other genes that regulate T-cell survival and proliferation.

Specifically, the researchers identified TNFRSF1B point mutations, TNFRSF1B gains, CTLA4-CD28 fusions, a TRAF3 deletion, and mutations in NFAT5, TEC, PIK3CD, PIK3R6, PIK3CG, PIK3R5, PIK3R4, VAV1, MALT1, CD28, and ITK.

Paul Khavari, MD, PhD, of Stanford University in California, and his colleagues conducted this research and described their findings in a letter to Nature Genetics.

TNFR2 mutations

The researchers noted that the most frequent recurrent point mutation they identified occurred at codon 377 of TNFRSF1B (5%; 4/73), resulting in a recurrent TNFR2 Thr377Ile mutant.

TNFR2 is a receptor that regulates T-cell signaling pathways, and the mutation locked the receptor into an always-on state, preventing the T-cell-survival pathway from shutting down.

Previous studies showed that patients with increased TNFR2 in their bloodstream had more aggressive forms of CTCL that were more likely to return quickly after treatment.

This led Dr Khavari and his colleagues to look at the other patients’ DNA to see if duplications could account for both the elevated levels in the blood and increased signaling to activate the T-cell-survival pathway. The team found that 10 of the patients had TNFRSF1B gains.

In total, TNFRSF1B was altered in 18% of patients (13/73), by point mutation or gain (both in 1 patient). The researchers said this suggests a potential role of oncogenic TNFR2 signaling in the development of CTCL.

The team uncovered evidence to support this role by growing cells in the lab with either the point mutation or the gain. Their experiment showed the T-cell-survival pathway was more active in these cells than in normal cells.

Now, the researchers are working to incorporate the mutations they identified into the DNA of mice to study the mutated genes’ effects and the actions of drugs on those genes.

Micrograph showing

mycosis fungoides

Researchers have identified 15 mutations that may drive cutaneous T-cell lymphoma (CTCL).

The team sequenced normal and cancerous samples from 73 patients with mycosis fungoides or Sézary syndrome.

This revealed recurrent alterations in the TNFR2 pathway, as well as mutations in phosphoinositide 3-kinase (PI3K)-related genes, NF-κB pathway genes, and other genes that regulate T-cell survival and proliferation.

Specifically, the researchers identified TNFRSF1B point mutations, TNFRSF1B gains, CTLA4-CD28 fusions, a TRAF3 deletion, and mutations in NFAT5, TEC, PIK3CD, PIK3R6, PIK3CG, PIK3R5, PIK3R4, VAV1, MALT1, CD28, and ITK.

Paul Khavari, MD, PhD, of Stanford University in California, and his colleagues conducted this research and described their findings in a letter to Nature Genetics.

TNFR2 mutations

The researchers noted that the most frequent recurrent point mutation they identified occurred at codon 377 of TNFRSF1B (5%; 4/73), resulting in a recurrent TNFR2 Thr377Ile mutant.

TNFR2 is a receptor that regulates T-cell signaling pathways, and the mutation locked the receptor into an always-on state, preventing the T-cell-survival pathway from shutting down.

Previous studies showed that patients with increased TNFR2 in their bloodstream had more aggressive forms of CTCL that were more likely to return quickly after treatment.

This led Dr Khavari and his colleagues to look at the other patients’ DNA to see if duplications could account for both the elevated levels in the blood and increased signaling to activate the T-cell-survival pathway. The team found that 10 of the patients had TNFRSF1B gains.

In total, TNFRSF1B was altered in 18% of patients (13/73), by point mutation or gain (both in 1 patient). The researchers said this suggests a potential role of oncogenic TNFR2 signaling in the development of CTCL.

The team uncovered evidence to support this role by growing cells in the lab with either the point mutation or the gain. Their experiment showed the T-cell-survival pathway was more active in these cells than in normal cells.

Now, the researchers are working to incorporate the mutations they identified into the DNA of mice to study the mutated genes’ effects and the actions of drugs on those genes.