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New insight into HSCs’ role in hematopoiesis
allows scientists to identify
differences in blood cell origin
Credit: Camargo Lab
By developing a tracking system for stem cells, researchers may have discovered previously unrecognized features of hematopoiesis.
Their work suggests the main drivers of steady-state hematopoiesis are not hematopoietic stem cells (HSCs) but their less pluripotent descendants, progenitor cells.
The team speculates that stable populations of long-lived progenitor cells are responsible for giving rise to specific blood cell types, while HSCs likely act as essential reserves.
The research, published in Nature, indicates that progenitor cells could be just as valuable as HSCs for blood regeneration therapies.
The work challenges what textbooks have long read: that HSCs maintain the day-to-day renewal of blood, a conclusion drawn from their importance in re-establishing blood cell populations after bone marrow transplants.
Due to a lack of tools to study how blood forms in a normal context, no one was able to track the origin of blood cells without doing a transplant.
Fernando Camargo, PhD, of Boston Children’s Hospital in Massachusetts, and his colleagues addressed this problem with a tool that generates a unique barcode in the DNA of all HSCs and their progenitor cells in a mouse.
When a tagged cell divides, all of its descendant cells possess the same barcode. This biological inventory system makes it possible to determine the number of HSCs/progenitors being used to make blood and how long they live, as well as answer fundamental questions about where individual blood cells come from.
“There’s never been such a robust experimental method that could allow people to look at lineage relationships between mature cell types in the body without doing transplantation,” said study author Jianlong Sun, PhD, also of Boston Children’s Hospital.
“One of the major directions we can now go is to revisit the entire blood cell hierarchy and see how the current knowledge holds true when we use this internal labeling system.”
“People have tried using viruses to tag blood cells in the past, but the cells needed to be taken out of the body, infected, and re-transplanted, which raised a number of issues,” Dr Camargo noted. “I wanted to figure out a way to label blood cells inside of the body, and the best idea I had was to use mobile genetic elements called transposons.”
A transposon is a piece of genetic code that can jump to a random point in DNA when exposed to the enzyme transposase. Dr Camargo’s approach works using transgenic mice that possess a single fish-derived transposon in all of their blood cells.
When one of these mice is exposed to transposase, each of its blood cells’ transposons changes location. The location in the DNA where a transposon moves acts as an individual cell’s barcode, so that if the mouse’s blood is taken a few months later, any cell with the same transposon location can be linked back to its parent cell.
Now, the researchers are planning to explore more applications for their barcode tool.
“We are also tremendously excited to use this tool to barcode and track descendants of different stem cells or progenitor cells for a range of conditions, from aging to the normal immune response,” Dr Sun said.
“We first used this technology for blood analysis. However, this system can also help address basic questions about cell populations in solid tissue. You can imagine being able to look at tumor progression or identify the precise origins of cancer cells that have broken off from a tumor and are now circulating in the blood.” 
allows scientists to identify
differences in blood cell origin
Credit: Camargo Lab
By developing a tracking system for stem cells, researchers may have discovered previously unrecognized features of hematopoiesis.
Their work suggests the main drivers of steady-state hematopoiesis are not hematopoietic stem cells (HSCs) but their less pluripotent descendants, progenitor cells.
The team speculates that stable populations of long-lived progenitor cells are responsible for giving rise to specific blood cell types, while HSCs likely act as essential reserves.
The research, published in Nature, indicates that progenitor cells could be just as valuable as HSCs for blood regeneration therapies.
The work challenges what textbooks have long read: that HSCs maintain the day-to-day renewal of blood, a conclusion drawn from their importance in re-establishing blood cell populations after bone marrow transplants.
Due to a lack of tools to study how blood forms in a normal context, no one was able to track the origin of blood cells without doing a transplant.
Fernando Camargo, PhD, of Boston Children’s Hospital in Massachusetts, and his colleagues addressed this problem with a tool that generates a unique barcode in the DNA of all HSCs and their progenitor cells in a mouse.
When a tagged cell divides, all of its descendant cells possess the same barcode. This biological inventory system makes it possible to determine the number of HSCs/progenitors being used to make blood and how long they live, as well as answer fundamental questions about where individual blood cells come from.
“There’s never been such a robust experimental method that could allow people to look at lineage relationships between mature cell types in the body without doing transplantation,” said study author Jianlong Sun, PhD, also of Boston Children’s Hospital.
“One of the major directions we can now go is to revisit the entire blood cell hierarchy and see how the current knowledge holds true when we use this internal labeling system.”
“People have tried using viruses to tag blood cells in the past, but the cells needed to be taken out of the body, infected, and re-transplanted, which raised a number of issues,” Dr Camargo noted. “I wanted to figure out a way to label blood cells inside of the body, and the best idea I had was to use mobile genetic elements called transposons.”
A transposon is a piece of genetic code that can jump to a random point in DNA when exposed to the enzyme transposase. Dr Camargo’s approach works using transgenic mice that possess a single fish-derived transposon in all of their blood cells.
When one of these mice is exposed to transposase, each of its blood cells’ transposons changes location. The location in the DNA where a transposon moves acts as an individual cell’s barcode, so that if the mouse’s blood is taken a few months later, any cell with the same transposon location can be linked back to its parent cell.
Now, the researchers are planning to explore more applications for their barcode tool.
“We are also tremendously excited to use this tool to barcode and track descendants of different stem cells or progenitor cells for a range of conditions, from aging to the normal immune response,” Dr Sun said.
“We first used this technology for blood analysis. However, this system can also help address basic questions about cell populations in solid tissue. You can imagine being able to look at tumor progression or identify the precise origins of cancer cells that have broken off from a tumor and are now circulating in the blood.”
allows scientists to identify
differences in blood cell origin
Credit: Camargo Lab
By developing a tracking system for stem cells, researchers may have discovered previously unrecognized features of hematopoiesis.
Their work suggests the main drivers of steady-state hematopoiesis are not hematopoietic stem cells (HSCs) but their less pluripotent descendants, progenitor cells.
The team speculates that stable populations of long-lived progenitor cells are responsible for giving rise to specific blood cell types, while HSCs likely act as essential reserves.
The research, published in Nature, indicates that progenitor cells could be just as valuable as HSCs for blood regeneration therapies.
The work challenges what textbooks have long read: that HSCs maintain the day-to-day renewal of blood, a conclusion drawn from their importance in re-establishing blood cell populations after bone marrow transplants.
Due to a lack of tools to study how blood forms in a normal context, no one was able to track the origin of blood cells without doing a transplant.
Fernando Camargo, PhD, of Boston Children’s Hospital in Massachusetts, and his colleagues addressed this problem with a tool that generates a unique barcode in the DNA of all HSCs and their progenitor cells in a mouse.
When a tagged cell divides, all of its descendant cells possess the same barcode. This biological inventory system makes it possible to determine the number of HSCs/progenitors being used to make blood and how long they live, as well as answer fundamental questions about where individual blood cells come from.
“There’s never been such a robust experimental method that could allow people to look at lineage relationships between mature cell types in the body without doing transplantation,” said study author Jianlong Sun, PhD, also of Boston Children’s Hospital.
“One of the major directions we can now go is to revisit the entire blood cell hierarchy and see how the current knowledge holds true when we use this internal labeling system.”
“People have tried using viruses to tag blood cells in the past, but the cells needed to be taken out of the body, infected, and re-transplanted, which raised a number of issues,” Dr Camargo noted. “I wanted to figure out a way to label blood cells inside of the body, and the best idea I had was to use mobile genetic elements called transposons.”
A transposon is a piece of genetic code that can jump to a random point in DNA when exposed to the enzyme transposase. Dr Camargo’s approach works using transgenic mice that possess a single fish-derived transposon in all of their blood cells.
When one of these mice is exposed to transposase, each of its blood cells’ transposons changes location. The location in the DNA where a transposon moves acts as an individual cell’s barcode, so that if the mouse’s blood is taken a few months later, any cell with the same transposon location can be linked back to its parent cell.
Now, the researchers are planning to explore more applications for their barcode tool.
“We are also tremendously excited to use this tool to barcode and track descendants of different stem cells or progenitor cells for a range of conditions, from aging to the normal immune response,” Dr Sun said.
“We first used this technology for blood analysis. However, this system can also help address basic questions about cell populations in solid tissue. You can imagine being able to look at tumor progression or identify the precise origins of cancer cells that have broken off from a tumor and are now circulating in the blood.”
NICE rejects obinutuzumab for CLL
Credit: Linda Bartlett
In a new draft guidance, the UK’s National Institute for Health and Care Excellence (NICE) has said it cannot recommend obinutuzumab (Gazyvaro) to treat chronic lymphocytic leukemia (CLL).
NICE CEO Sir Andrew Dillon said that although data suggest obinutuzumab is effective, there were too many “uncertainties” in the information submitted by Roche, the company developing the drug.
So NICE cannot be sure obinutuzumab would be an effective use of the National Health Service’s resources.
This is despite the fact that Roche offered to discount the drug’s list price of £26,496 per treatment course.
NICE is accepting comments on the draft guidance until 5 pm on October 23.
Obinutuzumab is a glycoengineered, humanized, monoclonal antibody that selectively binds to the extracellular domain of the CD20 antigen on B cells. The drug induces antibody-dependent cellular cytotoxicity and caspase-independent apoptosis.
The European Commission approved obinutuzumab in July for use in combination with chlorambucil to treat patients with previously untreated CLL who have comorbidities that make them ineligible to receive fludarabine-based therapy.
Obinutuzumab was approved for this indication in the US in November 2013.
Obinutuzumab is marketed as Gazyvaro in the European Union and Switzerland but as Gazyva in the US and the rest of the world.
Credit: Linda Bartlett
In a new draft guidance, the UK’s National Institute for Health and Care Excellence (NICE) has said it cannot recommend obinutuzumab (Gazyvaro) to treat chronic lymphocytic leukemia (CLL).
NICE CEO Sir Andrew Dillon said that although data suggest obinutuzumab is effective, there were too many “uncertainties” in the information submitted by Roche, the company developing the drug.
So NICE cannot be sure obinutuzumab would be an effective use of the National Health Service’s resources.
This is despite the fact that Roche offered to discount the drug’s list price of £26,496 per treatment course.
NICE is accepting comments on the draft guidance until 5 pm on October 23.
Obinutuzumab is a glycoengineered, humanized, monoclonal antibody that selectively binds to the extracellular domain of the CD20 antigen on B cells. The drug induces antibody-dependent cellular cytotoxicity and caspase-independent apoptosis.
The European Commission approved obinutuzumab in July for use in combination with chlorambucil to treat patients with previously untreated CLL who have comorbidities that make them ineligible to receive fludarabine-based therapy.
Obinutuzumab was approved for this indication in the US in November 2013.
Obinutuzumab is marketed as Gazyvaro in the European Union and Switzerland but as Gazyva in the US and the rest of the world.
Credit: Linda Bartlett
In a new draft guidance, the UK’s National Institute for Health and Care Excellence (NICE) has said it cannot recommend obinutuzumab (Gazyvaro) to treat chronic lymphocytic leukemia (CLL).
NICE CEO Sir Andrew Dillon said that although data suggest obinutuzumab is effective, there were too many “uncertainties” in the information submitted by Roche, the company developing the drug.
So NICE cannot be sure obinutuzumab would be an effective use of the National Health Service’s resources.
This is despite the fact that Roche offered to discount the drug’s list price of £26,496 per treatment course.
NICE is accepting comments on the draft guidance until 5 pm on October 23.
Obinutuzumab is a glycoengineered, humanized, monoclonal antibody that selectively binds to the extracellular domain of the CD20 antigen on B cells. The drug induces antibody-dependent cellular cytotoxicity and caspase-independent apoptosis.
The European Commission approved obinutuzumab in July for use in combination with chlorambucil to treat patients with previously untreated CLL who have comorbidities that make them ineligible to receive fludarabine-based therapy.
Obinutuzumab was approved for this indication in the US in November 2013.
Obinutuzumab is marketed as Gazyvaro in the European Union and Switzerland but as Gazyva in the US and the rest of the world.
Pediatric Surgical Comanagement
According to the 2012 Society of Hospital Medicine (SHM) survey, 94% of adult hospitalists and 74% of pediatric hospitalists provide inpatient care to surgical patients.[1] Many of these programs involve comanagement, which the SHM Comanagement Advisory Panel has described as a system of care featuring shared responsibility, authority, and accountability for hospitalized patients with medical and surgical needs.[2] Collaboration between medical and surgical teams for these patients has occurred commonly at some community institutions for decades, but may only be emerging at some tertiary care hospitals. The trend of comanagement appears to be increasing in popularity in adult medicine.[3] As in adult patients, comanagement for children undergoing surgical procedures, particularly those children with special healthcare needs (CSHCNs), has been proposed as a strategy for improving quality and costs. In this review, we will describe structural, quality, and financial implications of pediatric hospitalist comanagement programs, each of which include both potential benefits and drawbacks, as well as discuss a future research agenda for these programs.
ORGANIZATIONAL NEEDS AND STRUCTURE OF COMANAGEMENT PROGRAMS
Patterns of comanagement likely depend on hospital size and structure, both in adult patients[3] and in pediatrics. Children hospitalized for surgical procedures generally fall into 1 of 2 groups: those who are typically healthy and at low risk for complications, and those who are medically complex and at high risk. Healthy children often undergo high‐prevalence, low‐complexity surgical procedures such as tonsillectomy and hernia repairs;[4] these patients are commonly cared for at community hospitals by adult and pediatric surgeons. Whereas medically complex children also undergo these common procedures, they are more likely to be cared for at tertiary care centers and are also more likely to undergo higher‐complexity surgeries such as spinal fusions, hip osteotomies, and ventriculoperitoneal shunt placements.[4] Hospitalist comanagement programs at community hospitals and tertiary care centers may therefore have evolved differently in response to different needs of patients, providers, and organizations,[5] though some institutions may not fall neatly into 1 of these 2 categories.
Comanagement in Community Hospitals
A significant number of pediatric patients are hospitalized each year in community hospitals.[6] As noted above, children undergoing surgery in these settings are generally healthy, and may be cared for by surgeons with varying amounts of pediatric expertise. In this model, the surgeon may frequently be offsite when not in the operating room, necessitating some type of onsite postoperative coverage. In pediatrics, following adult models, this coverage need may be relatively straightforward: surgeons perform the procedure, followed by a medical team assuming postoperative care with surgical consultation. Because of general surgeons' varying experience with children, the American Academy of Pediatrics suggests that patients younger than 14 years or weighing less than 40 kg cared for by providers without routine pediatric experience should have a pediatric‐trained provider involved in their care,[7] though this suggestion does not mandate comanagement.
For children cared for by adult providers who have little experience with areas of pediatric‐specific care such as medication dosing and assessment of deterioration, we believe that involvement of a pediatric provider may impact care in a number of ways. A pediatric hospitalist's availability on the inpatient unit may allow him or her to better manage routine issues such as pain control and intravenous fluids without surgeon input, improving the efficiency of care. A pediatric hospitalist's general pediatric training may allow him or her to more quickly recognize when a child is medically deteriorating, or when transfer to a tertiary care center may be necessary, making care safer. However, no studies have specifically examined these variables. Future research should measure outcomes such as transfers to higher levels of care, medication errors, length of stay (LOS), and complication rates, especially in community hospital settings.
Comanagement in Tertiary Care Referral Centers
At tertiary care referral centers, surgeries in children are most often performed by pediatric surgeons. In these settings, providing routine hospitalist comanagement to all patients may be neither cost‐effective nor feasible. Adult studies have suggested that population‐targeted models can significantly improve several clinical outcomes. For example, in several studies of patients 65 years and older hospitalized with hip fractures, comanagement with a geriatric hospitalist was associated with improved clinical outcomes and shortened LOS.[8, 9, 10, 11, 12]
An analogous group of pediatric patients to the geriatric population may be CSHCNs or children who are medically complex. Several frameworks have been proposed to identify these patients.[13] Many institutions classify medically complex patients as those with complex chronic medical conditions (CCCs).[13, 14, 15] One framework to identify CSHCNs suggested including not only children with CCCs, but also those with (1) substantial service needs and/or family burden; (2) severe functional limitations; and/or (3) high rates of healthcare system utilization, often requiring the care of several subspecialty providers.[16] As the needs of these patients may be quite diverse, pediatric hospitalists may be involved in many aspects of their care, from preoperative evaluation,[17] to establishing protocols for best practices, to communicating with primary care providers, and even seeing patients in postoperative follow‐up clinics. These patients are known to be at high risk for surgical complications, readmissions,[14] medical errors,[18] lapses in communication, and high care costs. In 1 study, comanagement for children with neuromuscular scoliosis hospitalized for spinal fusion surgery has been associated with shorter LOS and less variability in LOS.[19] However, drawbacks of comanagement programs involving CSHCNs may include difficulty with consistent identification of the population who will most benefit from comanagement and higher initial costs of care.[18]
Models of Comanagement and Comanagement Agreements
A comanagement agreement should address 5 major questions: (1) Who is the primary service? (2) Who is the consulting/comanaging service? (3) Are consults as‐needed or automatic? (4) Who writes orders for the patient? (5) Which staffing model will be used for patient care?[20] Although each question above may be answered differently in different systems, the correct comanagement program is a program that aligns most closely with the patient population and care setting.[11, 20]
Several different models exist for hospitalistsurgeon comanagement programs[20, 21] (Table 1). Under the consultation model (model I), hospitalists become involved in the care of surgical patients only when requested to do so by the surgical team. Criteria for requesting this kind of consultation and the extent of responsibility afforded to the medical team are often not clearly defined, and may differ from hospital to hospital or even surgeon to surgeon.[22] Hospitalist involvement with adult patients with postoperative medical complications, which presumably employed this as‐needed model, has been associated with lower mortality and LOS[23]; whether this involvement provides similar benefits in children with postoperative complications has not been explicitly studied.
| Model | Attending Service | Consulting Service | Automatic Consultation | Who Writes Orders? | Notes |
|---|---|---|---|---|---|
| |||||
| I | Surgery | Pediatrics | No | Surgery | Similar to traditional consultation |
| II | Surgery | Pediatrics | Yes | Usually surgery | Basic comanagement, consultant may sign off |
| III | Pediatrics | Surgery | Yes | Usually pediatrics | Basic comanagement, consultant may sign off |
| IV | Combined | N/A | N/A | Each service writes own | True comanagement, no sign‐off from either service permitted |
The remaining models involve compulsory participation by both surgical and medical services. In models II and III, patients may be evaluated preoperatively; those felt to meet specific criteria for high medical complexity are either admitted to a medical service with automatic surgical consultation or admitted to a surgical service with automatic medical consultation. In both cases, writing of orders is handled in the same manner as any consultation model; depending on the service agreement, consulting services may sign off or may be required to be involved until discharge. In model IV, care is fully comanaged by medical and surgical services, with each service having ownership over orders pertaining to their discipline. Ethical concerns about such agreements outlined by the American Medical Association include whether all patients cared for under agreements II to IV will truly benefit from the cost of multispecialty care, and whether informed consent from patients themselves should be required given the cost implications.[24]
Comanagement models also vary with respect to frontline provider staffing. Models may incorporate nurse practitioners, hospitalists, physician assistants, or a combination thereof. These providers may assume a variety of roles, including preoperative patient evaluation, direct care of patients while hospitalized, and/or coordination of inpatient and outpatient postoperative care. Staffing requirements for hospitalists and/or mid‐level providers will differ significantly at different institutions based on surgical volume, patient complexity, and other local factors.
COMANAGEMENT AND QUALITY
Comanagement as a Family‐Centered Initiative
Development of a family‐centered culture of care, including care coordination, lies at the core of pediatric hospital medicine, particularly for CSHCNs.[25, 26] In the outpatient setting, family‐centered care has been associated with improved quality of care for CSHCNs.[27, 28] For families of hospitalized children, issues such as involvement in care and timely information transfer have been identified as high priorities.[29] An important tool for addressing these needs is family‐centered rounds (FCRs), which represent multidisciplinary rounds at the bedside involving families and patients as active shared decision makers in conjunction with the medical team.[30, 31] Although FCRs have not been studied in comanagement arrangements specifically, evidence suggests that this tool improves family centeredness and patient safety in nonsurgical patients,[32] and FCRs can likely have a similar impact on postoperative care.
A pediatric hospitalist comanagement program may impact quality and safety of care in a number of other ways. Hospitalists may offer improved access to clinical information for nurses and families, making care safer. One study of comanagement in adult neurosurgical patients found that access to hospitalists led to improved quality and safety of care as perceived by nurses and other members of the care team.[33] A study in pediatric patients found that nurses overwhelmingly supported having hospitalist involvement in complex children undergoing surgery; the same study found that pediatric hospitalists were particularly noted for their communication skills.[34]
Assessing Clinical Outcomes in Pediatric Hospitalist Comanagement Programs
Most studies evaluating the impact of surgical comanagement programs have focused on global metrics such as LOS, overall complication rates, and resource utilization. In adults, results of these studies have been mixed, suggesting that patient selection may be an important factor.[35] In pediatrics, 2 US studies have assessed these metrics at single centers. Simon et al. found that involvement of a pediatric hospitalist in comanagement of patients undergoing spinal fusion surgery significantly decreased LOS.[19] Rappaport et al. found that patients comanaged by hospitalists had lower utilization of laboratory tests and parenteral nutrition, though initial program costs significantly increased.[36] Studies outside the United States, including a study from Sweden,[37] have suggested that a multidisciplinary approach to children's surgical care, including the presence of pediatric specialists, reduced infection rate and other complications. These studies provide general support for the role of hospitalists in comanagement, although determining which aspects of care are most impacted may be difficult.
Comanagement programs might impact safety and quality negatively as well. Care may be fragmented, leading to provider and family dissatisfaction. Poor communication and multiple handoffs among multidisciplinary team members might interfere with the central role of the nurse in patient care.[38] Comanagement programs might lead to provider disengagement if providers feel that others will assume roles with which they may be unfamiliar or poorly trained.[35] This lack of knowledge may also affect communication with families, leading to conflicting messages among the care team and family frustration. In addition, the impact of comanagement programs on trainees such as residents, both surgical and pediatric, has received limited study.[39] Assessing pediatric comanagement programs' impact on communication, family‐centeredness, and trainees deserves further study.
FINANCIAL IMPLICATIONS OF PEDIATRIC COMANAGEMENT PROGRAMS
Children undergoing surgery require significant financial resources for their care. A study of 38 major US children's hospitals found that 3 of the top 10 conditions with the highest annual expenditures were surgical procedures.[4] The most costly procedure was spinal fusion for scoliosis, accounting for an average of $45,000 per admission and $610 million annually. Although a significant portion of these costs represented surgical devices and operating room time, these totals also included the cost of hospital services and in‐hospital complications. CSHCNs more often undergo high‐complexity procedures such as spinal fusions[36] and face greater risk for costly postoperative complications. The financial benefits that come from reductions in outcomes such as LOS and readmissions in this population are potentially large, but may depend on the payment model as described below.
Billing Models in Comanagement Programs
Several billing constructs exist in comanagement models. At many institutions, comanagement billing may resemble that for traditional consultation: the pediatric hospitalist bills for his/her services using standard initial and subsequent consultation billing coding for the child's medical conditions, and may sign off when the hospitalist feels recommendations are complete. Other models may also exist. Model IV comanagement may involve a prearranged financial agreement, in which billing modifiers are used to differentiate surgical care only (modifier 54) and postoperative medical care only (modifier 55). These modifiers, typically used for Medicare patients, indicate a split in a global surgical fee.[40]
The SHM has outlined financial considerations that should be addressed at the time of program inception and updated periodically, including identifying how each party will bill, who bills for which service, and monitoring collection rates and rejected claims.[2] Regardless of billing model, the main focus of comanagement must be quality of care, not financial considerations; situations in which the latter are emphasized at the expense of patient care may be unethical or illegal.[24] Regardless, surgical comanagement programs should seek maximal reimbursement in order to remain viable.
Value of Comanagement for a Healthcare Organization Under Fee‐for‐Service Payment
The value of any comanagement program is highly dependent on both the institution's payor mix and the healthcare organization's overarching goals. From a business perspective, a multidisciplinary approach may be perceived as resource intensive, but formal cost‐effectiveness analyses over time are limited. Theoretically, a traditional payment model involving hospitalist comanagement would be financially beneficial for a healthcare institution by allowing surgeons and surgical trainees more time to operate. However, these savings are difficult to quantify. Despite the fact that most hospitalist programs have no direct financial benefit to the institution, many hospital leaders seem willing to subsidize hospitalist programs based on measures such as patient and referring physician satisfaction with hospitalist care.[41] Postoperative complications, although unfortunate, may be a source of revenue under this model if paid by insurance companies in the usual manner, leading to a misalignment of quality and financial goals. Regardless, whether these programs are considered worthy investments to healthcare organizations will ultimately depend on evolving billing and reimbursement structures; to date, no formal survey of how comanagement programs bill and are reimbursed has been performed.
Value for an Organization in an Accountable Care Organization Model
Although a detailed discussion of accountable care organizations (ACOs) is beyond the scope of this article, stronger incentives in these structures for reducing resource utilization and complication rates may make hospitalist comanagement attractive in an ACO model.[42] ACO program evaluation is expected to be based on such data as patient surveys, documentation of care coordination, and several disease‐specific metrics.[43, 44] Several children's hospital‐based systems and mixed health systems have dedicated significant resources to establishing networks of providers that bridge inpatient and outpatient episodes of surgical care.[27, 28] One adult study has suggested lower costs associated with hospitalist comanagement for geriatric patients with hip fractures.[12] Comanagement programs may help meet quality and value goals, including enhancing care coordination between inpatient and outpatient care, and therefore may prove to be a beneficial investment for institutions. As the healthcare landscape evolves, formal study of the costs and benefits of pediatric comanagement models in ACO‐type care structures will be important.
SETTING A RESEARCH AGENDA
Pediatric hospitalist comanagement programs require vigorous study to evaluate their impact. Potential research targets include not only clinical data such as LOS, perioperative complication rates, readmission rates, and resource utilization, but also data regarding surgeon, nursing, and family satisfaction. These programs should also be evaluated in terms of how they impact trainees, both surgical and pediatric. Because of comanagement programs' complexities, we anticipate that they will impart both positive and negative effects on some of these factors. These programs will also require evaluation over time as they require significant education on the part of staff and families.[36]
In addition to affecting global metrics, pediatric hospitalists may also have a positive impact on surgical care by demonstrating leadership to improve systems of care relevant to surgical patients, including the use of guidelines. The American College of Surgeons' National Surgical Quality Improvement Program has identified 2 priorities that hospitalists may impact: surgical site infection (SSI) and pulmonary complications, which combined comprise greater than half of all 30‐day postoperative complications.[45] Regarding SSI prevention, hospitalist researchers are making valuable contributions to literature surrounding adherence to Centers for Disease Control and Prevention and Pediatric Orthopedic Society of North America guidelines.[46, 47, 48] Research is ongoing regarding how human and systems factors may impact the effectiveness of these guidelines, but also how reliably these guidelines are implemented.[49] In the area of pulmonary complications, pediatric hospitalists have followed the example of successful initiatives in adult surgery patients by developing and implementing postoperative protocols to prevent pulmonary complications such as postoperative pneumonia.[50] At 1 center, pediatric hospitalists have led efforts to implement a standardized respiratory care pathway for high‐risk orthopedic patients.[51] Evaluation of the effectiveness of such programs is currently ongoing, but early data show similar benefits to those demonstrated in adults.
CONCLUSIONS
Pediatric hospitalist comanagement programs for surgical patients have largely followed the path of adult programs. Limited data suggest that certain clinical outcomes may be improved under comanagement, but patient selection may be important. Although there is significant variety between programs, there exist several common themes, including the importance of clear delineation of roles and a central goal of improved care coordination. Ongoing research will hopefully shed more light on the impact of these programs, especially with regard to patient safety, hospitalist‐led quality‐improvement programs, and financial implications, particularly in different structures of care and reimbursement models.
Disclosure: Nothing to report.
- 2012 State of Hospital Medicine Report, Society of Hospital Medicine. Available at: http://www.hospitalmedicine.org/survey. Accessed on September 1, 2014.
- Society of Hospital Medicine Co‐Management Advisory Panel. A white paper on a guide to hospitalist/orthopedic surgery co‐management. SHM website. Available at: http://tools.hospitalmedicine.org/Implementation/Co‐ManagementWhitePaper‐final_5‐10‐10.pdf. Accessed on September 25, 2014.
- , , , , . Comanagement of hospitalized surgical patients by medicine physicians in the United States. Arch Intern Med. 2010;170(4):363–368.
- , , , et al. Prioritization of comparative effectiveness research topics in hospital pediatrics. Arch Pediatr Adolesc Med. 2012;166(12):1155–1164.
- , . Pediatric hospitalist comanagement of surgical patients: challenges and opportunities. Clin Pediatr (Phila). 2008;47(2):114–121.
- , . Utilization of pediatric hospitals in New York State. Pediatrics. 2003;111(5 pt 1):1068–1071.
- ; Committee on Hospital Care. Physicians' roles in coordinating care of hospitalized children. Pediatrics. 2003;111(3):707–709.
- , , , et al. Effects of a hospitalist care model on mortality of elderly patients with hip fractures. J Hosp Med. 2007;2(4):219–225.
- , , , et al. Effects of a hospitalist model on elderly patients with hip fracture. Arch Intern Med. 2005;165(7):796–801.
- , , , , , . Outcomes for older patients with hip fractures: the impact of orthopedic and geriatric medicine cocare. J Orthop Trauma. 2006;20(3):172–178; discussion 179–180.
- , , , . Geriatric co‐management of proximal femur fractures: total quality management and protocol‐driven care result in better outcomes for a frail patient population. J Am Geriatr Soc. 2008;56(7):1349–1356.
- , , , , , . Comanagement of geriatric patients with hip fractures: a retrospective, controlled, cohort study. Geriatr Orthop Surg Rehabil. 2013;4(1):10–15.
- , , , et al. Children with medical complexity: an emerging population for clinical and research initiatives. Pediatrics. 2011;127(3):529–538.
- , , , et al. How well can hospital readmission be predicted in a cohort of hospitalized children? A retrospective, multicenter study. Pediatrics. 2009;123(1):286–293.
- , , . Pediatric hospital medicine and children with medical complexity: past, present, and future. Curr Probl Pediatr Adolesc Health Care. 2012;42(5):113–119.
- , , , et al. A new definition of children with special health care needs. Pediatrics. 1998;102(1 pt 1):137–140.
- , , , , . Pediatric hospitalist preoperative evaluation of children with neuromuscular scoliosis. J Hosp Med. 2013;8(12):684–688.
- , , , , . Hospital admission medication reconciliation in medically complex children: an observational study. Arch Dis Child. 2010;95(4):250–255.
- , , , , , . Pediatric hospitalist comanagement of spinal fusion surgery patients. J Hosp Med. 2007;2(1):23–30.
- , . Principles of comanagement and the geriatric fracture center. Clin Geriatr Med. 2014;30(2):183–189.
- . How best to design surgical comanagement services for pediatric surgical patients? Hosp Pediatr. 2013;3(3):242–243.
- , , , , , . Effects of provider characteristics on care coordination under comanagement. J Hosp Med. 2010;5(9):508–513.
- , , , . Potential role of comanagement in “rescue” of surgical patients. Am J Manag Care. 2011;17(9):e333–e339.
- American Medical Association. 2008 report of the Council on Medical Service, policy sunset report for 1998 AMA socioeconomic policies. CMS Report 4, A‐08. Available at: http://www.ama‐assn.org/resources/doc/cms/a‐08cms4.pdf. Accessed on September 1, 2014.
- Committee on Hospital Care and Institute for Patient‐and Family‐Centered Care. Patient‐ and family‐centered care and the pediatrician's role. Pediatrics. 2012;129(2):394–404.
- Council on Children with Disabilities and Medical Home Implementation Project Advisory Committee. Patient‐ and family‐centered care coordination: a framework for integrating care for children and youth across multiple systems. Pediatrics. 2014;133(5):e1451–e1460.
- , , , , , . Care coordination for CSHCN: associations with family‐provider relations and family/child outcomes. Pediatrics. 2009;124(suppl 4):S428–S434.
- , , , et al. Evidence for family‐centered care for children with special health care needs: a systematic review. Acad Pediatr. 2011;11(2):136–143.
- , , . Parents' priorities and satisfaction with acute pediatric care. Arch Pediatr Adolesc Med. 2005;159(2):127–131.
- . Family‐centered rounds. Pediatr Clin North Am. 2014;61(4):663–670.
- , , , et al. Family‐centered rounds on pediatric wards: a PRIS network survey of US and Canadian hospitalists. Pediatrics. 2010;126(1):37–43.
- , , , , ; PIPS Group. Scoping review and approach to appraisal of interventions intended to involve patients in patient safety. J Health Serv Res Policy. 2010;15(suppl 1):17–25.
- , , , et al. Comanagement of surgical patients between neurosurgeons and hospitalists. Arch Intern Med. 2010;170(22):2004–2010.
- , , . Nurses' assessment of pediatric physicians: are hospitalists different? J Healthc Manag Am Coll Healthc Exec. 2008;53(1):14–24; discussion 24–25.
- . Just because you can, doesn't mean that you should: a call for the rational application of hospitalist comanagement. J Hosp Med. 2008;3(5):398–402.
- , , , et al. Outcomes and costs associated with hospitalist comanagement of medically complex children undergoing spinal fusion surgery. Hosp Pediatr. 2013;3(3):233–241.
- , , . Outcome of major spinal deformity surgery in high‐risk patients: comparison between two departments. Evid Based Spine Care J. 2010;1(3):11–18.
- , , , , , . Meeting the complex needs of the health care team: identification of nurse‐team communication practices perceived to enhance patient outcomes. Qual Health Res. 2010;20(1):15–28.
- , , , . A pediatric residency experience with surgical comanagement. Hosp Pediatr. 2013;3(2):144–148.
- U.S. Department of Health and Human Services. Centers for Medicaid and Medicare Services. MLN matters. Available at: http://www.cms.gov/Outreach‐and‐Education/Medicare‐Learning‐Network‐MLN/MLNMattersArticles/Downloads/MM7872.pdf. Accessed on September 1,2014.
- , , ; Research Advisory Committee of the American Board of Pediatrics. Assessing the value of pediatric hospitalist programs: the perspective of hospital leaders. Acad Pediatr. 2009;9(3):192–196.
- . Launching accountable care organizations—the proposed rule for the Medicare Shared Savings Program. N Engl J Med. 2011;364(16):e32.
- American Academy of Pediatrics. Accountable Care Organizations (ACOs) and Pediatricians: Evaluation and Engagement. Available at: http://www.aap.org/en‐us/professional‐resources/practice‐support/Pages/Accountable‐Care‐Organizations‐and‐Pediatricians‐Evaluation‐and‐Engagement.aspx. Accessed on September 25, 2014.
- , , , , . Delivery system characteristics and their association with quality and costs of care: implications for accountable care organizations [published online ahead of print February 21, 2014]. Health Care Manage Rev. doi: 10.1097/HMR.0000000000000014.
- , , , et al. Pediatric American College of Surgeons National Surgical Quality Improvement Program: feasibility of a novel, prospective assessment of surgical outcomes. J Pediatr Surg. 2011;46(1):115–121.
- , , , et al. Guideline for prevention of surgical site infection. Infect Control Hosp Epidemiol. 1999;20(4):247–278. Available at: http://www.cdc.gov/hicpac/pdf/guidelines/SSI_1999.pdf. Accessed on September 1, 2014.
- , , , et al. Building consensus: development of a Best Practice Guideline (BPG) for surgical site infection (SSI) prevention in high‐risk pediatric spine surgery. J Pediatr Orthop. 2013;33(5):471–478.
- , , , et al. Perioperative antibiotic use for spinal surgery procedures in US children's hospitals. Spine. 2013;38(7):609–616. Available at: http://www.ihi.org/education/Conferences/Forum2013/Pages/Scientific‐Symposium.aspx. Accessed on September 26, 2014.
- , , , , , , , , , , , . A human factors intervention to improve post‐operative antibiotic timing and prevent surgical site infection. Paper presented at: Institute for Healthcare Improvement Scientific Symposium; 2013; Orlando, FL. Abstract.
- , , , , . I COUGH: reducing postoperative pulmonary complications with a multidisciplinary patient care program. JAMA Surg. 2013;148(8):740–745. Available at: http://www.ihi.org/education/Conferences/Forum2013/Pages/Scientific‐Symposium.aspx. Accessed on September 26, 2014.
- , , , , , , , . Early postoperative respiratory care improves outcomes, adds value for hospitalized pediatric orthopedic patients. Poster presented at: Institute for Healthcare Improvement Scientific Symposium; 2013; Orlando, FL. Abstract.
According to the 2012 Society of Hospital Medicine (SHM) survey, 94% of adult hospitalists and 74% of pediatric hospitalists provide inpatient care to surgical patients.[1] Many of these programs involve comanagement, which the SHM Comanagement Advisory Panel has described as a system of care featuring shared responsibility, authority, and accountability for hospitalized patients with medical and surgical needs.[2] Collaboration between medical and surgical teams for these patients has occurred commonly at some community institutions for decades, but may only be emerging at some tertiary care hospitals. The trend of comanagement appears to be increasing in popularity in adult medicine.[3] As in adult patients, comanagement for children undergoing surgical procedures, particularly those children with special healthcare needs (CSHCNs), has been proposed as a strategy for improving quality and costs. In this review, we will describe structural, quality, and financial implications of pediatric hospitalist comanagement programs, each of which include both potential benefits and drawbacks, as well as discuss a future research agenda for these programs.
ORGANIZATIONAL NEEDS AND STRUCTURE OF COMANAGEMENT PROGRAMS
Patterns of comanagement likely depend on hospital size and structure, both in adult patients[3] and in pediatrics. Children hospitalized for surgical procedures generally fall into 1 of 2 groups: those who are typically healthy and at low risk for complications, and those who are medically complex and at high risk. Healthy children often undergo high‐prevalence, low‐complexity surgical procedures such as tonsillectomy and hernia repairs;[4] these patients are commonly cared for at community hospitals by adult and pediatric surgeons. Whereas medically complex children also undergo these common procedures, they are more likely to be cared for at tertiary care centers and are also more likely to undergo higher‐complexity surgeries such as spinal fusions, hip osteotomies, and ventriculoperitoneal shunt placements.[4] Hospitalist comanagement programs at community hospitals and tertiary care centers may therefore have evolved differently in response to different needs of patients, providers, and organizations,[5] though some institutions may not fall neatly into 1 of these 2 categories.
Comanagement in Community Hospitals
A significant number of pediatric patients are hospitalized each year in community hospitals.[6] As noted above, children undergoing surgery in these settings are generally healthy, and may be cared for by surgeons with varying amounts of pediatric expertise. In this model, the surgeon may frequently be offsite when not in the operating room, necessitating some type of onsite postoperative coverage. In pediatrics, following adult models, this coverage need may be relatively straightforward: surgeons perform the procedure, followed by a medical team assuming postoperative care with surgical consultation. Because of general surgeons' varying experience with children, the American Academy of Pediatrics suggests that patients younger than 14 years or weighing less than 40 kg cared for by providers without routine pediatric experience should have a pediatric‐trained provider involved in their care,[7] though this suggestion does not mandate comanagement.
For children cared for by adult providers who have little experience with areas of pediatric‐specific care such as medication dosing and assessment of deterioration, we believe that involvement of a pediatric provider may impact care in a number of ways. A pediatric hospitalist's availability on the inpatient unit may allow him or her to better manage routine issues such as pain control and intravenous fluids without surgeon input, improving the efficiency of care. A pediatric hospitalist's general pediatric training may allow him or her to more quickly recognize when a child is medically deteriorating, or when transfer to a tertiary care center may be necessary, making care safer. However, no studies have specifically examined these variables. Future research should measure outcomes such as transfers to higher levels of care, medication errors, length of stay (LOS), and complication rates, especially in community hospital settings.
Comanagement in Tertiary Care Referral Centers
At tertiary care referral centers, surgeries in children are most often performed by pediatric surgeons. In these settings, providing routine hospitalist comanagement to all patients may be neither cost‐effective nor feasible. Adult studies have suggested that population‐targeted models can significantly improve several clinical outcomes. For example, in several studies of patients 65 years and older hospitalized with hip fractures, comanagement with a geriatric hospitalist was associated with improved clinical outcomes and shortened LOS.[8, 9, 10, 11, 12]
An analogous group of pediatric patients to the geriatric population may be CSHCNs or children who are medically complex. Several frameworks have been proposed to identify these patients.[13] Many institutions classify medically complex patients as those with complex chronic medical conditions (CCCs).[13, 14, 15] One framework to identify CSHCNs suggested including not only children with CCCs, but also those with (1) substantial service needs and/or family burden; (2) severe functional limitations; and/or (3) high rates of healthcare system utilization, often requiring the care of several subspecialty providers.[16] As the needs of these patients may be quite diverse, pediatric hospitalists may be involved in many aspects of their care, from preoperative evaluation,[17] to establishing protocols for best practices, to communicating with primary care providers, and even seeing patients in postoperative follow‐up clinics. These patients are known to be at high risk for surgical complications, readmissions,[14] medical errors,[18] lapses in communication, and high care costs. In 1 study, comanagement for children with neuromuscular scoliosis hospitalized for spinal fusion surgery has been associated with shorter LOS and less variability in LOS.[19] However, drawbacks of comanagement programs involving CSHCNs may include difficulty with consistent identification of the population who will most benefit from comanagement and higher initial costs of care.[18]
Models of Comanagement and Comanagement Agreements
A comanagement agreement should address 5 major questions: (1) Who is the primary service? (2) Who is the consulting/comanaging service? (3) Are consults as‐needed or automatic? (4) Who writes orders for the patient? (5) Which staffing model will be used for patient care?[20] Although each question above may be answered differently in different systems, the correct comanagement program is a program that aligns most closely with the patient population and care setting.[11, 20]
Several different models exist for hospitalistsurgeon comanagement programs[20, 21] (Table 1). Under the consultation model (model I), hospitalists become involved in the care of surgical patients only when requested to do so by the surgical team. Criteria for requesting this kind of consultation and the extent of responsibility afforded to the medical team are often not clearly defined, and may differ from hospital to hospital or even surgeon to surgeon.[22] Hospitalist involvement with adult patients with postoperative medical complications, which presumably employed this as‐needed model, has been associated with lower mortality and LOS[23]; whether this involvement provides similar benefits in children with postoperative complications has not been explicitly studied.
| Model | Attending Service | Consulting Service | Automatic Consultation | Who Writes Orders? | Notes |
|---|---|---|---|---|---|
| |||||
| I | Surgery | Pediatrics | No | Surgery | Similar to traditional consultation |
| II | Surgery | Pediatrics | Yes | Usually surgery | Basic comanagement, consultant may sign off |
| III | Pediatrics | Surgery | Yes | Usually pediatrics | Basic comanagement, consultant may sign off |
| IV | Combined | N/A | N/A | Each service writes own | True comanagement, no sign‐off from either service permitted |
The remaining models involve compulsory participation by both surgical and medical services. In models II and III, patients may be evaluated preoperatively; those felt to meet specific criteria for high medical complexity are either admitted to a medical service with automatic surgical consultation or admitted to a surgical service with automatic medical consultation. In both cases, writing of orders is handled in the same manner as any consultation model; depending on the service agreement, consulting services may sign off or may be required to be involved until discharge. In model IV, care is fully comanaged by medical and surgical services, with each service having ownership over orders pertaining to their discipline. Ethical concerns about such agreements outlined by the American Medical Association include whether all patients cared for under agreements II to IV will truly benefit from the cost of multispecialty care, and whether informed consent from patients themselves should be required given the cost implications.[24]
Comanagement models also vary with respect to frontline provider staffing. Models may incorporate nurse practitioners, hospitalists, physician assistants, or a combination thereof. These providers may assume a variety of roles, including preoperative patient evaluation, direct care of patients while hospitalized, and/or coordination of inpatient and outpatient postoperative care. Staffing requirements for hospitalists and/or mid‐level providers will differ significantly at different institutions based on surgical volume, patient complexity, and other local factors.
COMANAGEMENT AND QUALITY
Comanagement as a Family‐Centered Initiative
Development of a family‐centered culture of care, including care coordination, lies at the core of pediatric hospital medicine, particularly for CSHCNs.[25, 26] In the outpatient setting, family‐centered care has been associated with improved quality of care for CSHCNs.[27, 28] For families of hospitalized children, issues such as involvement in care and timely information transfer have been identified as high priorities.[29] An important tool for addressing these needs is family‐centered rounds (FCRs), which represent multidisciplinary rounds at the bedside involving families and patients as active shared decision makers in conjunction with the medical team.[30, 31] Although FCRs have not been studied in comanagement arrangements specifically, evidence suggests that this tool improves family centeredness and patient safety in nonsurgical patients,[32] and FCRs can likely have a similar impact on postoperative care.
A pediatric hospitalist comanagement program may impact quality and safety of care in a number of other ways. Hospitalists may offer improved access to clinical information for nurses and families, making care safer. One study of comanagement in adult neurosurgical patients found that access to hospitalists led to improved quality and safety of care as perceived by nurses and other members of the care team.[33] A study in pediatric patients found that nurses overwhelmingly supported having hospitalist involvement in complex children undergoing surgery; the same study found that pediatric hospitalists were particularly noted for their communication skills.[34]
Assessing Clinical Outcomes in Pediatric Hospitalist Comanagement Programs
Most studies evaluating the impact of surgical comanagement programs have focused on global metrics such as LOS, overall complication rates, and resource utilization. In adults, results of these studies have been mixed, suggesting that patient selection may be an important factor.[35] In pediatrics, 2 US studies have assessed these metrics at single centers. Simon et al. found that involvement of a pediatric hospitalist in comanagement of patients undergoing spinal fusion surgery significantly decreased LOS.[19] Rappaport et al. found that patients comanaged by hospitalists had lower utilization of laboratory tests and parenteral nutrition, though initial program costs significantly increased.[36] Studies outside the United States, including a study from Sweden,[37] have suggested that a multidisciplinary approach to children's surgical care, including the presence of pediatric specialists, reduced infection rate and other complications. These studies provide general support for the role of hospitalists in comanagement, although determining which aspects of care are most impacted may be difficult.
Comanagement programs might impact safety and quality negatively as well. Care may be fragmented, leading to provider and family dissatisfaction. Poor communication and multiple handoffs among multidisciplinary team members might interfere with the central role of the nurse in patient care.[38] Comanagement programs might lead to provider disengagement if providers feel that others will assume roles with which they may be unfamiliar or poorly trained.[35] This lack of knowledge may also affect communication with families, leading to conflicting messages among the care team and family frustration. In addition, the impact of comanagement programs on trainees such as residents, both surgical and pediatric, has received limited study.[39] Assessing pediatric comanagement programs' impact on communication, family‐centeredness, and trainees deserves further study.
FINANCIAL IMPLICATIONS OF PEDIATRIC COMANAGEMENT PROGRAMS
Children undergoing surgery require significant financial resources for their care. A study of 38 major US children's hospitals found that 3 of the top 10 conditions with the highest annual expenditures were surgical procedures.[4] The most costly procedure was spinal fusion for scoliosis, accounting for an average of $45,000 per admission and $610 million annually. Although a significant portion of these costs represented surgical devices and operating room time, these totals also included the cost of hospital services and in‐hospital complications. CSHCNs more often undergo high‐complexity procedures such as spinal fusions[36] and face greater risk for costly postoperative complications. The financial benefits that come from reductions in outcomes such as LOS and readmissions in this population are potentially large, but may depend on the payment model as described below.
Billing Models in Comanagement Programs
Several billing constructs exist in comanagement models. At many institutions, comanagement billing may resemble that for traditional consultation: the pediatric hospitalist bills for his/her services using standard initial and subsequent consultation billing coding for the child's medical conditions, and may sign off when the hospitalist feels recommendations are complete. Other models may also exist. Model IV comanagement may involve a prearranged financial agreement, in which billing modifiers are used to differentiate surgical care only (modifier 54) and postoperative medical care only (modifier 55). These modifiers, typically used for Medicare patients, indicate a split in a global surgical fee.[40]
The SHM has outlined financial considerations that should be addressed at the time of program inception and updated periodically, including identifying how each party will bill, who bills for which service, and monitoring collection rates and rejected claims.[2] Regardless of billing model, the main focus of comanagement must be quality of care, not financial considerations; situations in which the latter are emphasized at the expense of patient care may be unethical or illegal.[24] Regardless, surgical comanagement programs should seek maximal reimbursement in order to remain viable.
Value of Comanagement for a Healthcare Organization Under Fee‐for‐Service Payment
The value of any comanagement program is highly dependent on both the institution's payor mix and the healthcare organization's overarching goals. From a business perspective, a multidisciplinary approach may be perceived as resource intensive, but formal cost‐effectiveness analyses over time are limited. Theoretically, a traditional payment model involving hospitalist comanagement would be financially beneficial for a healthcare institution by allowing surgeons and surgical trainees more time to operate. However, these savings are difficult to quantify. Despite the fact that most hospitalist programs have no direct financial benefit to the institution, many hospital leaders seem willing to subsidize hospitalist programs based on measures such as patient and referring physician satisfaction with hospitalist care.[41] Postoperative complications, although unfortunate, may be a source of revenue under this model if paid by insurance companies in the usual manner, leading to a misalignment of quality and financial goals. Regardless, whether these programs are considered worthy investments to healthcare organizations will ultimately depend on evolving billing and reimbursement structures; to date, no formal survey of how comanagement programs bill and are reimbursed has been performed.
Value for an Organization in an Accountable Care Organization Model
Although a detailed discussion of accountable care organizations (ACOs) is beyond the scope of this article, stronger incentives in these structures for reducing resource utilization and complication rates may make hospitalist comanagement attractive in an ACO model.[42] ACO program evaluation is expected to be based on such data as patient surveys, documentation of care coordination, and several disease‐specific metrics.[43, 44] Several children's hospital‐based systems and mixed health systems have dedicated significant resources to establishing networks of providers that bridge inpatient and outpatient episodes of surgical care.[27, 28] One adult study has suggested lower costs associated with hospitalist comanagement for geriatric patients with hip fractures.[12] Comanagement programs may help meet quality and value goals, including enhancing care coordination between inpatient and outpatient care, and therefore may prove to be a beneficial investment for institutions. As the healthcare landscape evolves, formal study of the costs and benefits of pediatric comanagement models in ACO‐type care structures will be important.
SETTING A RESEARCH AGENDA
Pediatric hospitalist comanagement programs require vigorous study to evaluate their impact. Potential research targets include not only clinical data such as LOS, perioperative complication rates, readmission rates, and resource utilization, but also data regarding surgeon, nursing, and family satisfaction. These programs should also be evaluated in terms of how they impact trainees, both surgical and pediatric. Because of comanagement programs' complexities, we anticipate that they will impart both positive and negative effects on some of these factors. These programs will also require evaluation over time as they require significant education on the part of staff and families.[36]
In addition to affecting global metrics, pediatric hospitalists may also have a positive impact on surgical care by demonstrating leadership to improve systems of care relevant to surgical patients, including the use of guidelines. The American College of Surgeons' National Surgical Quality Improvement Program has identified 2 priorities that hospitalists may impact: surgical site infection (SSI) and pulmonary complications, which combined comprise greater than half of all 30‐day postoperative complications.[45] Regarding SSI prevention, hospitalist researchers are making valuable contributions to literature surrounding adherence to Centers for Disease Control and Prevention and Pediatric Orthopedic Society of North America guidelines.[46, 47, 48] Research is ongoing regarding how human and systems factors may impact the effectiveness of these guidelines, but also how reliably these guidelines are implemented.[49] In the area of pulmonary complications, pediatric hospitalists have followed the example of successful initiatives in adult surgery patients by developing and implementing postoperative protocols to prevent pulmonary complications such as postoperative pneumonia.[50] At 1 center, pediatric hospitalists have led efforts to implement a standardized respiratory care pathway for high‐risk orthopedic patients.[51] Evaluation of the effectiveness of such programs is currently ongoing, but early data show similar benefits to those demonstrated in adults.
CONCLUSIONS
Pediatric hospitalist comanagement programs for surgical patients have largely followed the path of adult programs. Limited data suggest that certain clinical outcomes may be improved under comanagement, but patient selection may be important. Although there is significant variety between programs, there exist several common themes, including the importance of clear delineation of roles and a central goal of improved care coordination. Ongoing research will hopefully shed more light on the impact of these programs, especially with regard to patient safety, hospitalist‐led quality‐improvement programs, and financial implications, particularly in different structures of care and reimbursement models.
Disclosure: Nothing to report.
According to the 2012 Society of Hospital Medicine (SHM) survey, 94% of adult hospitalists and 74% of pediatric hospitalists provide inpatient care to surgical patients.[1] Many of these programs involve comanagement, which the SHM Comanagement Advisory Panel has described as a system of care featuring shared responsibility, authority, and accountability for hospitalized patients with medical and surgical needs.[2] Collaboration between medical and surgical teams for these patients has occurred commonly at some community institutions for decades, but may only be emerging at some tertiary care hospitals. The trend of comanagement appears to be increasing in popularity in adult medicine.[3] As in adult patients, comanagement for children undergoing surgical procedures, particularly those children with special healthcare needs (CSHCNs), has been proposed as a strategy for improving quality and costs. In this review, we will describe structural, quality, and financial implications of pediatric hospitalist comanagement programs, each of which include both potential benefits and drawbacks, as well as discuss a future research agenda for these programs.
ORGANIZATIONAL NEEDS AND STRUCTURE OF COMANAGEMENT PROGRAMS
Patterns of comanagement likely depend on hospital size and structure, both in adult patients[3] and in pediatrics. Children hospitalized for surgical procedures generally fall into 1 of 2 groups: those who are typically healthy and at low risk for complications, and those who are medically complex and at high risk. Healthy children often undergo high‐prevalence, low‐complexity surgical procedures such as tonsillectomy and hernia repairs;[4] these patients are commonly cared for at community hospitals by adult and pediatric surgeons. Whereas medically complex children also undergo these common procedures, they are more likely to be cared for at tertiary care centers and are also more likely to undergo higher‐complexity surgeries such as spinal fusions, hip osteotomies, and ventriculoperitoneal shunt placements.[4] Hospitalist comanagement programs at community hospitals and tertiary care centers may therefore have evolved differently in response to different needs of patients, providers, and organizations,[5] though some institutions may not fall neatly into 1 of these 2 categories.
Comanagement in Community Hospitals
A significant number of pediatric patients are hospitalized each year in community hospitals.[6] As noted above, children undergoing surgery in these settings are generally healthy, and may be cared for by surgeons with varying amounts of pediatric expertise. In this model, the surgeon may frequently be offsite when not in the operating room, necessitating some type of onsite postoperative coverage. In pediatrics, following adult models, this coverage need may be relatively straightforward: surgeons perform the procedure, followed by a medical team assuming postoperative care with surgical consultation. Because of general surgeons' varying experience with children, the American Academy of Pediatrics suggests that patients younger than 14 years or weighing less than 40 kg cared for by providers without routine pediatric experience should have a pediatric‐trained provider involved in their care,[7] though this suggestion does not mandate comanagement.
For children cared for by adult providers who have little experience with areas of pediatric‐specific care such as medication dosing and assessment of deterioration, we believe that involvement of a pediatric provider may impact care in a number of ways. A pediatric hospitalist's availability on the inpatient unit may allow him or her to better manage routine issues such as pain control and intravenous fluids without surgeon input, improving the efficiency of care. A pediatric hospitalist's general pediatric training may allow him or her to more quickly recognize when a child is medically deteriorating, or when transfer to a tertiary care center may be necessary, making care safer. However, no studies have specifically examined these variables. Future research should measure outcomes such as transfers to higher levels of care, medication errors, length of stay (LOS), and complication rates, especially in community hospital settings.
Comanagement in Tertiary Care Referral Centers
At tertiary care referral centers, surgeries in children are most often performed by pediatric surgeons. In these settings, providing routine hospitalist comanagement to all patients may be neither cost‐effective nor feasible. Adult studies have suggested that population‐targeted models can significantly improve several clinical outcomes. For example, in several studies of patients 65 years and older hospitalized with hip fractures, comanagement with a geriatric hospitalist was associated with improved clinical outcomes and shortened LOS.[8, 9, 10, 11, 12]
An analogous group of pediatric patients to the geriatric population may be CSHCNs or children who are medically complex. Several frameworks have been proposed to identify these patients.[13] Many institutions classify medically complex patients as those with complex chronic medical conditions (CCCs).[13, 14, 15] One framework to identify CSHCNs suggested including not only children with CCCs, but also those with (1) substantial service needs and/or family burden; (2) severe functional limitations; and/or (3) high rates of healthcare system utilization, often requiring the care of several subspecialty providers.[16] As the needs of these patients may be quite diverse, pediatric hospitalists may be involved in many aspects of their care, from preoperative evaluation,[17] to establishing protocols for best practices, to communicating with primary care providers, and even seeing patients in postoperative follow‐up clinics. These patients are known to be at high risk for surgical complications, readmissions,[14] medical errors,[18] lapses in communication, and high care costs. In 1 study, comanagement for children with neuromuscular scoliosis hospitalized for spinal fusion surgery has been associated with shorter LOS and less variability in LOS.[19] However, drawbacks of comanagement programs involving CSHCNs may include difficulty with consistent identification of the population who will most benefit from comanagement and higher initial costs of care.[18]
Models of Comanagement and Comanagement Agreements
A comanagement agreement should address 5 major questions: (1) Who is the primary service? (2) Who is the consulting/comanaging service? (3) Are consults as‐needed or automatic? (4) Who writes orders for the patient? (5) Which staffing model will be used for patient care?[20] Although each question above may be answered differently in different systems, the correct comanagement program is a program that aligns most closely with the patient population and care setting.[11, 20]
Several different models exist for hospitalistsurgeon comanagement programs[20, 21] (Table 1). Under the consultation model (model I), hospitalists become involved in the care of surgical patients only when requested to do so by the surgical team. Criteria for requesting this kind of consultation and the extent of responsibility afforded to the medical team are often not clearly defined, and may differ from hospital to hospital or even surgeon to surgeon.[22] Hospitalist involvement with adult patients with postoperative medical complications, which presumably employed this as‐needed model, has been associated with lower mortality and LOS[23]; whether this involvement provides similar benefits in children with postoperative complications has not been explicitly studied.
| Model | Attending Service | Consulting Service | Automatic Consultation | Who Writes Orders? | Notes |
|---|---|---|---|---|---|
| |||||
| I | Surgery | Pediatrics | No | Surgery | Similar to traditional consultation |
| II | Surgery | Pediatrics | Yes | Usually surgery | Basic comanagement, consultant may sign off |
| III | Pediatrics | Surgery | Yes | Usually pediatrics | Basic comanagement, consultant may sign off |
| IV | Combined | N/A | N/A | Each service writes own | True comanagement, no sign‐off from either service permitted |
The remaining models involve compulsory participation by both surgical and medical services. In models II and III, patients may be evaluated preoperatively; those felt to meet specific criteria for high medical complexity are either admitted to a medical service with automatic surgical consultation or admitted to a surgical service with automatic medical consultation. In both cases, writing of orders is handled in the same manner as any consultation model; depending on the service agreement, consulting services may sign off or may be required to be involved until discharge. In model IV, care is fully comanaged by medical and surgical services, with each service having ownership over orders pertaining to their discipline. Ethical concerns about such agreements outlined by the American Medical Association include whether all patients cared for under agreements II to IV will truly benefit from the cost of multispecialty care, and whether informed consent from patients themselves should be required given the cost implications.[24]
Comanagement models also vary with respect to frontline provider staffing. Models may incorporate nurse practitioners, hospitalists, physician assistants, or a combination thereof. These providers may assume a variety of roles, including preoperative patient evaluation, direct care of patients while hospitalized, and/or coordination of inpatient and outpatient postoperative care. Staffing requirements for hospitalists and/or mid‐level providers will differ significantly at different institutions based on surgical volume, patient complexity, and other local factors.
COMANAGEMENT AND QUALITY
Comanagement as a Family‐Centered Initiative
Development of a family‐centered culture of care, including care coordination, lies at the core of pediatric hospital medicine, particularly for CSHCNs.[25, 26] In the outpatient setting, family‐centered care has been associated with improved quality of care for CSHCNs.[27, 28] For families of hospitalized children, issues such as involvement in care and timely information transfer have been identified as high priorities.[29] An important tool for addressing these needs is family‐centered rounds (FCRs), which represent multidisciplinary rounds at the bedside involving families and patients as active shared decision makers in conjunction with the medical team.[30, 31] Although FCRs have not been studied in comanagement arrangements specifically, evidence suggests that this tool improves family centeredness and patient safety in nonsurgical patients,[32] and FCRs can likely have a similar impact on postoperative care.
A pediatric hospitalist comanagement program may impact quality and safety of care in a number of other ways. Hospitalists may offer improved access to clinical information for nurses and families, making care safer. One study of comanagement in adult neurosurgical patients found that access to hospitalists led to improved quality and safety of care as perceived by nurses and other members of the care team.[33] A study in pediatric patients found that nurses overwhelmingly supported having hospitalist involvement in complex children undergoing surgery; the same study found that pediatric hospitalists were particularly noted for their communication skills.[34]
Assessing Clinical Outcomes in Pediatric Hospitalist Comanagement Programs
Most studies evaluating the impact of surgical comanagement programs have focused on global metrics such as LOS, overall complication rates, and resource utilization. In adults, results of these studies have been mixed, suggesting that patient selection may be an important factor.[35] In pediatrics, 2 US studies have assessed these metrics at single centers. Simon et al. found that involvement of a pediatric hospitalist in comanagement of patients undergoing spinal fusion surgery significantly decreased LOS.[19] Rappaport et al. found that patients comanaged by hospitalists had lower utilization of laboratory tests and parenteral nutrition, though initial program costs significantly increased.[36] Studies outside the United States, including a study from Sweden,[37] have suggested that a multidisciplinary approach to children's surgical care, including the presence of pediatric specialists, reduced infection rate and other complications. These studies provide general support for the role of hospitalists in comanagement, although determining which aspects of care are most impacted may be difficult.
Comanagement programs might impact safety and quality negatively as well. Care may be fragmented, leading to provider and family dissatisfaction. Poor communication and multiple handoffs among multidisciplinary team members might interfere with the central role of the nurse in patient care.[38] Comanagement programs might lead to provider disengagement if providers feel that others will assume roles with which they may be unfamiliar or poorly trained.[35] This lack of knowledge may also affect communication with families, leading to conflicting messages among the care team and family frustration. In addition, the impact of comanagement programs on trainees such as residents, both surgical and pediatric, has received limited study.[39] Assessing pediatric comanagement programs' impact on communication, family‐centeredness, and trainees deserves further study.
FINANCIAL IMPLICATIONS OF PEDIATRIC COMANAGEMENT PROGRAMS
Children undergoing surgery require significant financial resources for their care. A study of 38 major US children's hospitals found that 3 of the top 10 conditions with the highest annual expenditures were surgical procedures.[4] The most costly procedure was spinal fusion for scoliosis, accounting for an average of $45,000 per admission and $610 million annually. Although a significant portion of these costs represented surgical devices and operating room time, these totals also included the cost of hospital services and in‐hospital complications. CSHCNs more often undergo high‐complexity procedures such as spinal fusions[36] and face greater risk for costly postoperative complications. The financial benefits that come from reductions in outcomes such as LOS and readmissions in this population are potentially large, but may depend on the payment model as described below.
Billing Models in Comanagement Programs
Several billing constructs exist in comanagement models. At many institutions, comanagement billing may resemble that for traditional consultation: the pediatric hospitalist bills for his/her services using standard initial and subsequent consultation billing coding for the child's medical conditions, and may sign off when the hospitalist feels recommendations are complete. Other models may also exist. Model IV comanagement may involve a prearranged financial agreement, in which billing modifiers are used to differentiate surgical care only (modifier 54) and postoperative medical care only (modifier 55). These modifiers, typically used for Medicare patients, indicate a split in a global surgical fee.[40]
The SHM has outlined financial considerations that should be addressed at the time of program inception and updated periodically, including identifying how each party will bill, who bills for which service, and monitoring collection rates and rejected claims.[2] Regardless of billing model, the main focus of comanagement must be quality of care, not financial considerations; situations in which the latter are emphasized at the expense of patient care may be unethical or illegal.[24] Regardless, surgical comanagement programs should seek maximal reimbursement in order to remain viable.
Value of Comanagement for a Healthcare Organization Under Fee‐for‐Service Payment
The value of any comanagement program is highly dependent on both the institution's payor mix and the healthcare organization's overarching goals. From a business perspective, a multidisciplinary approach may be perceived as resource intensive, but formal cost‐effectiveness analyses over time are limited. Theoretically, a traditional payment model involving hospitalist comanagement would be financially beneficial for a healthcare institution by allowing surgeons and surgical trainees more time to operate. However, these savings are difficult to quantify. Despite the fact that most hospitalist programs have no direct financial benefit to the institution, many hospital leaders seem willing to subsidize hospitalist programs based on measures such as patient and referring physician satisfaction with hospitalist care.[41] Postoperative complications, although unfortunate, may be a source of revenue under this model if paid by insurance companies in the usual manner, leading to a misalignment of quality and financial goals. Regardless, whether these programs are considered worthy investments to healthcare organizations will ultimately depend on evolving billing and reimbursement structures; to date, no formal survey of how comanagement programs bill and are reimbursed has been performed.
Value for an Organization in an Accountable Care Organization Model
Although a detailed discussion of accountable care organizations (ACOs) is beyond the scope of this article, stronger incentives in these structures for reducing resource utilization and complication rates may make hospitalist comanagement attractive in an ACO model.[42] ACO program evaluation is expected to be based on such data as patient surveys, documentation of care coordination, and several disease‐specific metrics.[43, 44] Several children's hospital‐based systems and mixed health systems have dedicated significant resources to establishing networks of providers that bridge inpatient and outpatient episodes of surgical care.[27, 28] One adult study has suggested lower costs associated with hospitalist comanagement for geriatric patients with hip fractures.[12] Comanagement programs may help meet quality and value goals, including enhancing care coordination between inpatient and outpatient care, and therefore may prove to be a beneficial investment for institutions. As the healthcare landscape evolves, formal study of the costs and benefits of pediatric comanagement models in ACO‐type care structures will be important.
SETTING A RESEARCH AGENDA
Pediatric hospitalist comanagement programs require vigorous study to evaluate their impact. Potential research targets include not only clinical data such as LOS, perioperative complication rates, readmission rates, and resource utilization, but also data regarding surgeon, nursing, and family satisfaction. These programs should also be evaluated in terms of how they impact trainees, both surgical and pediatric. Because of comanagement programs' complexities, we anticipate that they will impart both positive and negative effects on some of these factors. These programs will also require evaluation over time as they require significant education on the part of staff and families.[36]
In addition to affecting global metrics, pediatric hospitalists may also have a positive impact on surgical care by demonstrating leadership to improve systems of care relevant to surgical patients, including the use of guidelines. The American College of Surgeons' National Surgical Quality Improvement Program has identified 2 priorities that hospitalists may impact: surgical site infection (SSI) and pulmonary complications, which combined comprise greater than half of all 30‐day postoperative complications.[45] Regarding SSI prevention, hospitalist researchers are making valuable contributions to literature surrounding adherence to Centers for Disease Control and Prevention and Pediatric Orthopedic Society of North America guidelines.[46, 47, 48] Research is ongoing regarding how human and systems factors may impact the effectiveness of these guidelines, but also how reliably these guidelines are implemented.[49] In the area of pulmonary complications, pediatric hospitalists have followed the example of successful initiatives in adult surgery patients by developing and implementing postoperative protocols to prevent pulmonary complications such as postoperative pneumonia.[50] At 1 center, pediatric hospitalists have led efforts to implement a standardized respiratory care pathway for high‐risk orthopedic patients.[51] Evaluation of the effectiveness of such programs is currently ongoing, but early data show similar benefits to those demonstrated in adults.
CONCLUSIONS
Pediatric hospitalist comanagement programs for surgical patients have largely followed the path of adult programs. Limited data suggest that certain clinical outcomes may be improved under comanagement, but patient selection may be important. Although there is significant variety between programs, there exist several common themes, including the importance of clear delineation of roles and a central goal of improved care coordination. Ongoing research will hopefully shed more light on the impact of these programs, especially with regard to patient safety, hospitalist‐led quality‐improvement programs, and financial implications, particularly in different structures of care and reimbursement models.
Disclosure: Nothing to report.
- 2012 State of Hospital Medicine Report, Society of Hospital Medicine. Available at: http://www.hospitalmedicine.org/survey. Accessed on September 1, 2014.
- Society of Hospital Medicine Co‐Management Advisory Panel. A white paper on a guide to hospitalist/orthopedic surgery co‐management. SHM website. Available at: http://tools.hospitalmedicine.org/Implementation/Co‐ManagementWhitePaper‐final_5‐10‐10.pdf. Accessed on September 25, 2014.
- , , , , . Comanagement of hospitalized surgical patients by medicine physicians in the United States. Arch Intern Med. 2010;170(4):363–368.
- , , , et al. Prioritization of comparative effectiveness research topics in hospital pediatrics. Arch Pediatr Adolesc Med. 2012;166(12):1155–1164.
- , . Pediatric hospitalist comanagement of surgical patients: challenges and opportunities. Clin Pediatr (Phila). 2008;47(2):114–121.
- , . Utilization of pediatric hospitals in New York State. Pediatrics. 2003;111(5 pt 1):1068–1071.
- ; Committee on Hospital Care. Physicians' roles in coordinating care of hospitalized children. Pediatrics. 2003;111(3):707–709.
- , , , et al. Effects of a hospitalist care model on mortality of elderly patients with hip fractures. J Hosp Med. 2007;2(4):219–225.
- , , , et al. Effects of a hospitalist model on elderly patients with hip fracture. Arch Intern Med. 2005;165(7):796–801.
- , , , , , . Outcomes for older patients with hip fractures: the impact of orthopedic and geriatric medicine cocare. J Orthop Trauma. 2006;20(3):172–178; discussion 179–180.
- , , , . Geriatric co‐management of proximal femur fractures: total quality management and protocol‐driven care result in better outcomes for a frail patient population. J Am Geriatr Soc. 2008;56(7):1349–1356.
- , , , , , . Comanagement of geriatric patients with hip fractures: a retrospective, controlled, cohort study. Geriatr Orthop Surg Rehabil. 2013;4(1):10–15.
- , , , et al. Children with medical complexity: an emerging population for clinical and research initiatives. Pediatrics. 2011;127(3):529–538.
- , , , et al. How well can hospital readmission be predicted in a cohort of hospitalized children? A retrospective, multicenter study. Pediatrics. 2009;123(1):286–293.
- , , . Pediatric hospital medicine and children with medical complexity: past, present, and future. Curr Probl Pediatr Adolesc Health Care. 2012;42(5):113–119.
- , , , et al. A new definition of children with special health care needs. Pediatrics. 1998;102(1 pt 1):137–140.
- , , , , . Pediatric hospitalist preoperative evaluation of children with neuromuscular scoliosis. J Hosp Med. 2013;8(12):684–688.
- , , , , . Hospital admission medication reconciliation in medically complex children: an observational study. Arch Dis Child. 2010;95(4):250–255.
- , , , , , . Pediatric hospitalist comanagement of spinal fusion surgery patients. J Hosp Med. 2007;2(1):23–30.
- , . Principles of comanagement and the geriatric fracture center. Clin Geriatr Med. 2014;30(2):183–189.
- . How best to design surgical comanagement services for pediatric surgical patients? Hosp Pediatr. 2013;3(3):242–243.
- , , , , , . Effects of provider characteristics on care coordination under comanagement. J Hosp Med. 2010;5(9):508–513.
- , , , . Potential role of comanagement in “rescue” of surgical patients. Am J Manag Care. 2011;17(9):e333–e339.
- American Medical Association. 2008 report of the Council on Medical Service, policy sunset report for 1998 AMA socioeconomic policies. CMS Report 4, A‐08. Available at: http://www.ama‐assn.org/resources/doc/cms/a‐08cms4.pdf. Accessed on September 1, 2014.
- Committee on Hospital Care and Institute for Patient‐and Family‐Centered Care. Patient‐ and family‐centered care and the pediatrician's role. Pediatrics. 2012;129(2):394–404.
- Council on Children with Disabilities and Medical Home Implementation Project Advisory Committee. Patient‐ and family‐centered care coordination: a framework for integrating care for children and youth across multiple systems. Pediatrics. 2014;133(5):e1451–e1460.
- , , , , , . Care coordination for CSHCN: associations with family‐provider relations and family/child outcomes. Pediatrics. 2009;124(suppl 4):S428–S434.
- , , , et al. Evidence for family‐centered care for children with special health care needs: a systematic review. Acad Pediatr. 2011;11(2):136–143.
- , , . Parents' priorities and satisfaction with acute pediatric care. Arch Pediatr Adolesc Med. 2005;159(2):127–131.
- . Family‐centered rounds. Pediatr Clin North Am. 2014;61(4):663–670.
- , , , et al. Family‐centered rounds on pediatric wards: a PRIS network survey of US and Canadian hospitalists. Pediatrics. 2010;126(1):37–43.
- , , , , ; PIPS Group. Scoping review and approach to appraisal of interventions intended to involve patients in patient safety. J Health Serv Res Policy. 2010;15(suppl 1):17–25.
- , , , et al. Comanagement of surgical patients between neurosurgeons and hospitalists. Arch Intern Med. 2010;170(22):2004–2010.
- , , . Nurses' assessment of pediatric physicians: are hospitalists different? J Healthc Manag Am Coll Healthc Exec. 2008;53(1):14–24; discussion 24–25.
- . Just because you can, doesn't mean that you should: a call for the rational application of hospitalist comanagement. J Hosp Med. 2008;3(5):398–402.
- , , , et al. Outcomes and costs associated with hospitalist comanagement of medically complex children undergoing spinal fusion surgery. Hosp Pediatr. 2013;3(3):233–241.
- , , . Outcome of major spinal deformity surgery in high‐risk patients: comparison between two departments. Evid Based Spine Care J. 2010;1(3):11–18.
- , , , , , . Meeting the complex needs of the health care team: identification of nurse‐team communication practices perceived to enhance patient outcomes. Qual Health Res. 2010;20(1):15–28.
- , , , . A pediatric residency experience with surgical comanagement. Hosp Pediatr. 2013;3(2):144–148.
- U.S. Department of Health and Human Services. Centers for Medicaid and Medicare Services. MLN matters. Available at: http://www.cms.gov/Outreach‐and‐Education/Medicare‐Learning‐Network‐MLN/MLNMattersArticles/Downloads/MM7872.pdf. Accessed on September 1,2014.
- , , ; Research Advisory Committee of the American Board of Pediatrics. Assessing the value of pediatric hospitalist programs: the perspective of hospital leaders. Acad Pediatr. 2009;9(3):192–196.
- . Launching accountable care organizations—the proposed rule for the Medicare Shared Savings Program. N Engl J Med. 2011;364(16):e32.
- American Academy of Pediatrics. Accountable Care Organizations (ACOs) and Pediatricians: Evaluation and Engagement. Available at: http://www.aap.org/en‐us/professional‐resources/practice‐support/Pages/Accountable‐Care‐Organizations‐and‐Pediatricians‐Evaluation‐and‐Engagement.aspx. Accessed on September 25, 2014.
- , , , , . Delivery system characteristics and their association with quality and costs of care: implications for accountable care organizations [published online ahead of print February 21, 2014]. Health Care Manage Rev. doi: 10.1097/HMR.0000000000000014.
- , , , et al. Pediatric American College of Surgeons National Surgical Quality Improvement Program: feasibility of a novel, prospective assessment of surgical outcomes. J Pediatr Surg. 2011;46(1):115–121.
- , , , et al. Guideline for prevention of surgical site infection. Infect Control Hosp Epidemiol. 1999;20(4):247–278. Available at: http://www.cdc.gov/hicpac/pdf/guidelines/SSI_1999.pdf. Accessed on September 1, 2014.
- , , , et al. Building consensus: development of a Best Practice Guideline (BPG) for surgical site infection (SSI) prevention in high‐risk pediatric spine surgery. J Pediatr Orthop. 2013;33(5):471–478.
- , , , et al. Perioperative antibiotic use for spinal surgery procedures in US children's hospitals. Spine. 2013;38(7):609–616. Available at: http://www.ihi.org/education/Conferences/Forum2013/Pages/Scientific‐Symposium.aspx. Accessed on September 26, 2014.
- , , , , , , , , , , , . A human factors intervention to improve post‐operative antibiotic timing and prevent surgical site infection. Paper presented at: Institute for Healthcare Improvement Scientific Symposium; 2013; Orlando, FL. Abstract.
- , , , , . I COUGH: reducing postoperative pulmonary complications with a multidisciplinary patient care program. JAMA Surg. 2013;148(8):740–745. Available at: http://www.ihi.org/education/Conferences/Forum2013/Pages/Scientific‐Symposium.aspx. Accessed on September 26, 2014.
- , , , , , , , . Early postoperative respiratory care improves outcomes, adds value for hospitalized pediatric orthopedic patients. Poster presented at: Institute for Healthcare Improvement Scientific Symposium; 2013; Orlando, FL. Abstract.
- 2012 State of Hospital Medicine Report, Society of Hospital Medicine. Available at: http://www.hospitalmedicine.org/survey. Accessed on September 1, 2014.
- Society of Hospital Medicine Co‐Management Advisory Panel. A white paper on a guide to hospitalist/orthopedic surgery co‐management. SHM website. Available at: http://tools.hospitalmedicine.org/Implementation/Co‐ManagementWhitePaper‐final_5‐10‐10.pdf. Accessed on September 25, 2014.
- , , , , . Comanagement of hospitalized surgical patients by medicine physicians in the United States. Arch Intern Med. 2010;170(4):363–368.
- , , , et al. Prioritization of comparative effectiveness research topics in hospital pediatrics. Arch Pediatr Adolesc Med. 2012;166(12):1155–1164.
- , . Pediatric hospitalist comanagement of surgical patients: challenges and opportunities. Clin Pediatr (Phila). 2008;47(2):114–121.
- , . Utilization of pediatric hospitals in New York State. Pediatrics. 2003;111(5 pt 1):1068–1071.
- ; Committee on Hospital Care. Physicians' roles in coordinating care of hospitalized children. Pediatrics. 2003;111(3):707–709.
- , , , et al. Effects of a hospitalist care model on mortality of elderly patients with hip fractures. J Hosp Med. 2007;2(4):219–225.
- , , , et al. Effects of a hospitalist model on elderly patients with hip fracture. Arch Intern Med. 2005;165(7):796–801.
- , , , , , . Outcomes for older patients with hip fractures: the impact of orthopedic and geriatric medicine cocare. J Orthop Trauma. 2006;20(3):172–178; discussion 179–180.
- , , , . Geriatric co‐management of proximal femur fractures: total quality management and protocol‐driven care result in better outcomes for a frail patient population. J Am Geriatr Soc. 2008;56(7):1349–1356.
- , , , , , . Comanagement of geriatric patients with hip fractures: a retrospective, controlled, cohort study. Geriatr Orthop Surg Rehabil. 2013;4(1):10–15.
- , , , et al. Children with medical complexity: an emerging population for clinical and research initiatives. Pediatrics. 2011;127(3):529–538.
- , , , et al. How well can hospital readmission be predicted in a cohort of hospitalized children? A retrospective, multicenter study. Pediatrics. 2009;123(1):286–293.
- , , . Pediatric hospital medicine and children with medical complexity: past, present, and future. Curr Probl Pediatr Adolesc Health Care. 2012;42(5):113–119.
- , , , et al. A new definition of children with special health care needs. Pediatrics. 1998;102(1 pt 1):137–140.
- , , , , . Pediatric hospitalist preoperative evaluation of children with neuromuscular scoliosis. J Hosp Med. 2013;8(12):684–688.
- , , , , . Hospital admission medication reconciliation in medically complex children: an observational study. Arch Dis Child. 2010;95(4):250–255.
- , , , , , . Pediatric hospitalist comanagement of spinal fusion surgery patients. J Hosp Med. 2007;2(1):23–30.
- , . Principles of comanagement and the geriatric fracture center. Clin Geriatr Med. 2014;30(2):183–189.
- . How best to design surgical comanagement services for pediatric surgical patients? Hosp Pediatr. 2013;3(3):242–243.
- , , , , , . Effects of provider characteristics on care coordination under comanagement. J Hosp Med. 2010;5(9):508–513.
- , , , . Potential role of comanagement in “rescue” of surgical patients. Am J Manag Care. 2011;17(9):e333–e339.
- American Medical Association. 2008 report of the Council on Medical Service, policy sunset report for 1998 AMA socioeconomic policies. CMS Report 4, A‐08. Available at: http://www.ama‐assn.org/resources/doc/cms/a‐08cms4.pdf. Accessed on September 1, 2014.
- Committee on Hospital Care and Institute for Patient‐and Family‐Centered Care. Patient‐ and family‐centered care and the pediatrician's role. Pediatrics. 2012;129(2):394–404.
- Council on Children with Disabilities and Medical Home Implementation Project Advisory Committee. Patient‐ and family‐centered care coordination: a framework for integrating care for children and youth across multiple systems. Pediatrics. 2014;133(5):e1451–e1460.
- , , , , , . Care coordination for CSHCN: associations with family‐provider relations and family/child outcomes. Pediatrics. 2009;124(suppl 4):S428–S434.
- , , , et al. Evidence for family‐centered care for children with special health care needs: a systematic review. Acad Pediatr. 2011;11(2):136–143.
- , , . Parents' priorities and satisfaction with acute pediatric care. Arch Pediatr Adolesc Med. 2005;159(2):127–131.
- . Family‐centered rounds. Pediatr Clin North Am. 2014;61(4):663–670.
- , , , et al. Family‐centered rounds on pediatric wards: a PRIS network survey of US and Canadian hospitalists. Pediatrics. 2010;126(1):37–43.
- , , , , ; PIPS Group. Scoping review and approach to appraisal of interventions intended to involve patients in patient safety. J Health Serv Res Policy. 2010;15(suppl 1):17–25.
- , , , et al. Comanagement of surgical patients between neurosurgeons and hospitalists. Arch Intern Med. 2010;170(22):2004–2010.
- , , . Nurses' assessment of pediatric physicians: are hospitalists different? J Healthc Manag Am Coll Healthc Exec. 2008;53(1):14–24; discussion 24–25.
- . Just because you can, doesn't mean that you should: a call for the rational application of hospitalist comanagement. J Hosp Med. 2008;3(5):398–402.
- , , , et al. Outcomes and costs associated with hospitalist comanagement of medically complex children undergoing spinal fusion surgery. Hosp Pediatr. 2013;3(3):233–241.
- , , . Outcome of major spinal deformity surgery in high‐risk patients: comparison between two departments. Evid Based Spine Care J. 2010;1(3):11–18.
- , , , , , . Meeting the complex needs of the health care team: identification of nurse‐team communication practices perceived to enhance patient outcomes. Qual Health Res. 2010;20(1):15–28.
- , , , . A pediatric residency experience with surgical comanagement. Hosp Pediatr. 2013;3(2):144–148.
- U.S. Department of Health and Human Services. Centers for Medicaid and Medicare Services. MLN matters. Available at: http://www.cms.gov/Outreach‐and‐Education/Medicare‐Learning‐Network‐MLN/MLNMattersArticles/Downloads/MM7872.pdf. Accessed on September 1,2014.
- , , ; Research Advisory Committee of the American Board of Pediatrics. Assessing the value of pediatric hospitalist programs: the perspective of hospital leaders. Acad Pediatr. 2009;9(3):192–196.
- . Launching accountable care organizations—the proposed rule for the Medicare Shared Savings Program. N Engl J Med. 2011;364(16):e32.
- American Academy of Pediatrics. Accountable Care Organizations (ACOs) and Pediatricians: Evaluation and Engagement. Available at: http://www.aap.org/en‐us/professional‐resources/practice‐support/Pages/Accountable‐Care‐Organizations‐and‐Pediatricians‐Evaluation‐and‐Engagement.aspx. Accessed on September 25, 2014.
- , , , , . Delivery system characteristics and their association with quality and costs of care: implications for accountable care organizations [published online ahead of print February 21, 2014]. Health Care Manage Rev. doi: 10.1097/HMR.0000000000000014.
- , , , et al. Pediatric American College of Surgeons National Surgical Quality Improvement Program: feasibility of a novel, prospective assessment of surgical outcomes. J Pediatr Surg. 2011;46(1):115–121.
- , , , et al. Guideline for prevention of surgical site infection. Infect Control Hosp Epidemiol. 1999;20(4):247–278. Available at: http://www.cdc.gov/hicpac/pdf/guidelines/SSI_1999.pdf. Accessed on September 1, 2014.
- , , , et al. Building consensus: development of a Best Practice Guideline (BPG) for surgical site infection (SSI) prevention in high‐risk pediatric spine surgery. J Pediatr Orthop. 2013;33(5):471–478.
- , , , et al. Perioperative antibiotic use for spinal surgery procedures in US children's hospitals. Spine. 2013;38(7):609–616. Available at: http://www.ihi.org/education/Conferences/Forum2013/Pages/Scientific‐Symposium.aspx. Accessed on September 26, 2014.
- , , , , , , , , , , , . A human factors intervention to improve post‐operative antibiotic timing and prevent surgical site infection. Paper presented at: Institute for Healthcare Improvement Scientific Symposium; 2013; Orlando, FL. Abstract.
- , , , , . I COUGH: reducing postoperative pulmonary complications with a multidisciplinary patient care program. JAMA Surg. 2013;148(8):740–745. Available at: http://www.ihi.org/education/Conferences/Forum2013/Pages/Scientific‐Symposium.aspx. Accessed on September 26, 2014.
- , , , , , , , . Early postoperative respiratory care improves outcomes, adds value for hospitalized pediatric orthopedic patients. Poster presented at: Institute for Healthcare Improvement Scientific Symposium; 2013; Orlando, FL. Abstract.
Novel capsule could replace injections
Credit: USDA
Scientists have created a novel drug capsule coated with tiny needles that can inject drugs directly into the lining of the stomach after the capsule is swallowed.
In experiments with pigs, the capsule delivered insulin more efficiently than an injection under the skin, and there were no harmful side effects as the capsule passed through the digestive system.
The researchers anticipate the capsule would be most useful for delivering biopharmaceuticals such as antibodies to treat cancers and other disorders.
“This could be a way that the patient can circumvent the need to have an infusion or subcutaneous administration of a drug,” said Giovanni Traverso, MB BChir, PhD, of Massachusetts General Hospital in Boston.
He and his colleagues described their capsule in the Journal of Pharmaceutical Sciences.
The team had set out to design a capsule that would serve as a platform for the delivery of a wide range of therapeutics, prevent degradation of the drugs, and inject the payload directly into the lining of the gastrointestinal tract.
Their prototype acrylic capsule, 2 cm long and 1 cm in diameter, includes a reservoir for the drug and is coated with hollow, stainless steel needles about 5 mm long.
Previous studies of accidental ingestion of sharp objects in human patients have suggested that it could be safe to swallow a capsule coated with short needles. Because there are no pain receptors in the gastrointestinal tract, patients would not feel any pain from the drug injection.
To test whether this type of capsule could allow safe and effective drug delivery, the researchers tested it in pigs, with insulin as the drug payload.
It took more than a week for the capsules to move through the entire digestive tract, and the researchers found no traces of tissue damage, supporting the potential safety of this novel approach.
They also found the microneedles successfully injected insulin into the lining of the stomach, small intestine, and colon, causing the animals’ blood glucose levels to drop. This reduction in blood glucose was faster and larger than the drop seen when the same amount of glucose was given by subcutaneous injection.
“The kinetics are much better, and much faster-onset, than those seen with traditional under-the-skin administration,” Dr Traverso said. “For molecules that are particularly difficult to absorb, this would be a way of actually administering them at much higher efficiency.”
This approach could also be used to administer vaccines that normally have to be injected, the researchers said.
The team now plans to modify the capsule so that peristalsis would slowly squeeze the drug out of the capsule as it travels through the digestive tract.
They are also working on capsules with needles made of degradable polymers and sugar that would break off and become embedded in the gut lining, where they would slowly disintegrate and release the drug. This would further minimize any safety concern.
Credit: USDA
Scientists have created a novel drug capsule coated with tiny needles that can inject drugs directly into the lining of the stomach after the capsule is swallowed.
In experiments with pigs, the capsule delivered insulin more efficiently than an injection under the skin, and there were no harmful side effects as the capsule passed through the digestive system.
The researchers anticipate the capsule would be most useful for delivering biopharmaceuticals such as antibodies to treat cancers and other disorders.
“This could be a way that the patient can circumvent the need to have an infusion or subcutaneous administration of a drug,” said Giovanni Traverso, MB BChir, PhD, of Massachusetts General Hospital in Boston.
He and his colleagues described their capsule in the Journal of Pharmaceutical Sciences.
The team had set out to design a capsule that would serve as a platform for the delivery of a wide range of therapeutics, prevent degradation of the drugs, and inject the payload directly into the lining of the gastrointestinal tract.
Their prototype acrylic capsule, 2 cm long and 1 cm in diameter, includes a reservoir for the drug and is coated with hollow, stainless steel needles about 5 mm long.
Previous studies of accidental ingestion of sharp objects in human patients have suggested that it could be safe to swallow a capsule coated with short needles. Because there are no pain receptors in the gastrointestinal tract, patients would not feel any pain from the drug injection.
To test whether this type of capsule could allow safe and effective drug delivery, the researchers tested it in pigs, with insulin as the drug payload.
It took more than a week for the capsules to move through the entire digestive tract, and the researchers found no traces of tissue damage, supporting the potential safety of this novel approach.
They also found the microneedles successfully injected insulin into the lining of the stomach, small intestine, and colon, causing the animals’ blood glucose levels to drop. This reduction in blood glucose was faster and larger than the drop seen when the same amount of glucose was given by subcutaneous injection.
“The kinetics are much better, and much faster-onset, than those seen with traditional under-the-skin administration,” Dr Traverso said. “For molecules that are particularly difficult to absorb, this would be a way of actually administering them at much higher efficiency.”
This approach could also be used to administer vaccines that normally have to be injected, the researchers said.
The team now plans to modify the capsule so that peristalsis would slowly squeeze the drug out of the capsule as it travels through the digestive tract.
They are also working on capsules with needles made of degradable polymers and sugar that would break off and become embedded in the gut lining, where they would slowly disintegrate and release the drug. This would further minimize any safety concern.
Credit: USDA
Scientists have created a novel drug capsule coated with tiny needles that can inject drugs directly into the lining of the stomach after the capsule is swallowed.
In experiments with pigs, the capsule delivered insulin more efficiently than an injection under the skin, and there were no harmful side effects as the capsule passed through the digestive system.
The researchers anticipate the capsule would be most useful for delivering biopharmaceuticals such as antibodies to treat cancers and other disorders.
“This could be a way that the patient can circumvent the need to have an infusion or subcutaneous administration of a drug,” said Giovanni Traverso, MB BChir, PhD, of Massachusetts General Hospital in Boston.
He and his colleagues described their capsule in the Journal of Pharmaceutical Sciences.
The team had set out to design a capsule that would serve as a platform for the delivery of a wide range of therapeutics, prevent degradation of the drugs, and inject the payload directly into the lining of the gastrointestinal tract.
Their prototype acrylic capsule, 2 cm long and 1 cm in diameter, includes a reservoir for the drug and is coated with hollow, stainless steel needles about 5 mm long.
Previous studies of accidental ingestion of sharp objects in human patients have suggested that it could be safe to swallow a capsule coated with short needles. Because there are no pain receptors in the gastrointestinal tract, patients would not feel any pain from the drug injection.
To test whether this type of capsule could allow safe and effective drug delivery, the researchers tested it in pigs, with insulin as the drug payload.
It took more than a week for the capsules to move through the entire digestive tract, and the researchers found no traces of tissue damage, supporting the potential safety of this novel approach.
They also found the microneedles successfully injected insulin into the lining of the stomach, small intestine, and colon, causing the animals’ blood glucose levels to drop. This reduction in blood glucose was faster and larger than the drop seen when the same amount of glucose was given by subcutaneous injection.
“The kinetics are much better, and much faster-onset, than those seen with traditional under-the-skin administration,” Dr Traverso said. “For molecules that are particularly difficult to absorb, this would be a way of actually administering them at much higher efficiency.”
This approach could also be used to administer vaccines that normally have to be injected, the researchers said.
The team now plans to modify the capsule so that peristalsis would slowly squeeze the drug out of the capsule as it travels through the digestive tract.
They are also working on capsules with needles made of degradable polymers and sugar that would break off and become embedded in the gut lining, where they would slowly disintegrate and release the drug. This would further minimize any safety concern.
Biomarker predicts bone loss in premenopausal breast cancer patients
CHICAGO – A premenopausal breast cancer patient’s follicle-stimulating hormone level upon completion of chemotherapy predicts her risk of bone loss during the ensuing 12 months, Dr. Laila S. Tabatabai reported at the joint meeting of the International Congress of Endocrinology and the Endocrine Society.
“This may have significant implications for preserving bone health in premenopausal women with breast cancer. Appropriate use of FSH as a marker for premature ovarian failure and as a predictor of bone loss after breast cancer treatment may allow for the timely implementation of preventive measures to reduce fracture risk,” said Dr. Tabatabai of Johns Hopkins University, Baltimore.
She presented a secondary analysis from the Exercise for Bone Health: Young Breast Cancer Survivors Study, in which 206 women who were under age 55 and had completed adjuvant chemotherapy for breast cancer were randomized to a 12-month structured exercise program conducted through the YMCA or to a control group that received a monthly health newsletter.
Investigators measured baseline levels of FSH, bone turnover markers, calciotropic hormones, and high-sensitivity C-reactive protein. At 1 year follow-up, only baseline FSH level was significantly related to bone loss.
After adjustment for age, ethnicity, baseline bone mineral density, and assignment to the exercise or control arm, multivariate analysis showed that only women in the lowest tertile for baseline FSH – that is, a level of 21.1 IU/L or less – maintained their baseline bone mineral density at the lumbar spine. They averaged a 0.007% increase over 12 months. In contrast, women in the middle tertile, with a baseline FSH of 21.2-61.6 IU/L, had a mean 0.96% decrease in bone density, and those in the highest tertile, with an FSH of 61.7-124.6 IU/L, averaged a 2.2% bone loss.
“Of note, bone loss was seen with an FSH greater than 21 IU/L, a lower level than is typical of diagnostic criteria for premature ovarian failure,” Dr. Tabatabai observed.
Tamoxifen therapy, time since chemotherapy, and baseline estradiol levels were not related to bone loss or preservation. Baseline CTX (urinary C-terminal crosslinking telopeptide) was the only bone turnover marker associated with subsequent bone loss, but this relationship was marginal.
Also noteworthy was the finding that absence of menstruation did not predict bone loss, said Dr. Tabatabai. Less than 60% of women in the lowest FSH tertile reported menstruating both at baseline and at 12 months, yet they maintained bone mass.
Chemotherapy in premenopausal women often results in premature ovarian failure, bone loss, and amenorrhea. This comes about because the medications damage ovarian follicles and steroid-producing cells, with resultant reduced production of estradiol and inhibin B. This results in loss of feedback inhibition of pituitary gonadotropins along with increased FSH levels, Dr. Tabatabai explained.
She said that since hers is the first study to look at biomarkers to predict bone loss in premenopausal breast cancer patients after chemotherapy, the findings need confirmation. Further studies also should aim to pin down the optimal timing of FSH measurement in relation to breast cancer treatment.
CHICAGO – A premenopausal breast cancer patient’s follicle-stimulating hormone level upon completion of chemotherapy predicts her risk of bone loss during the ensuing 12 months, Dr. Laila S. Tabatabai reported at the joint meeting of the International Congress of Endocrinology and the Endocrine Society.
“This may have significant implications for preserving bone health in premenopausal women with breast cancer. Appropriate use of FSH as a marker for premature ovarian failure and as a predictor of bone loss after breast cancer treatment may allow for the timely implementation of preventive measures to reduce fracture risk,” said Dr. Tabatabai of Johns Hopkins University, Baltimore.
She presented a secondary analysis from the Exercise for Bone Health: Young Breast Cancer Survivors Study, in which 206 women who were under age 55 and had completed adjuvant chemotherapy for breast cancer were randomized to a 12-month structured exercise program conducted through the YMCA or to a control group that received a monthly health newsletter.
Investigators measured baseline levels of FSH, bone turnover markers, calciotropic hormones, and high-sensitivity C-reactive protein. At 1 year follow-up, only baseline FSH level was significantly related to bone loss.
After adjustment for age, ethnicity, baseline bone mineral density, and assignment to the exercise or control arm, multivariate analysis showed that only women in the lowest tertile for baseline FSH – that is, a level of 21.1 IU/L or less – maintained their baseline bone mineral density at the lumbar spine. They averaged a 0.007% increase over 12 months. In contrast, women in the middle tertile, with a baseline FSH of 21.2-61.6 IU/L, had a mean 0.96% decrease in bone density, and those in the highest tertile, with an FSH of 61.7-124.6 IU/L, averaged a 2.2% bone loss.
“Of note, bone loss was seen with an FSH greater than 21 IU/L, a lower level than is typical of diagnostic criteria for premature ovarian failure,” Dr. Tabatabai observed.
Tamoxifen therapy, time since chemotherapy, and baseline estradiol levels were not related to bone loss or preservation. Baseline CTX (urinary C-terminal crosslinking telopeptide) was the only bone turnover marker associated with subsequent bone loss, but this relationship was marginal.
Also noteworthy was the finding that absence of menstruation did not predict bone loss, said Dr. Tabatabai. Less than 60% of women in the lowest FSH tertile reported menstruating both at baseline and at 12 months, yet they maintained bone mass.
Chemotherapy in premenopausal women often results in premature ovarian failure, bone loss, and amenorrhea. This comes about because the medications damage ovarian follicles and steroid-producing cells, with resultant reduced production of estradiol and inhibin B. This results in loss of feedback inhibition of pituitary gonadotropins along with increased FSH levels, Dr. Tabatabai explained.
She said that since hers is the first study to look at biomarkers to predict bone loss in premenopausal breast cancer patients after chemotherapy, the findings need confirmation. Further studies also should aim to pin down the optimal timing of FSH measurement in relation to breast cancer treatment.
CHICAGO – A premenopausal breast cancer patient’s follicle-stimulating hormone level upon completion of chemotherapy predicts her risk of bone loss during the ensuing 12 months, Dr. Laila S. Tabatabai reported at the joint meeting of the International Congress of Endocrinology and the Endocrine Society.
“This may have significant implications for preserving bone health in premenopausal women with breast cancer. Appropriate use of FSH as a marker for premature ovarian failure and as a predictor of bone loss after breast cancer treatment may allow for the timely implementation of preventive measures to reduce fracture risk,” said Dr. Tabatabai of Johns Hopkins University, Baltimore.
She presented a secondary analysis from the Exercise for Bone Health: Young Breast Cancer Survivors Study, in which 206 women who were under age 55 and had completed adjuvant chemotherapy for breast cancer were randomized to a 12-month structured exercise program conducted through the YMCA or to a control group that received a monthly health newsletter.
Investigators measured baseline levels of FSH, bone turnover markers, calciotropic hormones, and high-sensitivity C-reactive protein. At 1 year follow-up, only baseline FSH level was significantly related to bone loss.
After adjustment for age, ethnicity, baseline bone mineral density, and assignment to the exercise or control arm, multivariate analysis showed that only women in the lowest tertile for baseline FSH – that is, a level of 21.1 IU/L or less – maintained their baseline bone mineral density at the lumbar spine. They averaged a 0.007% increase over 12 months. In contrast, women in the middle tertile, with a baseline FSH of 21.2-61.6 IU/L, had a mean 0.96% decrease in bone density, and those in the highest tertile, with an FSH of 61.7-124.6 IU/L, averaged a 2.2% bone loss.
“Of note, bone loss was seen with an FSH greater than 21 IU/L, a lower level than is typical of diagnostic criteria for premature ovarian failure,” Dr. Tabatabai observed.
Tamoxifen therapy, time since chemotherapy, and baseline estradiol levels were not related to bone loss or preservation. Baseline CTX (urinary C-terminal crosslinking telopeptide) was the only bone turnover marker associated with subsequent bone loss, but this relationship was marginal.
Also noteworthy was the finding that absence of menstruation did not predict bone loss, said Dr. Tabatabai. Less than 60% of women in the lowest FSH tertile reported menstruating both at baseline and at 12 months, yet they maintained bone mass.
Chemotherapy in premenopausal women often results in premature ovarian failure, bone loss, and amenorrhea. This comes about because the medications damage ovarian follicles and steroid-producing cells, with resultant reduced production of estradiol and inhibin B. This results in loss of feedback inhibition of pituitary gonadotropins along with increased FSH levels, Dr. Tabatabai explained.
She said that since hers is the first study to look at biomarkers to predict bone loss in premenopausal breast cancer patients after chemotherapy, the findings need confirmation. Further studies also should aim to pin down the optimal timing of FSH measurement in relation to breast cancer treatment.
Key clinical point: A premenopausal breast cancer patient’s FSH level upon completion of adjuvant chemotherapy identifies whether she ought to be placed on preventive antiosteoporosis medication to reduce fracture risk.
Major finding: Premenopausal breast cancer patients with an FSH level greater than 21.1 IU/L after completion of chemotherapy had a significant rate of bone loss during the subsequent 12 months.
Data source: A secondary analysis of a prospective, randomized, controlled trial involving 206 women who underwent adjuvant chemotherapy for premenopausal breast cancer.
Disclosures: The study was funded by the National Institutes of Health. The presenter reported having no financial conflicts.
VIDEO: Smartphone ECG detects atrial fibrillation
SANTA CLARA, CALIF. – When Dr. Omar Dawood demonstrated the AliveCor Heart Monitor with a new app and algorithm for detecting atrial fibrillation on stage at the Health 2.0 fall conference 2014, it showed that his heart was in normal sinus rhythm – but he had a heart rate of 135 beats per minute.
Chalk it up to the excitement of speaking before an audience of physicians and technologists about this new mobile ECG tool, Dr. Dawood said. “I’m not always that anxious.”
The AliveCor device attaches to the back of iPhones or Android-based smartphones and sells for $60-$199, depending on the model of smartphone. The Food and Drug Administration approved it in 2013, and patients have used it since March 2014. The device sends an ECG reading to a cardiologist or cardiac technician, who sends a reply within 24 hours.
With the new, free app, however, patients get an immediate result from the device showing whether or not they are likely to have atrial fibrillation. The FDA cleared the algorithm for the app in August 2014, and the company launched it on the marketplace at the Health 2.0 conference.
Validation studies have shown that the AliveCor system performs comparably to a traditional 12-lead ECG, Dr. Dawood said in a video interview.
For other recent news on studies of AliveCor in clinical settings, see our Evidence-Based Apps column.
Dr. Dawood, a surgeon by training, is a clinical adviser at AliveCor and also works for a separate technology company.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
On Twitter @sherryboschert
SANTA CLARA, CALIF. – When Dr. Omar Dawood demonstrated the AliveCor Heart Monitor with a new app and algorithm for detecting atrial fibrillation on stage at the Health 2.0 fall conference 2014, it showed that his heart was in normal sinus rhythm – but he had a heart rate of 135 beats per minute.
Chalk it up to the excitement of speaking before an audience of physicians and technologists about this new mobile ECG tool, Dr. Dawood said. “I’m not always that anxious.”
The AliveCor device attaches to the back of iPhones or Android-based smartphones and sells for $60-$199, depending on the model of smartphone. The Food and Drug Administration approved it in 2013, and patients have used it since March 2014. The device sends an ECG reading to a cardiologist or cardiac technician, who sends a reply within 24 hours.
With the new, free app, however, patients get an immediate result from the device showing whether or not they are likely to have atrial fibrillation. The FDA cleared the algorithm for the app in August 2014, and the company launched it on the marketplace at the Health 2.0 conference.
Validation studies have shown that the AliveCor system performs comparably to a traditional 12-lead ECG, Dr. Dawood said in a video interview.
For other recent news on studies of AliveCor in clinical settings, see our Evidence-Based Apps column.
Dr. Dawood, a surgeon by training, is a clinical adviser at AliveCor and also works for a separate technology company.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
On Twitter @sherryboschert
SANTA CLARA, CALIF. – When Dr. Omar Dawood demonstrated the AliveCor Heart Monitor with a new app and algorithm for detecting atrial fibrillation on stage at the Health 2.0 fall conference 2014, it showed that his heart was in normal sinus rhythm – but he had a heart rate of 135 beats per minute.
Chalk it up to the excitement of speaking before an audience of physicians and technologists about this new mobile ECG tool, Dr. Dawood said. “I’m not always that anxious.”
The AliveCor device attaches to the back of iPhones or Android-based smartphones and sells for $60-$199, depending on the model of smartphone. The Food and Drug Administration approved it in 2013, and patients have used it since March 2014. The device sends an ECG reading to a cardiologist or cardiac technician, who sends a reply within 24 hours.
With the new, free app, however, patients get an immediate result from the device showing whether or not they are likely to have atrial fibrillation. The FDA cleared the algorithm for the app in August 2014, and the company launched it on the marketplace at the Health 2.0 conference.
Validation studies have shown that the AliveCor system performs comparably to a traditional 12-lead ECG, Dr. Dawood said in a video interview.
For other recent news on studies of AliveCor in clinical settings, see our Evidence-Based Apps column.
Dr. Dawood, a surgeon by training, is a clinical adviser at AliveCor and also works for a separate technology company.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
On Twitter @sherryboschert
Penile Rash Worries Man (And Wife)
A 61-year-old man presents with an asymptomatic but worrisome (to him) penile rash that manifested over a two-day period several weeks ago. OTC miconazole cream, triple-antibiotic creams, and most recently, a two-day course of fluconazole (200 mg bid) have not helped.
The patient denies any sexual exposure outside his marriage, as does his wife. Both are in good health in other respects, although the wife has been treated for lymphoma (long since declared cured).
At first, the patient denies any other skin problems. However, with specific questioning, he admits to having a chronic scaly and slightly itchy rash that periodically appears in the same places: bilateral brows, nasolabial folds, various spots in his beard, and both external ear canals.
Additional history taking reveals that the patient has been under a great deal of stress lately. His father recently died, leaving him to deal with a number of issues, and his work shift changed, requiring him to sleep during the day and work at night.
EXAMINATION
The penile rash is macular, smooth, strikingly red, and shiny. It covers the dorsal, distal penile shaft, spilling onto the glans. It looks wet but is quite dry. His groin, upper intergluteal area, and axillae are free of any changes.
A fine pink rash is seen in the glabella, extending into both brows. Similar areas of focal scaling on pink bases are also noted in the beard area and in both external auditory meati.
What is the diagnosis?
DISCUSSION
This is the way seborrheic dermatitis (SD) acts: It sits around for years, causing minor problems in common areas (eg, face, scalp, ears, and beard). Then the stress of life intrudes, the candle is being burnt from both ends, and SD blossoms, appearing in places such as the chest, groin, suprapubic area, axillae, and genitals.
On the genitals, SD is often bright red, with little if any scale. Why? The moisture and friction particular to the genital and intertriginous (skin on skin) areas prevent scale from accumulating.
Penile rashes generally get everyone’s attention, including that of the patient’s sexual partner(s). For the average nonclinician, the list of possible explanations is infinite—and worrisome. The situation is, in some ways, worse for the average primary care provider, who will almost always decree such a rash a “yeast infection” (though it seldom responds to anti-yeast medications—for good reason: Otherwise healthy circumcised men almost never develop yeast infections anywhere, let alone on the penis).
If you remove “yeast” from the differential, the average primary care provider will be lost. An abbreviated differential list for penile rashes and conditions includes:
• Psoriasis
• Seborrhea
• Contact vs irritant dermatitis
• Eczema/lichen simplex chronicus
• Lichen sclerosis et atrophicus (traditionally termed balanitis xerotica obliterans or BXO when it occurs on the penis)
• Lichen planus
• Reiter syndrome
• Scabies
• Erythroplasia of Queyrat (superficial squamous cell carcinoma)
• Melanoma
• Herpes simplex
• Molluscum
• Pearly penile papules
• Tyson’s glands (prominent pilosebaceous glands on the penile shaft)
• Angiokeratoma of Fordyce
• Condyloma accuminata
• Primary syphilis chancre
• Fixed-drug eruption
(Note that while yeast is not on this list, it certainly could be considered in an uncircumcised hyperglycemic patient.)
The top five items on the list would cover 90% of patients with penile rashes. Seborrheic dermatitis is utterly common but only rarely recognized when it occurs in unusual areas (as in this case).
For this patient, I prescribed topical hydrocortisone 2.5% cream (to be applied bid to all affected areas) and advised him to shampoo the areas daily with ketoconazole-containing shampoo. But the main thing I did for him, and his wife, was provide peace of mind about all the terrible conditions he didn’t have. With treatment, his penile lesions resolved within two weeks.
TAKE-HOME LEARNING POINTS
• Seborrheic dermatitis (SD) is common in the scalp, on the face, and in the ears, but it can also appear on the chest, axillae, or genitals.
• Yeast infections are quite uncommon in otherwise healthy men.
• Stress is often a triggering factor with worsening SD.
• Asking about and finding corroborative areas of involvement (face, ears, brows, scalp) can help in diagnosing atypical cases of SD.
A 61-year-old man presents with an asymptomatic but worrisome (to him) penile rash that manifested over a two-day period several weeks ago. OTC miconazole cream, triple-antibiotic creams, and most recently, a two-day course of fluconazole (200 mg bid) have not helped.
The patient denies any sexual exposure outside his marriage, as does his wife. Both are in good health in other respects, although the wife has been treated for lymphoma (long since declared cured).
At first, the patient denies any other skin problems. However, with specific questioning, he admits to having a chronic scaly and slightly itchy rash that periodically appears in the same places: bilateral brows, nasolabial folds, various spots in his beard, and both external ear canals.
Additional history taking reveals that the patient has been under a great deal of stress lately. His father recently died, leaving him to deal with a number of issues, and his work shift changed, requiring him to sleep during the day and work at night.
EXAMINATION
The penile rash is macular, smooth, strikingly red, and shiny. It covers the dorsal, distal penile shaft, spilling onto the glans. It looks wet but is quite dry. His groin, upper intergluteal area, and axillae are free of any changes.
A fine pink rash is seen in the glabella, extending into both brows. Similar areas of focal scaling on pink bases are also noted in the beard area and in both external auditory meati.
What is the diagnosis?
DISCUSSION
This is the way seborrheic dermatitis (SD) acts: It sits around for years, causing minor problems in common areas (eg, face, scalp, ears, and beard). Then the stress of life intrudes, the candle is being burnt from both ends, and SD blossoms, appearing in places such as the chest, groin, suprapubic area, axillae, and genitals.
On the genitals, SD is often bright red, with little if any scale. Why? The moisture and friction particular to the genital and intertriginous (skin on skin) areas prevent scale from accumulating.
Penile rashes generally get everyone’s attention, including that of the patient’s sexual partner(s). For the average nonclinician, the list of possible explanations is infinite—and worrisome. The situation is, in some ways, worse for the average primary care provider, who will almost always decree such a rash a “yeast infection” (though it seldom responds to anti-yeast medications—for good reason: Otherwise healthy circumcised men almost never develop yeast infections anywhere, let alone on the penis).
If you remove “yeast” from the differential, the average primary care provider will be lost. An abbreviated differential list for penile rashes and conditions includes:
• Psoriasis
• Seborrhea
• Contact vs irritant dermatitis
• Eczema/lichen simplex chronicus
• Lichen sclerosis et atrophicus (traditionally termed balanitis xerotica obliterans or BXO when it occurs on the penis)
• Lichen planus
• Reiter syndrome
• Scabies
• Erythroplasia of Queyrat (superficial squamous cell carcinoma)
• Melanoma
• Herpes simplex
• Molluscum
• Pearly penile papules
• Tyson’s glands (prominent pilosebaceous glands on the penile shaft)
• Angiokeratoma of Fordyce
• Condyloma accuminata
• Primary syphilis chancre
• Fixed-drug eruption
(Note that while yeast is not on this list, it certainly could be considered in an uncircumcised hyperglycemic patient.)
The top five items on the list would cover 90% of patients with penile rashes. Seborrheic dermatitis is utterly common but only rarely recognized when it occurs in unusual areas (as in this case).
For this patient, I prescribed topical hydrocortisone 2.5% cream (to be applied bid to all affected areas) and advised him to shampoo the areas daily with ketoconazole-containing shampoo. But the main thing I did for him, and his wife, was provide peace of mind about all the terrible conditions he didn’t have. With treatment, his penile lesions resolved within two weeks.
TAKE-HOME LEARNING POINTS
• Seborrheic dermatitis (SD) is common in the scalp, on the face, and in the ears, but it can also appear on the chest, axillae, or genitals.
• Yeast infections are quite uncommon in otherwise healthy men.
• Stress is often a triggering factor with worsening SD.
• Asking about and finding corroborative areas of involvement (face, ears, brows, scalp) can help in diagnosing atypical cases of SD.
A 61-year-old man presents with an asymptomatic but worrisome (to him) penile rash that manifested over a two-day period several weeks ago. OTC miconazole cream, triple-antibiotic creams, and most recently, a two-day course of fluconazole (200 mg bid) have not helped.
The patient denies any sexual exposure outside his marriage, as does his wife. Both are in good health in other respects, although the wife has been treated for lymphoma (long since declared cured).
At first, the patient denies any other skin problems. However, with specific questioning, he admits to having a chronic scaly and slightly itchy rash that periodically appears in the same places: bilateral brows, nasolabial folds, various spots in his beard, and both external ear canals.
Additional history taking reveals that the patient has been under a great deal of stress lately. His father recently died, leaving him to deal with a number of issues, and his work shift changed, requiring him to sleep during the day and work at night.
EXAMINATION
The penile rash is macular, smooth, strikingly red, and shiny. It covers the dorsal, distal penile shaft, spilling onto the glans. It looks wet but is quite dry. His groin, upper intergluteal area, and axillae are free of any changes.
A fine pink rash is seen in the glabella, extending into both brows. Similar areas of focal scaling on pink bases are also noted in the beard area and in both external auditory meati.
What is the diagnosis?
DISCUSSION
This is the way seborrheic dermatitis (SD) acts: It sits around for years, causing minor problems in common areas (eg, face, scalp, ears, and beard). Then the stress of life intrudes, the candle is being burnt from both ends, and SD blossoms, appearing in places such as the chest, groin, suprapubic area, axillae, and genitals.
On the genitals, SD is often bright red, with little if any scale. Why? The moisture and friction particular to the genital and intertriginous (skin on skin) areas prevent scale from accumulating.
Penile rashes generally get everyone’s attention, including that of the patient’s sexual partner(s). For the average nonclinician, the list of possible explanations is infinite—and worrisome. The situation is, in some ways, worse for the average primary care provider, who will almost always decree such a rash a “yeast infection” (though it seldom responds to anti-yeast medications—for good reason: Otherwise healthy circumcised men almost never develop yeast infections anywhere, let alone on the penis).
If you remove “yeast” from the differential, the average primary care provider will be lost. An abbreviated differential list for penile rashes and conditions includes:
• Psoriasis
• Seborrhea
• Contact vs irritant dermatitis
• Eczema/lichen simplex chronicus
• Lichen sclerosis et atrophicus (traditionally termed balanitis xerotica obliterans or BXO when it occurs on the penis)
• Lichen planus
• Reiter syndrome
• Scabies
• Erythroplasia of Queyrat (superficial squamous cell carcinoma)
• Melanoma
• Herpes simplex
• Molluscum
• Pearly penile papules
• Tyson’s glands (prominent pilosebaceous glands on the penile shaft)
• Angiokeratoma of Fordyce
• Condyloma accuminata
• Primary syphilis chancre
• Fixed-drug eruption
(Note that while yeast is not on this list, it certainly could be considered in an uncircumcised hyperglycemic patient.)
The top five items on the list would cover 90% of patients with penile rashes. Seborrheic dermatitis is utterly common but only rarely recognized when it occurs in unusual areas (as in this case).
For this patient, I prescribed topical hydrocortisone 2.5% cream (to be applied bid to all affected areas) and advised him to shampoo the areas daily with ketoconazole-containing shampoo. But the main thing I did for him, and his wife, was provide peace of mind about all the terrible conditions he didn’t have. With treatment, his penile lesions resolved within two weeks.
TAKE-HOME LEARNING POINTS
• Seborrheic dermatitis (SD) is common in the scalp, on the face, and in the ears, but it can also appear on the chest, axillae, or genitals.
• Yeast infections are quite uncommon in otherwise healthy men.
• Stress is often a triggering factor with worsening SD.
• Asking about and finding corroborative areas of involvement (face, ears, brows, scalp) can help in diagnosing atypical cases of SD.
New business model puts dermatology ‘back in the hands of the dermatologist’
Dermatology has yet to conquer the cosmetic corner of the specialty. That’s according to Dr. Leslie S. Baumann, of the Miami-based, Skin Type Solutions, who explains a new franchise model she says will help “put dermatology back in the hands of dermatologists.”
In this interview, Dr. Baumann, who writes the Cosmeceutical Critique column for Skin & Allergy News, explains her new franchise method for selling skin care products in the dermatologist’s office, and why she thinks it will “disrupt” business as usual in the retail skin care marketplace, including for online retailers.
The following is an edited transcript of the interview, which you can hear in its entirety here.
SAN: Welcome, Dr. Baumann. You recently wrote that you were helping to “put dermatology back in the hands of dermatologists.” Can you expand on that?
Dr. Baumann: I find that most patients really don’t buy their products from dermatologists. They buy them from Sephora, CVS, or the department store, but it’s dermatologists who have years of training about skin, and consumers don’t realize that the dermatologist’s office is the natural choice for where to buy their skin care products. I know that in some parts of the country, access to dermatologists is limited. I think that if a person can see a dermatologist, then that should be where they go for products as well, but that’s not happening. I think dermatologists have done a poor job in getting the word out that we’re the complete skin care experts.
SAN: So, you’ve created a business model to help with this. Please explain how it works.
Dr. Baumann: I love the science of skin care ingredients, and I want to prescribe the right skin care products to my patients. I was at the University of Miami for about 15 years. We didn’t have a huge staff, and I went through the whole skin care evaluation process and created the correct regimen myself. The original evaluation regimen took about 45 minutes, and I realized that patients would probably purchase products from me at first, but the next time, they would buy them somewhere else.
So, I streamlined my approach to make it faster and not require a lot of staff. I determined that I needed to divide patients into skin types. I came up with 16 main skin types, based on four issues: oily vs. dry; sensitive vs. resistant; pigmented vs. unpigmented; and whether the skin is wrinkle-prone. This was the basis of my book, “The Skin Type Solution,” which was a New York Times Bestseller. This showed me that consumers really care about skin products.
The biggest challenge was to get my staff to be able to correctly diagnose the skin type. It took me years to develop my questionnaire, and we have done all kinds of clinical trials to validate it. Now my staff can administer that questionnaire on an iPad, and it automatically calculates the skin type.
The next step was figuring out which products work for each skin type, and then presetting regimens. I found the best products from the companies that had the best technology, and then I tested those on different skin types. I might have five or six products from four or five different brands for one skin type.
SAN: And you are confident that mixing products from the different brands and all the different ingredients won’t somehow irritate the patient’s skin?
Dr. Baumann: I have done a lot of research on cosmetic ingredients; that’s really my core competency. One company might have the best sunscreen technology, but that doesn’t mean they have the best retinol technology, yet every brand feels that pressure to have lots of different products. However, because I do the research trials for the companies, I know each one’s best technology. So, I find the best technology and apply it like a Rubik’s Cube to each skin type’s need, so they always get the best product, and then I test the product. I have been testing this method since 2005.
SAN: What about eponymous skin care lines?
Dr. Baumann: When you go private label, you hire a formulator the way you’d hire a personal chef. That person may not be the scientist who invented that technology. When you have a private label, there is no way you can achieve the same results as you can when you are sourcing products from the best scientists in the world. I know who these people are because I do the research trials. I also know the ingredient supply companies who have the basic scientists in the lab, tinkering with the cell cultures and looking at the mitochondria, so I know where those basic ingredients go. Because I have a large following after the sale of my book and my online blog, I can get volume discounts from the companies. I created a store in the office, and each shelf is color-coded by skin type so it’s easy to know what products to buy,
My friend, who franchised Blimpie’s sandwich shops, was in my office one day watching customers take everything off the shelf and purchase all of it, and he convinced me to franchise it.
It’s important to understand why we chose this model. If you are a cosmetics company, you are not allowed to tell doctors how much to charge for the products because it violates antitrust laws. This allows some people to buy products and then dump them cheaply on the Internet. We control that by having the doctors sign an agreement that they will not sell the products online, and if they do, we cut them off.
SAN: How do you ensure that the products in your franchises aren’t elsewhere on the Internet?
Dr. Baumann: The plan is that once we have enough doctors in the program, we will negotiate with the manufacturers to create products that are exclusive to us.
SAN: Is this a revolution?
Dr. Baumann: That’s the point. It’s putting the power back in the hands of the dermatologist because we are the authorities on skin care. We need to be the ones that people get all the best news and products from first. Just imagine a world where a great new skin care technology comes out, and the only place you can get it is from the dermatologists. That’s going to drive so much business into the dermatologist’s office, and will help dermatologists build their general and cosmetic practice. The beauty of my system is that it trains your staff to identify the most appropriate products for each patient, but I have selected those products. I tested this method in six dermatologists’ offices, and we found that the product exchange rate went from about 35% to 3%. So, when your patient has a better outcome, they are more likely to trust you, and more likely to refer friends to you.
SAN: But what if a patient doesn’t have access to a dermatologist and the model for purchasing skin care products does change? It sounds like it will be harder for them to get the skin care they need.
Dr. Baumann: That is a great question. It’s a problem I have to figure out how to solve. Right now we’re considering Skype consults. This is not considered practicing medicine, so you can do it across state lines.
SAN: Do you plan to franchise dermatologists only or would you also sell the franchise rights to medical spas and physicians other than dermatologists?
Dr. Baumann: That’s really against my philosophy. I want to bring skin care back to the dermatologist. Did you know that only 15 percent of dermatologists sell skin care products in their practice? It’s difficult for them to set the system up and buy products from the different companies. My company streamlines that process. Another reason many dermatologists don’t sell products is because of ethical concerns. I believe if you are offering patients the best products for their skin types, products they can’t get somewhere else, and at the best price, then that is ethical. When you’re just selling things to make money by taking advantage of the patient-doctor relationship, then I am absolutely against it.
SAN: Why might a dermatologist turn away from this franchise model?
Dr. Baumann: There is no reason not to do it, because the startup costs are minimal. The only reason they might not want to do it is if they have their own skin care brand. A doctor could still sell his or her own brand, but they wouldn’t be able to have it on the Skin Type Solutions shelves, and that gets complicated. Based on patient surveys I’ve done, people don’t really want private skin care labels. I think they feel very suspicious of them. My system solves that problem by helping consumers realize the doctor isn’t pretending they invented these products. This is a more honest approach, in my opinion. That might be controversial, but that’s how I feel.
SAN: It sounds like the cosmetic manufacturers would favor this if you like their line.
Dr. Baumann: My system favors good technology. So the charlatans who are trying to sell stem cell therapies or peptides that don’t work aren’t going to like my system. My system favors the geniuses in the lab who don’t know how to get their technology out there, and I know a lot of them. We’ll be able to find that technology and then launch it through dermatology practices. This helps the genius underdogs who don’t know what to do with what they’ve discovered.
Dr. Baumann is chief executive officer of the Baumann Cosmetic & Research Institute in the Design District in Miami. She founded the Cosmetic Dermatology Center at the University of Miami in 1997. Dr. Baumann wrote the textbook “Cosmetic Dermatology: Principles and Practice” (McGraw-Hill, New York 2002) , and a book for consumers, “The Skin Type Solution” (New York: Bantam Dell, 2006). She has contributed to the Cosmeceutical Critique column in Skin & Allergy News since January 2001. Her latest book, “Cosmeceuticals and Cosmetic Ingredients,” will be published in November 2014. Dr. Baumann has received funding for clinical grants from Allergan, Aveeno, Avon Products, Evolus, Galderma, GlaxoSmithKline, Kythera, Mary Kay, Medicis Pharmaceuticals, Neutrogena, Philosophy,Topix Pharmaceuticals, and Unilever.
On Twitter @whitneymcknight
Dermatology has yet to conquer the cosmetic corner of the specialty. That’s according to Dr. Leslie S. Baumann, of the Miami-based, Skin Type Solutions, who explains a new franchise model she says will help “put dermatology back in the hands of dermatologists.”
In this interview, Dr. Baumann, who writes the Cosmeceutical Critique column for Skin & Allergy News, explains her new franchise method for selling skin care products in the dermatologist’s office, and why she thinks it will “disrupt” business as usual in the retail skin care marketplace, including for online retailers.
The following is an edited transcript of the interview, which you can hear in its entirety here.
SAN: Welcome, Dr. Baumann. You recently wrote that you were helping to “put dermatology back in the hands of dermatologists.” Can you expand on that?
Dr. Baumann: I find that most patients really don’t buy their products from dermatologists. They buy them from Sephora, CVS, or the department store, but it’s dermatologists who have years of training about skin, and consumers don’t realize that the dermatologist’s office is the natural choice for where to buy their skin care products. I know that in some parts of the country, access to dermatologists is limited. I think that if a person can see a dermatologist, then that should be where they go for products as well, but that’s not happening. I think dermatologists have done a poor job in getting the word out that we’re the complete skin care experts.
SAN: So, you’ve created a business model to help with this. Please explain how it works.
Dr. Baumann: I love the science of skin care ingredients, and I want to prescribe the right skin care products to my patients. I was at the University of Miami for about 15 years. We didn’t have a huge staff, and I went through the whole skin care evaluation process and created the correct regimen myself. The original evaluation regimen took about 45 minutes, and I realized that patients would probably purchase products from me at first, but the next time, they would buy them somewhere else.
So, I streamlined my approach to make it faster and not require a lot of staff. I determined that I needed to divide patients into skin types. I came up with 16 main skin types, based on four issues: oily vs. dry; sensitive vs. resistant; pigmented vs. unpigmented; and whether the skin is wrinkle-prone. This was the basis of my book, “The Skin Type Solution,” which was a New York Times Bestseller. This showed me that consumers really care about skin products.
The biggest challenge was to get my staff to be able to correctly diagnose the skin type. It took me years to develop my questionnaire, and we have done all kinds of clinical trials to validate it. Now my staff can administer that questionnaire on an iPad, and it automatically calculates the skin type.
The next step was figuring out which products work for each skin type, and then presetting regimens. I found the best products from the companies that had the best technology, and then I tested those on different skin types. I might have five or six products from four or five different brands for one skin type.
SAN: And you are confident that mixing products from the different brands and all the different ingredients won’t somehow irritate the patient’s skin?
Dr. Baumann: I have done a lot of research on cosmetic ingredients; that’s really my core competency. One company might have the best sunscreen technology, but that doesn’t mean they have the best retinol technology, yet every brand feels that pressure to have lots of different products. However, because I do the research trials for the companies, I know each one’s best technology. So, I find the best technology and apply it like a Rubik’s Cube to each skin type’s need, so they always get the best product, and then I test the product. I have been testing this method since 2005.
SAN: What about eponymous skin care lines?
Dr. Baumann: When you go private label, you hire a formulator the way you’d hire a personal chef. That person may not be the scientist who invented that technology. When you have a private label, there is no way you can achieve the same results as you can when you are sourcing products from the best scientists in the world. I know who these people are because I do the research trials. I also know the ingredient supply companies who have the basic scientists in the lab, tinkering with the cell cultures and looking at the mitochondria, so I know where those basic ingredients go. Because I have a large following after the sale of my book and my online blog, I can get volume discounts from the companies. I created a store in the office, and each shelf is color-coded by skin type so it’s easy to know what products to buy,
My friend, who franchised Blimpie’s sandwich shops, was in my office one day watching customers take everything off the shelf and purchase all of it, and he convinced me to franchise it.
It’s important to understand why we chose this model. If you are a cosmetics company, you are not allowed to tell doctors how much to charge for the products because it violates antitrust laws. This allows some people to buy products and then dump them cheaply on the Internet. We control that by having the doctors sign an agreement that they will not sell the products online, and if they do, we cut them off.
SAN: How do you ensure that the products in your franchises aren’t elsewhere on the Internet?
Dr. Baumann: The plan is that once we have enough doctors in the program, we will negotiate with the manufacturers to create products that are exclusive to us.
SAN: Is this a revolution?
Dr. Baumann: That’s the point. It’s putting the power back in the hands of the dermatologist because we are the authorities on skin care. We need to be the ones that people get all the best news and products from first. Just imagine a world where a great new skin care technology comes out, and the only place you can get it is from the dermatologists. That’s going to drive so much business into the dermatologist’s office, and will help dermatologists build their general and cosmetic practice. The beauty of my system is that it trains your staff to identify the most appropriate products for each patient, but I have selected those products. I tested this method in six dermatologists’ offices, and we found that the product exchange rate went from about 35% to 3%. So, when your patient has a better outcome, they are more likely to trust you, and more likely to refer friends to you.
SAN: But what if a patient doesn’t have access to a dermatologist and the model for purchasing skin care products does change? It sounds like it will be harder for them to get the skin care they need.
Dr. Baumann: That is a great question. It’s a problem I have to figure out how to solve. Right now we’re considering Skype consults. This is not considered practicing medicine, so you can do it across state lines.
SAN: Do you plan to franchise dermatologists only or would you also sell the franchise rights to medical spas and physicians other than dermatologists?
Dr. Baumann: That’s really against my philosophy. I want to bring skin care back to the dermatologist. Did you know that only 15 percent of dermatologists sell skin care products in their practice? It’s difficult for them to set the system up and buy products from the different companies. My company streamlines that process. Another reason many dermatologists don’t sell products is because of ethical concerns. I believe if you are offering patients the best products for their skin types, products they can’t get somewhere else, and at the best price, then that is ethical. When you’re just selling things to make money by taking advantage of the patient-doctor relationship, then I am absolutely against it.
SAN: Why might a dermatologist turn away from this franchise model?
Dr. Baumann: There is no reason not to do it, because the startup costs are minimal. The only reason they might not want to do it is if they have their own skin care brand. A doctor could still sell his or her own brand, but they wouldn’t be able to have it on the Skin Type Solutions shelves, and that gets complicated. Based on patient surveys I’ve done, people don’t really want private skin care labels. I think they feel very suspicious of them. My system solves that problem by helping consumers realize the doctor isn’t pretending they invented these products. This is a more honest approach, in my opinion. That might be controversial, but that’s how I feel.
SAN: It sounds like the cosmetic manufacturers would favor this if you like their line.
Dr. Baumann: My system favors good technology. So the charlatans who are trying to sell stem cell therapies or peptides that don’t work aren’t going to like my system. My system favors the geniuses in the lab who don’t know how to get their technology out there, and I know a lot of them. We’ll be able to find that technology and then launch it through dermatology practices. This helps the genius underdogs who don’t know what to do with what they’ve discovered.
Dr. Baumann is chief executive officer of the Baumann Cosmetic & Research Institute in the Design District in Miami. She founded the Cosmetic Dermatology Center at the University of Miami in 1997. Dr. Baumann wrote the textbook “Cosmetic Dermatology: Principles and Practice” (McGraw-Hill, New York 2002) , and a book for consumers, “The Skin Type Solution” (New York: Bantam Dell, 2006). She has contributed to the Cosmeceutical Critique column in Skin & Allergy News since January 2001. Her latest book, “Cosmeceuticals and Cosmetic Ingredients,” will be published in November 2014. Dr. Baumann has received funding for clinical grants from Allergan, Aveeno, Avon Products, Evolus, Galderma, GlaxoSmithKline, Kythera, Mary Kay, Medicis Pharmaceuticals, Neutrogena, Philosophy,Topix Pharmaceuticals, and Unilever.
On Twitter @whitneymcknight
Dermatology has yet to conquer the cosmetic corner of the specialty. That’s according to Dr. Leslie S. Baumann, of the Miami-based, Skin Type Solutions, who explains a new franchise model she says will help “put dermatology back in the hands of dermatologists.”
In this interview, Dr. Baumann, who writes the Cosmeceutical Critique column for Skin & Allergy News, explains her new franchise method for selling skin care products in the dermatologist’s office, and why she thinks it will “disrupt” business as usual in the retail skin care marketplace, including for online retailers.
The following is an edited transcript of the interview, which you can hear in its entirety here.
SAN: Welcome, Dr. Baumann. You recently wrote that you were helping to “put dermatology back in the hands of dermatologists.” Can you expand on that?
Dr. Baumann: I find that most patients really don’t buy their products from dermatologists. They buy them from Sephora, CVS, or the department store, but it’s dermatologists who have years of training about skin, and consumers don’t realize that the dermatologist’s office is the natural choice for where to buy their skin care products. I know that in some parts of the country, access to dermatologists is limited. I think that if a person can see a dermatologist, then that should be where they go for products as well, but that’s not happening. I think dermatologists have done a poor job in getting the word out that we’re the complete skin care experts.
SAN: So, you’ve created a business model to help with this. Please explain how it works.
Dr. Baumann: I love the science of skin care ingredients, and I want to prescribe the right skin care products to my patients. I was at the University of Miami for about 15 years. We didn’t have a huge staff, and I went through the whole skin care evaluation process and created the correct regimen myself. The original evaluation regimen took about 45 minutes, and I realized that patients would probably purchase products from me at first, but the next time, they would buy them somewhere else.
So, I streamlined my approach to make it faster and not require a lot of staff. I determined that I needed to divide patients into skin types. I came up with 16 main skin types, based on four issues: oily vs. dry; sensitive vs. resistant; pigmented vs. unpigmented; and whether the skin is wrinkle-prone. This was the basis of my book, “The Skin Type Solution,” which was a New York Times Bestseller. This showed me that consumers really care about skin products.
The biggest challenge was to get my staff to be able to correctly diagnose the skin type. It took me years to develop my questionnaire, and we have done all kinds of clinical trials to validate it. Now my staff can administer that questionnaire on an iPad, and it automatically calculates the skin type.
The next step was figuring out which products work for each skin type, and then presetting regimens. I found the best products from the companies that had the best technology, and then I tested those on different skin types. I might have five or six products from four or five different brands for one skin type.
SAN: And you are confident that mixing products from the different brands and all the different ingredients won’t somehow irritate the patient’s skin?
Dr. Baumann: I have done a lot of research on cosmetic ingredients; that’s really my core competency. One company might have the best sunscreen technology, but that doesn’t mean they have the best retinol technology, yet every brand feels that pressure to have lots of different products. However, because I do the research trials for the companies, I know each one’s best technology. So, I find the best technology and apply it like a Rubik’s Cube to each skin type’s need, so they always get the best product, and then I test the product. I have been testing this method since 2005.
SAN: What about eponymous skin care lines?
Dr. Baumann: When you go private label, you hire a formulator the way you’d hire a personal chef. That person may not be the scientist who invented that technology. When you have a private label, there is no way you can achieve the same results as you can when you are sourcing products from the best scientists in the world. I know who these people are because I do the research trials. I also know the ingredient supply companies who have the basic scientists in the lab, tinkering with the cell cultures and looking at the mitochondria, so I know where those basic ingredients go. Because I have a large following after the sale of my book and my online blog, I can get volume discounts from the companies. I created a store in the office, and each shelf is color-coded by skin type so it’s easy to know what products to buy,
My friend, who franchised Blimpie’s sandwich shops, was in my office one day watching customers take everything off the shelf and purchase all of it, and he convinced me to franchise it.
It’s important to understand why we chose this model. If you are a cosmetics company, you are not allowed to tell doctors how much to charge for the products because it violates antitrust laws. This allows some people to buy products and then dump them cheaply on the Internet. We control that by having the doctors sign an agreement that they will not sell the products online, and if they do, we cut them off.
SAN: How do you ensure that the products in your franchises aren’t elsewhere on the Internet?
Dr. Baumann: The plan is that once we have enough doctors in the program, we will negotiate with the manufacturers to create products that are exclusive to us.
SAN: Is this a revolution?
Dr. Baumann: That’s the point. It’s putting the power back in the hands of the dermatologist because we are the authorities on skin care. We need to be the ones that people get all the best news and products from first. Just imagine a world where a great new skin care technology comes out, and the only place you can get it is from the dermatologists. That’s going to drive so much business into the dermatologist’s office, and will help dermatologists build their general and cosmetic practice. The beauty of my system is that it trains your staff to identify the most appropriate products for each patient, but I have selected those products. I tested this method in six dermatologists’ offices, and we found that the product exchange rate went from about 35% to 3%. So, when your patient has a better outcome, they are more likely to trust you, and more likely to refer friends to you.
SAN: But what if a patient doesn’t have access to a dermatologist and the model for purchasing skin care products does change? It sounds like it will be harder for them to get the skin care they need.
Dr. Baumann: That is a great question. It’s a problem I have to figure out how to solve. Right now we’re considering Skype consults. This is not considered practicing medicine, so you can do it across state lines.
SAN: Do you plan to franchise dermatologists only or would you also sell the franchise rights to medical spas and physicians other than dermatologists?
Dr. Baumann: That’s really against my philosophy. I want to bring skin care back to the dermatologist. Did you know that only 15 percent of dermatologists sell skin care products in their practice? It’s difficult for them to set the system up and buy products from the different companies. My company streamlines that process. Another reason many dermatologists don’t sell products is because of ethical concerns. I believe if you are offering patients the best products for their skin types, products they can’t get somewhere else, and at the best price, then that is ethical. When you’re just selling things to make money by taking advantage of the patient-doctor relationship, then I am absolutely against it.
SAN: Why might a dermatologist turn away from this franchise model?
Dr. Baumann: There is no reason not to do it, because the startup costs are minimal. The only reason they might not want to do it is if they have their own skin care brand. A doctor could still sell his or her own brand, but they wouldn’t be able to have it on the Skin Type Solutions shelves, and that gets complicated. Based on patient surveys I’ve done, people don’t really want private skin care labels. I think they feel very suspicious of them. My system solves that problem by helping consumers realize the doctor isn’t pretending they invented these products. This is a more honest approach, in my opinion. That might be controversial, but that’s how I feel.
SAN: It sounds like the cosmetic manufacturers would favor this if you like their line.
Dr. Baumann: My system favors good technology. So the charlatans who are trying to sell stem cell therapies or peptides that don’t work aren’t going to like my system. My system favors the geniuses in the lab who don’t know how to get their technology out there, and I know a lot of them. We’ll be able to find that technology and then launch it through dermatology practices. This helps the genius underdogs who don’t know what to do with what they’ve discovered.
Dr. Baumann is chief executive officer of the Baumann Cosmetic & Research Institute in the Design District in Miami. She founded the Cosmetic Dermatology Center at the University of Miami in 1997. Dr. Baumann wrote the textbook “Cosmetic Dermatology: Principles and Practice” (McGraw-Hill, New York 2002) , and a book for consumers, “The Skin Type Solution” (New York: Bantam Dell, 2006). She has contributed to the Cosmeceutical Critique column in Skin & Allergy News since January 2001. Her latest book, “Cosmeceuticals and Cosmetic Ingredients,” will be published in November 2014. Dr. Baumann has received funding for clinical grants from Allergan, Aveeno, Avon Products, Evolus, Galderma, GlaxoSmithKline, Kythera, Mary Kay, Medicis Pharmaceuticals, Neutrogena, Philosophy,Topix Pharmaceuticals, and Unilever.
On Twitter @whitneymcknight
Lungs donated after asphyxiation, drowning found suitable for transplant
Patients who received lung transplants from donors who died of asphyxiation or drowning had similar survival rates and clinical outcomes as those whose donors died of other causes, according to a large registry analysis in the October issue of The Annals of Thoracic Surgery.
“Asphyxiation or drowning as a donor cause of death should not automatically exclude the organ from transplant consideration,” said Dr. Bryan A. Whitson of Ohio State University, Columbus, and his associates. Donor death from asphyxiation or drowning did not significantly affect rates of airway dehiscence, transplant rejection, posttransplant stroke or dialysis, or long-term survival.
Lungs donated after asphyxiation or drowning should be carefully evaluated for parenchymal injury, microbial contamination, and the possibility of primary graft dysfunction, the researchers cautioned. For example, asphyxiation and drowning can alter lung surfactant levels (Ann. Thorac. Surg. 2014;98:1145-51).
The analysis included 18,205 U.S. adults who underwent lung transplantation between 1987 and 2010, including 309 patients whose donors had reportedly died from drowning or asphyxiation. Patients were identified from the UNOS/OPTN STAR (United Network for Organ Sharing/Organ Procurement and Transplantation Network Standard Transplant Analysis and Research) database, which is overseen by the U.S. Department of Health & Human Services.
Ten-year survival curves did not vary based on donor cause of death, either when analyzed individually or when asphyxiation or drowning was compared with all other causes (P = .52), the researchers said. In fact, pulmonary deaths were significantly less common (5.8%) among recipients whose donors had died of asphyxiation or drowning compared with other causes (9.5%; P = .02).
Donor death from drowning and asphyxiation also did not significantly affect rates of treatment for transplant rejection within the first year after surgery (50.8% vs. 47.4% for all other causes of donor death), or posttransplant rates of stroke (0.7% vs. 2.1%) or dialysis (5.4% vs. 5.2%), the investigators said. However, hospital length of stay averaged 0.8 days longer when donors had died of asphyxiation or drowning compared with other causes (27.3 vs. 26.5 days; P < 0.001).
Dr. Jacques-Pierre Fontaine comments: The shortage of suitable donor lungs remains an important problem. Less than 20% of lungs being offered for donation are being used. The notion that asphyxiation or drowning excludes a patient from being a potential donor is widespread among some clinicians.
This extensive retrospective review of the robust UNOS Database demonstrates that recipients of lungs from donors who died from asphyxiation or drowning have similar 10-year survival and post-transplant complication rates. In carefully selected donors, these lungs may be successfully used. Furthermore, "optimization" of marginal donor lungs may become more prevalent as ex-vivo lung perfusion technology evolves.
Dr. Fontaine specializes in thoracic surgery at the Moffitt Cancer Center in Tampa, Florida.
Dr. Jacques-Pierre Fontaine comments: The shortage of suitable donor lungs remains an important problem. Less than 20% of lungs being offered for donation are being used. The notion that asphyxiation or drowning excludes a patient from being a potential donor is widespread among some clinicians.
This extensive retrospective review of the robust UNOS Database demonstrates that recipients of lungs from donors who died from asphyxiation or drowning have similar 10-year survival and post-transplant complication rates. In carefully selected donors, these lungs may be successfully used. Furthermore, "optimization" of marginal donor lungs may become more prevalent as ex-vivo lung perfusion technology evolves.
Dr. Fontaine specializes in thoracic surgery at the Moffitt Cancer Center in Tampa, Florida.
Dr. Jacques-Pierre Fontaine comments: The shortage of suitable donor lungs remains an important problem. Less than 20% of lungs being offered for donation are being used. The notion that asphyxiation or drowning excludes a patient from being a potential donor is widespread among some clinicians.
This extensive retrospective review of the robust UNOS Database demonstrates that recipients of lungs from donors who died from asphyxiation or drowning have similar 10-year survival and post-transplant complication rates. In carefully selected donors, these lungs may be successfully used. Furthermore, "optimization" of marginal donor lungs may become more prevalent as ex-vivo lung perfusion technology evolves.
Dr. Fontaine specializes in thoracic surgery at the Moffitt Cancer Center in Tampa, Florida.
Patients who received lung transplants from donors who died of asphyxiation or drowning had similar survival rates and clinical outcomes as those whose donors died of other causes, according to a large registry analysis in the October issue of The Annals of Thoracic Surgery.
“Asphyxiation or drowning as a donor cause of death should not automatically exclude the organ from transplant consideration,” said Dr. Bryan A. Whitson of Ohio State University, Columbus, and his associates. Donor death from asphyxiation or drowning did not significantly affect rates of airway dehiscence, transplant rejection, posttransplant stroke or dialysis, or long-term survival.
Lungs donated after asphyxiation or drowning should be carefully evaluated for parenchymal injury, microbial contamination, and the possibility of primary graft dysfunction, the researchers cautioned. For example, asphyxiation and drowning can alter lung surfactant levels (Ann. Thorac. Surg. 2014;98:1145-51).
The analysis included 18,205 U.S. adults who underwent lung transplantation between 1987 and 2010, including 309 patients whose donors had reportedly died from drowning or asphyxiation. Patients were identified from the UNOS/OPTN STAR (United Network for Organ Sharing/Organ Procurement and Transplantation Network Standard Transplant Analysis and Research) database, which is overseen by the U.S. Department of Health & Human Services.
Ten-year survival curves did not vary based on donor cause of death, either when analyzed individually or when asphyxiation or drowning was compared with all other causes (P = .52), the researchers said. In fact, pulmonary deaths were significantly less common (5.8%) among recipients whose donors had died of asphyxiation or drowning compared with other causes (9.5%; P = .02).
Donor death from drowning and asphyxiation also did not significantly affect rates of treatment for transplant rejection within the first year after surgery (50.8% vs. 47.4% for all other causes of donor death), or posttransplant rates of stroke (0.7% vs. 2.1%) or dialysis (5.4% vs. 5.2%), the investigators said. However, hospital length of stay averaged 0.8 days longer when donors had died of asphyxiation or drowning compared with other causes (27.3 vs. 26.5 days; P < 0.001).
Patients who received lung transplants from donors who died of asphyxiation or drowning had similar survival rates and clinical outcomes as those whose donors died of other causes, according to a large registry analysis in the October issue of The Annals of Thoracic Surgery.
“Asphyxiation or drowning as a donor cause of death should not automatically exclude the organ from transplant consideration,” said Dr. Bryan A. Whitson of Ohio State University, Columbus, and his associates. Donor death from asphyxiation or drowning did not significantly affect rates of airway dehiscence, transplant rejection, posttransplant stroke or dialysis, or long-term survival.
Lungs donated after asphyxiation or drowning should be carefully evaluated for parenchymal injury, microbial contamination, and the possibility of primary graft dysfunction, the researchers cautioned. For example, asphyxiation and drowning can alter lung surfactant levels (Ann. Thorac. Surg. 2014;98:1145-51).
The analysis included 18,205 U.S. adults who underwent lung transplantation between 1987 and 2010, including 309 patients whose donors had reportedly died from drowning or asphyxiation. Patients were identified from the UNOS/OPTN STAR (United Network for Organ Sharing/Organ Procurement and Transplantation Network Standard Transplant Analysis and Research) database, which is overseen by the U.S. Department of Health & Human Services.
Ten-year survival curves did not vary based on donor cause of death, either when analyzed individually or when asphyxiation or drowning was compared with all other causes (P = .52), the researchers said. In fact, pulmonary deaths were significantly less common (5.8%) among recipients whose donors had died of asphyxiation or drowning compared with other causes (9.5%; P = .02).
Donor death from drowning and asphyxiation also did not significantly affect rates of treatment for transplant rejection within the first year after surgery (50.8% vs. 47.4% for all other causes of donor death), or posttransplant rates of stroke (0.7% vs. 2.1%) or dialysis (5.4% vs. 5.2%), the investigators said. However, hospital length of stay averaged 0.8 days longer when donors had died of asphyxiation or drowning compared with other causes (27.3 vs. 26.5 days; P < 0.001).
Key clinical point: Lung transplant recipients had good outcomes and long-term survival in cases involving donors who died of asphyxiation or drowning.
Major finding: Pulmonary deaths were significantly less common (5.8%) among recipients whose donors had died of asphyxiation or drowning compared with other causes (9.5%; P = .02).
Data source: Retrospective registry analysis of 18,250 lung transplant recipients.
Disclosures: The authors did not report funding sources or conflicts of interest.
Is Gustav next?
Thursday was a rough day. Not for me, but for my front-desk personnel. I wouldn’t even have known about it, if Nilda hadn’t clued me in.
“I’m a preschool teacher,” she said, after asking about Botox for underarm sweating. “So I have a lot of patience. But your front-desk people are amazing.”
“What do you mean?” I asked her.
“This lady walks in without an appointment,” she said. “Several people are trying to check in, and she just waltzes over and says, ‘The doctor said I could come in whenever I wanted.’”
I smiled. “That’s Harriet. She’s worried that she has an infection. We make allowances for people over 90.”
“And then there was a woman who didn’t even want to be seen,” Nilda went on. “She’d gotten a bill she didn’t approve of, and she kept going on and on.
“Your secretary said she would call the insurance company to look into it, but the woman kept saying, ‘I’ve been a patient here for 20 years, and there’s never been a problem with the insurance.’
“It would have been fine for your secretary to politely tell the woman she’d take care of it, but now she had to get back to patients trying to register. But she didn’t lose her cool, just kept repeating that she would call the patient’s insurer and let her know.”
I thanked Nilda very much for the feedback. “Most people don’t bother to comment unless they have a complaint,” I said, “so I appreciate your taking the time to say something positive. I’ll be sure to pass it on.”
“And I thought preschool children were tough,” said Nilda.
At lunch, I asked the staff what had been going on.
“Must be a full moon,” said Irma, her eyes twinkling. “The registration desk was like a zoo, what with all the new patients and the old ones who hadn’t been here in years re-registering. And in the middle of it all, a lady whose husband had already checked in and sat down kept calling out, ‘Is Gustav next’?”
“The man sitting next to her – must have been Gustav himself – grumbled at her to please keep quiet, but she kept calling out, ‘Is Gustav next?’
“Then Dorit comes in, complaining about her bill. It turns out that her insurance changed in May, but she had forgotten about it, and she didn’t understand what the change would mean for payment. I told her I would call her insurer and find out.
“ ‘I’ve been a patient here for 20 years,’ she kept saying. ‘So don’t overcharge me!’
“I told her I would let her know what her insurer said and promised that we wouldn’t overcharge her on the copay.
“In the meantime, Harriet, the walk-in, kept standing in front of the window saying, ‘Doctor Rockoff said I could come in whenever I want, and my son-in-law took off work to bring me in and he’s waiting outside.’
“And while Harriet was saying that, the lady in the chair kept calling out, ‘Is Gustav next? Is Gustav next?’ ”
I smiled to myself, trying to think of which absurdist playwright could do justice to what went on that morning in my waiting room, and maybe on lots of mornings and afternoons in waiting rooms everywhere.
“You should know,” I told Irma and the rest of the staff, “that one of the patients commented on how well you all did. You handled all that insanity while staying cool and polite. Great job!”
Of course, we have to stay vigilant for rude or discourteous behavior on the part of our staff. But that same staff often protects us from some pretty unreasonable behavior that patients sometimes can throw at them. It makes sense to make a point of telling our front-desk representatives from time to time how much we appreciate the graceful way they handle the guff and allow us to focus on each patient in the exam room.
Meantime, I am working on my new drama, a sequel to Waiting for Godot. I will call it, Is Gustav Next?
Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Skin & Allergy News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years.
Thursday was a rough day. Not for me, but for my front-desk personnel. I wouldn’t even have known about it, if Nilda hadn’t clued me in.
“I’m a preschool teacher,” she said, after asking about Botox for underarm sweating. “So I have a lot of patience. But your front-desk people are amazing.”
“What do you mean?” I asked her.
“This lady walks in without an appointment,” she said. “Several people are trying to check in, and she just waltzes over and says, ‘The doctor said I could come in whenever I wanted.’”
I smiled. “That’s Harriet. She’s worried that she has an infection. We make allowances for people over 90.”
“And then there was a woman who didn’t even want to be seen,” Nilda went on. “She’d gotten a bill she didn’t approve of, and she kept going on and on.
“Your secretary said she would call the insurance company to look into it, but the woman kept saying, ‘I’ve been a patient here for 20 years, and there’s never been a problem with the insurance.’
“It would have been fine for your secretary to politely tell the woman she’d take care of it, but now she had to get back to patients trying to register. But she didn’t lose her cool, just kept repeating that she would call the patient’s insurer and let her know.”
I thanked Nilda very much for the feedback. “Most people don’t bother to comment unless they have a complaint,” I said, “so I appreciate your taking the time to say something positive. I’ll be sure to pass it on.”
“And I thought preschool children were tough,” said Nilda.
At lunch, I asked the staff what had been going on.
“Must be a full moon,” said Irma, her eyes twinkling. “The registration desk was like a zoo, what with all the new patients and the old ones who hadn’t been here in years re-registering. And in the middle of it all, a lady whose husband had already checked in and sat down kept calling out, ‘Is Gustav next’?”
“The man sitting next to her – must have been Gustav himself – grumbled at her to please keep quiet, but she kept calling out, ‘Is Gustav next?’
“Then Dorit comes in, complaining about her bill. It turns out that her insurance changed in May, but she had forgotten about it, and she didn’t understand what the change would mean for payment. I told her I would call her insurer and find out.
“ ‘I’ve been a patient here for 20 years,’ she kept saying. ‘So don’t overcharge me!’
“I told her I would let her know what her insurer said and promised that we wouldn’t overcharge her on the copay.
“In the meantime, Harriet, the walk-in, kept standing in front of the window saying, ‘Doctor Rockoff said I could come in whenever I want, and my son-in-law took off work to bring me in and he’s waiting outside.’
“And while Harriet was saying that, the lady in the chair kept calling out, ‘Is Gustav next? Is Gustav next?’ ”
I smiled to myself, trying to think of which absurdist playwright could do justice to what went on that morning in my waiting room, and maybe on lots of mornings and afternoons in waiting rooms everywhere.
“You should know,” I told Irma and the rest of the staff, “that one of the patients commented on how well you all did. You handled all that insanity while staying cool and polite. Great job!”
Of course, we have to stay vigilant for rude or discourteous behavior on the part of our staff. But that same staff often protects us from some pretty unreasonable behavior that patients sometimes can throw at them. It makes sense to make a point of telling our front-desk representatives from time to time how much we appreciate the graceful way they handle the guff and allow us to focus on each patient in the exam room.
Meantime, I am working on my new drama, a sequel to Waiting for Godot. I will call it, Is Gustav Next?
Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Skin & Allergy News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years.
Thursday was a rough day. Not for me, but for my front-desk personnel. I wouldn’t even have known about it, if Nilda hadn’t clued me in.
“I’m a preschool teacher,” she said, after asking about Botox for underarm sweating. “So I have a lot of patience. But your front-desk people are amazing.”
“What do you mean?” I asked her.
“This lady walks in without an appointment,” she said. “Several people are trying to check in, and she just waltzes over and says, ‘The doctor said I could come in whenever I wanted.’”
I smiled. “That’s Harriet. She’s worried that she has an infection. We make allowances for people over 90.”
“And then there was a woman who didn’t even want to be seen,” Nilda went on. “She’d gotten a bill she didn’t approve of, and she kept going on and on.
“Your secretary said she would call the insurance company to look into it, but the woman kept saying, ‘I’ve been a patient here for 20 years, and there’s never been a problem with the insurance.’
“It would have been fine for your secretary to politely tell the woman she’d take care of it, but now she had to get back to patients trying to register. But she didn’t lose her cool, just kept repeating that she would call the patient’s insurer and let her know.”
I thanked Nilda very much for the feedback. “Most people don’t bother to comment unless they have a complaint,” I said, “so I appreciate your taking the time to say something positive. I’ll be sure to pass it on.”
“And I thought preschool children were tough,” said Nilda.
At lunch, I asked the staff what had been going on.
“Must be a full moon,” said Irma, her eyes twinkling. “The registration desk was like a zoo, what with all the new patients and the old ones who hadn’t been here in years re-registering. And in the middle of it all, a lady whose husband had already checked in and sat down kept calling out, ‘Is Gustav next’?”
“The man sitting next to her – must have been Gustav himself – grumbled at her to please keep quiet, but she kept calling out, ‘Is Gustav next?’
“Then Dorit comes in, complaining about her bill. It turns out that her insurance changed in May, but she had forgotten about it, and she didn’t understand what the change would mean for payment. I told her I would call her insurer and find out.
“ ‘I’ve been a patient here for 20 years,’ she kept saying. ‘So don’t overcharge me!’
“I told her I would let her know what her insurer said and promised that we wouldn’t overcharge her on the copay.
“In the meantime, Harriet, the walk-in, kept standing in front of the window saying, ‘Doctor Rockoff said I could come in whenever I want, and my son-in-law took off work to bring me in and he’s waiting outside.’
“And while Harriet was saying that, the lady in the chair kept calling out, ‘Is Gustav next? Is Gustav next?’ ”
I smiled to myself, trying to think of which absurdist playwright could do justice to what went on that morning in my waiting room, and maybe on lots of mornings and afternoons in waiting rooms everywhere.
“You should know,” I told Irma and the rest of the staff, “that one of the patients commented on how well you all did. You handled all that insanity while staying cool and polite. Great job!”
Of course, we have to stay vigilant for rude or discourteous behavior on the part of our staff. But that same staff often protects us from some pretty unreasonable behavior that patients sometimes can throw at them. It makes sense to make a point of telling our front-desk representatives from time to time how much we appreciate the graceful way they handle the guff and allow us to focus on each patient in the exam room.
Meantime, I am working on my new drama, a sequel to Waiting for Godot. I will call it, Is Gustav Next?
Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Skin & Allergy News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years.
