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PPEs — Haystacks and Needles
A story in a recent edition of this newspaper reported on a disturbing, but not surprising, study by a third-year pediatric resident at the University of California, Davis, School of Medicine. Looking at just the Preparticipaton Physical Evaluations (PPEs) she could find at her institution, Tammy Ng, MD, found that only slightly more than a quarter “addressed all the criteria” on the American Academy of Pediatrics (AAP) standardized form. Although more than half included inquiries about respiratory symptoms, less than half contained questions about a cardiovascular history. The lack of consistency across all the forms reviewed was the most dramatic finding.
Having participated in more than my share of PPEs as a school physician, a primary care pediatrician, and a multi-sport high school and college athlete, I was not surprised by Dr. Ng’s findings. In high school my teammates and I considered our trip to see Old Doctor Hinds (not his real name) in the second week of August “a joke.” A few of us with “white coat” hypertension, like myself, had to be settled down and have our blood pressure retaken. But other than that wrinkle, we all passed. The football coach had his own eyeball screening tool and wouldn’t allow kids he thought were too small to play football.
Reading this study rekindled a question that surfaced every sports season as I faced days of looking at forms, many of them fished out of backpacks in a crumbled mass. I squeezed in new patients or old patients who were out of date on their physicals, not wanting any youngster to miss out on the politically important first practice of the pre-season. Why was I doing it? What was my goal? In more than four hundred thousand office visit encounters, I had never knowingly missed a case that resulted in a sudden sports-related death. Where was the evidence that PPEs had any protective value? Now a third-year pediatric resident is bold enough to tell us that we have done such a sloppy job of collecting data that we aren’t anywhere close to having the raw material with which to answer my decades-old questions and concerns.
Has our needles-in-the-haystack strategy saved any lives? I suspect a few of you can describe scenarios in which asking the right question of the right person at the right time prevented a sports-related sudden death. But, looking at bigger picture, what were the downsides for the entire population with a system in which those questions weren’t asked?
How many young people didn’t play a sport because their parents couldn’t afford the doctor visit or maintain a family structure that would allow them to find the lost form and drive it to the doctor’s office on Friday afternoon. Not every athletic director or physician’s staff is flexible or sympathetic enough to deal with that level of family dysfunction.
The AAP has recently focused its attention on the problems associated with overspecialization and overtraining in an attempt to make youth sports more safe. But, in reality that target audience is a small, elite, highly motivated group. The bigger problem is the rest of the population, in which too few children are physically active and participation in organized youth sports is decreasing. There are many reasons for that trajectory, but shouldn’t we be doing everything we can to reduce the barriers preventing young people from being more active? One of those barriers is a PPE system that is so riddled with inconsistencies that we have no idea as to its utility.
Certainly, bigger and more robust studies can be done, but there will be a long lead time to determine if a better PPE system might be effective. But there is a different approach. Instead of looking for needles with retrospective questions relying on patients’ and parents’ memories, why not use AI to mine patients’ old records for any language that may be buried in the history that could raise a yellow flag. Of course not every significant episode of syncope results in a chart entry. But, if we can make EMRs do our bidding instead being a thorn in our sides, records from long-forgotten episodes at an urgent care center while on vacation should merge with patients global record and light up when AI goes hunting.
If we can get our act together, the process that my teenage buddies and I considered a joke could become an efficient and possibly life-saving exercise.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at [email protected].
A story in a recent edition of this newspaper reported on a disturbing, but not surprising, study by a third-year pediatric resident at the University of California, Davis, School of Medicine. Looking at just the Preparticipaton Physical Evaluations (PPEs) she could find at her institution, Tammy Ng, MD, found that only slightly more than a quarter “addressed all the criteria” on the American Academy of Pediatrics (AAP) standardized form. Although more than half included inquiries about respiratory symptoms, less than half contained questions about a cardiovascular history. The lack of consistency across all the forms reviewed was the most dramatic finding.
Having participated in more than my share of PPEs as a school physician, a primary care pediatrician, and a multi-sport high school and college athlete, I was not surprised by Dr. Ng’s findings. In high school my teammates and I considered our trip to see Old Doctor Hinds (not his real name) in the second week of August “a joke.” A few of us with “white coat” hypertension, like myself, had to be settled down and have our blood pressure retaken. But other than that wrinkle, we all passed. The football coach had his own eyeball screening tool and wouldn’t allow kids he thought were too small to play football.
Reading this study rekindled a question that surfaced every sports season as I faced days of looking at forms, many of them fished out of backpacks in a crumbled mass. I squeezed in new patients or old patients who were out of date on their physicals, not wanting any youngster to miss out on the politically important first practice of the pre-season. Why was I doing it? What was my goal? In more than four hundred thousand office visit encounters, I had never knowingly missed a case that resulted in a sudden sports-related death. Where was the evidence that PPEs had any protective value? Now a third-year pediatric resident is bold enough to tell us that we have done such a sloppy job of collecting data that we aren’t anywhere close to having the raw material with which to answer my decades-old questions and concerns.
Has our needles-in-the-haystack strategy saved any lives? I suspect a few of you can describe scenarios in which asking the right question of the right person at the right time prevented a sports-related sudden death. But, looking at bigger picture, what were the downsides for the entire population with a system in which those questions weren’t asked?
How many young people didn’t play a sport because their parents couldn’t afford the doctor visit or maintain a family structure that would allow them to find the lost form and drive it to the doctor’s office on Friday afternoon. Not every athletic director or physician’s staff is flexible or sympathetic enough to deal with that level of family dysfunction.
The AAP has recently focused its attention on the problems associated with overspecialization and overtraining in an attempt to make youth sports more safe. But, in reality that target audience is a small, elite, highly motivated group. The bigger problem is the rest of the population, in which too few children are physically active and participation in organized youth sports is decreasing. There are many reasons for that trajectory, but shouldn’t we be doing everything we can to reduce the barriers preventing young people from being more active? One of those barriers is a PPE system that is so riddled with inconsistencies that we have no idea as to its utility.
Certainly, bigger and more robust studies can be done, but there will be a long lead time to determine if a better PPE system might be effective. But there is a different approach. Instead of looking for needles with retrospective questions relying on patients’ and parents’ memories, why not use AI to mine patients’ old records for any language that may be buried in the history that could raise a yellow flag. Of course not every significant episode of syncope results in a chart entry. But, if we can make EMRs do our bidding instead being a thorn in our sides, records from long-forgotten episodes at an urgent care center while on vacation should merge with patients global record and light up when AI goes hunting.
If we can get our act together, the process that my teenage buddies and I considered a joke could become an efficient and possibly life-saving exercise.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at [email protected].
A story in a recent edition of this newspaper reported on a disturbing, but not surprising, study by a third-year pediatric resident at the University of California, Davis, School of Medicine. Looking at just the Preparticipaton Physical Evaluations (PPEs) she could find at her institution, Tammy Ng, MD, found that only slightly more than a quarter “addressed all the criteria” on the American Academy of Pediatrics (AAP) standardized form. Although more than half included inquiries about respiratory symptoms, less than half contained questions about a cardiovascular history. The lack of consistency across all the forms reviewed was the most dramatic finding.
Having participated in more than my share of PPEs as a school physician, a primary care pediatrician, and a multi-sport high school and college athlete, I was not surprised by Dr. Ng’s findings. In high school my teammates and I considered our trip to see Old Doctor Hinds (not his real name) in the second week of August “a joke.” A few of us with “white coat” hypertension, like myself, had to be settled down and have our blood pressure retaken. But other than that wrinkle, we all passed. The football coach had his own eyeball screening tool and wouldn’t allow kids he thought were too small to play football.
Reading this study rekindled a question that surfaced every sports season as I faced days of looking at forms, many of them fished out of backpacks in a crumbled mass. I squeezed in new patients or old patients who were out of date on their physicals, not wanting any youngster to miss out on the politically important first practice of the pre-season. Why was I doing it? What was my goal? In more than four hundred thousand office visit encounters, I had never knowingly missed a case that resulted in a sudden sports-related death. Where was the evidence that PPEs had any protective value? Now a third-year pediatric resident is bold enough to tell us that we have done such a sloppy job of collecting data that we aren’t anywhere close to having the raw material with which to answer my decades-old questions and concerns.
Has our needles-in-the-haystack strategy saved any lives? I suspect a few of you can describe scenarios in which asking the right question of the right person at the right time prevented a sports-related sudden death. But, looking at bigger picture, what were the downsides for the entire population with a system in which those questions weren’t asked?
How many young people didn’t play a sport because their parents couldn’t afford the doctor visit or maintain a family structure that would allow them to find the lost form and drive it to the doctor’s office on Friday afternoon. Not every athletic director or physician’s staff is flexible or sympathetic enough to deal with that level of family dysfunction.
The AAP has recently focused its attention on the problems associated with overspecialization and overtraining in an attempt to make youth sports more safe. But, in reality that target audience is a small, elite, highly motivated group. The bigger problem is the rest of the population, in which too few children are physically active and participation in organized youth sports is decreasing. There are many reasons for that trajectory, but shouldn’t we be doing everything we can to reduce the barriers preventing young people from being more active? One of those barriers is a PPE system that is so riddled with inconsistencies that we have no idea as to its utility.
Certainly, bigger and more robust studies can be done, but there will be a long lead time to determine if a better PPE system might be effective. But there is a different approach. Instead of looking for needles with retrospective questions relying on patients’ and parents’ memories, why not use AI to mine patients’ old records for any language that may be buried in the history that could raise a yellow flag. Of course not every significant episode of syncope results in a chart entry. But, if we can make EMRs do our bidding instead being a thorn in our sides, records from long-forgotten episodes at an urgent care center while on vacation should merge with patients global record and light up when AI goes hunting.
If we can get our act together, the process that my teenage buddies and I considered a joke could become an efficient and possibly life-saving exercise.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at [email protected].
Pediatric Atopic Dermatitis: Study Suggests Treatment May Impact Atopic March
TOPLINE:
METHODOLOGY:
- Researchers conducted a retrospective cohort study using data from the US Collaborative Network, focusing on pediatric patients aged 18 years and younger with two AD diagnoses at least 30 days apart.
- Patients were divided into two cohorts: Those treated with dupilumab (n = 2192) and those who received conventional therapies (n = 2192), including systemic corticosteroids or conventional immunomodulators. They were stratified into three age groups: Preschoolers (< 6 years), school-aged children (6 to < 12 years), and adolescents (12-18 years).
- Both cohorts underwent 1:1 propensity score matching based on current age, age at index (first prescription of dupilumab or conventional therapy), sex, race, comorbidities, laboratory measurements, and prior medications. The primary outcome was atopic march progression, defined by incident asthma or allergic rhinitis.
TAKEAWAY:
- Over 3 years, the dupilumab-treated cohort had a significantly lower cumulative incidence of atopic march progression (20.09% vs 27.22%; P < .001), asthma (9.43% vs 14.64%; P = .001), and allergic rhinitis (13.57% vs 20.52%; P = .003) than the conventional therapy cohort.
- The risk for atopic march progression, asthma, and allergic rhinitis was also significantly reduced by 32%, 40%, and 31%, respectively, in the dupilumab vs conventional therapy cohort.
- Age-specific analyses found that the protective effect of dupilumab against allergic rhinitis was the most pronounced in adolescents (hazard ratio [HR], 0.503; 95% CI, 0.322-0.784), followed by school-aged children (HR, 0.577; 95% CI, 0.399-0.834), and preschoolers (HR, 0.623; 95% CI, 0.412-0.942).
- However, dupilumab was associated with reduced risk for asthma only in preschoolers (HR, 0.427; 95% CI, 0.247-0.738) and not in school-aged children or adolescents.
IN PRACTICE:
“Dupilumab in AD not only treats the disease but may influence atopic march mechanisms, suggesting its role as a disease-modifying atopic march drug,” the authors wrote, adding that more research “with extended follow-up and proof-of-concept is warranted.”
SOURCE:
The study was led by Teng-Li Lin, MD, Department of Dermatology, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Chiayi, Taiwan, and was published online on June 13, 2024, in the Journal of the American Academy of Dermatology.
LIMITATIONS:
The observational nature of the study limited the ability to infer direct causality between dupilumab use and reduced atopic march risk. Lack of detailed information on AD severity, total dosage, and duration of medication treatment may affect the interpretation of the study’s findings. The demographic data suggest that the dupilumab cohort had more severe AD, so the observed risk reduction may be greater than that reported in this study.
DISCLOSURES:
The study was supported in part by the National Science and Technology Council, Taiwan, and Taichung Veterans General Hospital. The authors had no relevant conflicts of interest.
This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.
A version of this article appeared on Medscape.com .
TOPLINE:
METHODOLOGY:
- Researchers conducted a retrospective cohort study using data from the US Collaborative Network, focusing on pediatric patients aged 18 years and younger with two AD diagnoses at least 30 days apart.
- Patients were divided into two cohorts: Those treated with dupilumab (n = 2192) and those who received conventional therapies (n = 2192), including systemic corticosteroids or conventional immunomodulators. They were stratified into three age groups: Preschoolers (< 6 years), school-aged children (6 to < 12 years), and adolescents (12-18 years).
- Both cohorts underwent 1:1 propensity score matching based on current age, age at index (first prescription of dupilumab or conventional therapy), sex, race, comorbidities, laboratory measurements, and prior medications. The primary outcome was atopic march progression, defined by incident asthma or allergic rhinitis.
TAKEAWAY:
- Over 3 years, the dupilumab-treated cohort had a significantly lower cumulative incidence of atopic march progression (20.09% vs 27.22%; P < .001), asthma (9.43% vs 14.64%; P = .001), and allergic rhinitis (13.57% vs 20.52%; P = .003) than the conventional therapy cohort.
- The risk for atopic march progression, asthma, and allergic rhinitis was also significantly reduced by 32%, 40%, and 31%, respectively, in the dupilumab vs conventional therapy cohort.
- Age-specific analyses found that the protective effect of dupilumab against allergic rhinitis was the most pronounced in adolescents (hazard ratio [HR], 0.503; 95% CI, 0.322-0.784), followed by school-aged children (HR, 0.577; 95% CI, 0.399-0.834), and preschoolers (HR, 0.623; 95% CI, 0.412-0.942).
- However, dupilumab was associated with reduced risk for asthma only in preschoolers (HR, 0.427; 95% CI, 0.247-0.738) and not in school-aged children or adolescents.
IN PRACTICE:
“Dupilumab in AD not only treats the disease but may influence atopic march mechanisms, suggesting its role as a disease-modifying atopic march drug,” the authors wrote, adding that more research “with extended follow-up and proof-of-concept is warranted.”
SOURCE:
The study was led by Teng-Li Lin, MD, Department of Dermatology, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Chiayi, Taiwan, and was published online on June 13, 2024, in the Journal of the American Academy of Dermatology.
LIMITATIONS:
The observational nature of the study limited the ability to infer direct causality between dupilumab use and reduced atopic march risk. Lack of detailed information on AD severity, total dosage, and duration of medication treatment may affect the interpretation of the study’s findings. The demographic data suggest that the dupilumab cohort had more severe AD, so the observed risk reduction may be greater than that reported in this study.
DISCLOSURES:
The study was supported in part by the National Science and Technology Council, Taiwan, and Taichung Veterans General Hospital. The authors had no relevant conflicts of interest.
This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.
A version of this article appeared on Medscape.com .
TOPLINE:
METHODOLOGY:
- Researchers conducted a retrospective cohort study using data from the US Collaborative Network, focusing on pediatric patients aged 18 years and younger with two AD diagnoses at least 30 days apart.
- Patients were divided into two cohorts: Those treated with dupilumab (n = 2192) and those who received conventional therapies (n = 2192), including systemic corticosteroids or conventional immunomodulators. They were stratified into three age groups: Preschoolers (< 6 years), school-aged children (6 to < 12 years), and adolescents (12-18 years).
- Both cohorts underwent 1:1 propensity score matching based on current age, age at index (first prescription of dupilumab or conventional therapy), sex, race, comorbidities, laboratory measurements, and prior medications. The primary outcome was atopic march progression, defined by incident asthma or allergic rhinitis.
TAKEAWAY:
- Over 3 years, the dupilumab-treated cohort had a significantly lower cumulative incidence of atopic march progression (20.09% vs 27.22%; P < .001), asthma (9.43% vs 14.64%; P = .001), and allergic rhinitis (13.57% vs 20.52%; P = .003) than the conventional therapy cohort.
- The risk for atopic march progression, asthma, and allergic rhinitis was also significantly reduced by 32%, 40%, and 31%, respectively, in the dupilumab vs conventional therapy cohort.
- Age-specific analyses found that the protective effect of dupilumab against allergic rhinitis was the most pronounced in adolescents (hazard ratio [HR], 0.503; 95% CI, 0.322-0.784), followed by school-aged children (HR, 0.577; 95% CI, 0.399-0.834), and preschoolers (HR, 0.623; 95% CI, 0.412-0.942).
- However, dupilumab was associated with reduced risk for asthma only in preschoolers (HR, 0.427; 95% CI, 0.247-0.738) and not in school-aged children or adolescents.
IN PRACTICE:
“Dupilumab in AD not only treats the disease but may influence atopic march mechanisms, suggesting its role as a disease-modifying atopic march drug,” the authors wrote, adding that more research “with extended follow-up and proof-of-concept is warranted.”
SOURCE:
The study was led by Teng-Li Lin, MD, Department of Dermatology, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Chiayi, Taiwan, and was published online on June 13, 2024, in the Journal of the American Academy of Dermatology.
LIMITATIONS:
The observational nature of the study limited the ability to infer direct causality between dupilumab use and reduced atopic march risk. Lack of detailed information on AD severity, total dosage, and duration of medication treatment may affect the interpretation of the study’s findings. The demographic data suggest that the dupilumab cohort had more severe AD, so the observed risk reduction may be greater than that reported in this study.
DISCLOSURES:
The study was supported in part by the National Science and Technology Council, Taiwan, and Taichung Veterans General Hospital. The authors had no relevant conflicts of interest.
This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.
A version of this article appeared on Medscape.com .
US Hospitals Prone to Cyberattacks Like One That Impacted Patient Care at Ascension, Experts Say
In the wake of a debilitating cyberattack against one of the nation’s largest health care systems, Marvin Ruckle, a nurse at an Ascension hospital in Wichita, Kansas, said he had a frightening experience: He nearly gave a baby “the wrong dose of narcotic” because of confusing paperwork.
A May 8 ransomware attack against Ascension, a Catholic health system with 140 hospitals in at least 10 states, locked providers out of systems that track and coordinate nearly every aspect of patient care. They include its systems for electronic health records, some phones, and ones “utilized to order certain tests, procedures and medications,” the company said in a May 9 statement.
More than a dozen doctors and nurses who work for the sprawling health system told Michigan Public and KFF Health News that patient care at its hospitals across the nation was compromised in the fallout of the cyberattack over the past several weeks. Clinicians working for hospitals in three states described harrowing lapses, including delayed or lost lab results, medication errors, and an absence of routine safety checks via technology to prevent potentially fatal mistakes.
Despite a precipitous rise in cyberattacks against the health sector in recent years, a weeks-long disruption of this magnitude is beyond what most health systems are prepared for, said John S. Clark, an associate chief pharmacy officer at the University of Michigan health system.
“I don’t believe that anyone is fully prepared,” he said. Most emergency management plans “are designed around long-term downtimes that are into one, two, or three days.”
Ascension in a public statement May 9 said its care teams were “trained for these kinds of disruptions,” but did not respond to questions in early June about whether it had prepared for longer periods of downtime. Ascension said June 14 it had restored access to electronic health records across its network, but that patient “medical records and other information collected between May 8” and when the service was restored “may be temporarily inaccessible as we work to update the portal with information collected during the system downtime.”
Ruckle said he “had no training” for the cyberattack.
Back to Paper
Lisa Watson, an intensive care unit nurse at Ascension Via Christi St. Francis hospital in Wichita, described her own close call. She said she nearly administered the wrong medication to a critically ill patient because she couldn’t scan it as she normally would. “My patient probably would have passed away had I not caught it,” she said.
Watson is no stranger to using paper for patients’ medical charts, saying she did so “for probably half of my career,” before electronic health records became ubiquitous in hospitals. What happened after the cyberattack was “by no means the same.”
“When we paper-charted, we had systems in place to get those orders to other departments in a timely manner,” she said, “and those have all gone away.”
Melissa LaRue, an ICU nurse at Ascension Saint Agnes Hospital in Baltimore, described a close call with “administering the wrong dosage” of a patient’s blood pressure medication. “Luckily,” she said, it was “triple-checked and remedied before that could happen. But I think the potential for harm is there when you have so much information and paperwork that you have to go through.”
Clinicians say their hospitals have relied on slapdash workarounds, using handwritten notes, faxes, sticky notes, and basic computer spreadsheets — many devised on the fly by doctors and nurses — to care for patients.
More than a dozen other nurses and doctors, some of them without union protections, at Ascension hospitals in Michigan recounted situations in which they say patient care was compromised. Those clinicians spoke on the condition that they not be named for fear of retaliation by their employer.
An Ascension hospital emergency room doctor in Detroit said a man on the city’s east side was given a dangerous narcotic intended for another patient because of a paperwork mix-up. As a result, the patient’s breathing slowed to the point that he had to be put on a ventilator. “We intubated him and we sent him to the ICU because he got the wrong medication.”
A nurse in a Michigan Ascension hospital ER said a woman with low blood sugar and “altered mental status” went into cardiac arrest and died after staff said they waited four hours for lab results they needed to determine how to treat her, but never received. “If I started having crushing chest pain in the middle of work and thought I was having a big one, I would grab someone to drive me down the street to another hospital,” the same ER nurse said.
Similar concerns reportedly led a travel nurse at an Ascension hospital in Indiana to quit. “I just want to warn those patients that are coming to any of the Ascension facilities that there will be delays in care. There is potential for error and for harm,” Justin Neisser told CBS4 in Indianapolis in May.
Several nurses and doctors at Ascension hospitals said they feared the errors they’ve witnessed since the cyberattack began could threaten their professional licenses. “This is how a RaDonda Vaught happens,” one nurse said, referring to the Tennessee nurse who was convicted of criminally negligent homicide in 2022 for a fatal drug error.
Reporters were not able to review records to verify clinicians’ claims because of privacy laws surrounding patients’ medical information that apply to health care professionals.
Ascension declined to answer questions about claims that care has been affected by the ransomware attack. “As we have made clear throughout this cyber attack which has impacted our system and our dedicated clinical providers, caring for our patients is our highest priority,” Sean Fitzpatrick, Ascension’s vice president of external communications, said via email on June 3. “We are confident that our care providers in our hospitals and facilities continue to provide quality medical care.”
The federal government requires hospitals to protect patients’ sensitive health data, according to cybersecurity experts. However, there are no federal requirements for hospitals to prevent or prepare for cyberattacks that could compromise their electronic systems.
Hospitals: ‘The No.1 Target of Ransomware’
“We’ve started to think about these as public health issues and disasters on the scale of earthquakes or hurricanes,” said Jeff Tully, a co-director of the Center for Healthcare Cybersecurity at the University of California-San Diego. “These types of cybersecurity incidents should be thought of as a matter of when, and not if.”
Josh Corman, a cybersecurity expert and advocate, said ransom crews regard hospitals as the perfect prey: “They have terrible security and they’ll pay. So almost immediately, hospitals went to the No. 1 target of ransomware.”
In 2023, the health sector experienced the largest share of ransomware attacks of 16 infrastructure sectors considered vital to national security or safety, according to an FBI report on internet crimes. In March, the federal Department of Health and Human Services said reported large breaches involving ransomware had jumped by 264% over the past five years.
A cyberattack this year on Change Healthcare, a unit of UnitedHealth Group’s Optum division that processes billions of health care transactions every year, crippled the business of providers, pharmacies, and hospitals.
In May, UnitedHealth Group CEO Andrew Witty told lawmakers the company paid a $22 million ransom as a result of the Change Healthcare attack — which occurred after hackers accessed a company portal that didn’t have multifactor authentication, a basic cybersecurity tool.
The Biden administration in recent months has pushed to bolster health care cybersecurity standards, but it’s not clear which new measures will be required.
In January, HHS nudged companies to improve email security, add multifactor authentication, and institute cybersecurity training and testing, among other voluntary measures. The Centers for Medicare & Medicaid Services is expected to release new requirements for hospitals, but the scope and timing are unclear. The same is true of an update HHS is expected to make to patient privacy regulations.
HHS said the voluntary measures “will inform the creation of new enforceable cybersecurity standards,” department spokesperson Jeff Nesbit said in a statement.
“The recent cyberattack at Ascension only underscores the need for everyone in the health care ecosystem to do their part to secure their systems and protect patients,” Nesbit said.
Meanwhile, lobbyists for the hospital industry contend cybersecurity mandates or penalties are misplaced and would curtail hospitals’ resources to fend off attacks.
“Hospitals and health systems are not the primary source of cyber risk exposure facing the health care sector,” the American Hospital Association, the largest lobbying group for U.S. hospitals, said in an April statement prepared for U.S. House lawmakers. Most large data breaches that hit hospitals in 2023 originated with third-party “business associates” or other health entities, including CMS itself, the AHA statement said.
Hospitals consolidating into large multistate health systems face increased risk of data breaches and ransomware attacks, according to one study. Ascension in 2022 was the third-largest hospital chain in the U.S. by number of beds, according to the most recent data from the federal Agency for Healthcare Research and Quality.
And while cybersecurity regulations can quickly become outdated, they can at least make it clear that if health systems fail to implement basic protections there “should be consequences for that,” Jim Bagian, a former director of the National Center for Patient Safety at the Veterans Health Administration, told Michigan Public’s Stateside.
Patients can pay the price when lapses occur. Those in hospital care face a greater likelihood of death during a cyberattack, according to researchers at the University of Minnesota School of Public Health.
Workers concerned about patient safety at Ascension hospitals in Michigan have called for the company to make changes.
“We implore Ascension to recognize the internal problems that continue to plague its hospitals, both publicly and transparently,” said Dina Carlisle, a nurse and the president of the OPEIU Local 40 union, which represents nurses at Ascension Providence Rochester. At least 125 staff members at that Ascension hospital have signed a petition asking administrators to temporarily reduce elective surgeries and nonemergency patient admissions, like under the protocols many hospitals adopted early in the covid-19 pandemic.
Watson, the Kansas ICU nurse, said in late May that nurses had urged management to bring in more nurses to help manage the workflow. “Everything that we say has fallen on deaf ears,” she said.
“It is very hard to be a nurse at Ascension right now,” Watson said in late May. “It is very hard to be a patient at Ascension right now.”
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In the wake of a debilitating cyberattack against one of the nation’s largest health care systems, Marvin Ruckle, a nurse at an Ascension hospital in Wichita, Kansas, said he had a frightening experience: He nearly gave a baby “the wrong dose of narcotic” because of confusing paperwork.
A May 8 ransomware attack against Ascension, a Catholic health system with 140 hospitals in at least 10 states, locked providers out of systems that track and coordinate nearly every aspect of patient care. They include its systems for electronic health records, some phones, and ones “utilized to order certain tests, procedures and medications,” the company said in a May 9 statement.
More than a dozen doctors and nurses who work for the sprawling health system told Michigan Public and KFF Health News that patient care at its hospitals across the nation was compromised in the fallout of the cyberattack over the past several weeks. Clinicians working for hospitals in three states described harrowing lapses, including delayed or lost lab results, medication errors, and an absence of routine safety checks via technology to prevent potentially fatal mistakes.
Despite a precipitous rise in cyberattacks against the health sector in recent years, a weeks-long disruption of this magnitude is beyond what most health systems are prepared for, said John S. Clark, an associate chief pharmacy officer at the University of Michigan health system.
“I don’t believe that anyone is fully prepared,” he said. Most emergency management plans “are designed around long-term downtimes that are into one, two, or three days.”
Ascension in a public statement May 9 said its care teams were “trained for these kinds of disruptions,” but did not respond to questions in early June about whether it had prepared for longer periods of downtime. Ascension said June 14 it had restored access to electronic health records across its network, but that patient “medical records and other information collected between May 8” and when the service was restored “may be temporarily inaccessible as we work to update the portal with information collected during the system downtime.”
Ruckle said he “had no training” for the cyberattack.
Back to Paper
Lisa Watson, an intensive care unit nurse at Ascension Via Christi St. Francis hospital in Wichita, described her own close call. She said she nearly administered the wrong medication to a critically ill patient because she couldn’t scan it as she normally would. “My patient probably would have passed away had I not caught it,” she said.
Watson is no stranger to using paper for patients’ medical charts, saying she did so “for probably half of my career,” before electronic health records became ubiquitous in hospitals. What happened after the cyberattack was “by no means the same.”
“When we paper-charted, we had systems in place to get those orders to other departments in a timely manner,” she said, “and those have all gone away.”
Melissa LaRue, an ICU nurse at Ascension Saint Agnes Hospital in Baltimore, described a close call with “administering the wrong dosage” of a patient’s blood pressure medication. “Luckily,” she said, it was “triple-checked and remedied before that could happen. But I think the potential for harm is there when you have so much information and paperwork that you have to go through.”
Clinicians say their hospitals have relied on slapdash workarounds, using handwritten notes, faxes, sticky notes, and basic computer spreadsheets — many devised on the fly by doctors and nurses — to care for patients.
More than a dozen other nurses and doctors, some of them without union protections, at Ascension hospitals in Michigan recounted situations in which they say patient care was compromised. Those clinicians spoke on the condition that they not be named for fear of retaliation by their employer.
An Ascension hospital emergency room doctor in Detroit said a man on the city’s east side was given a dangerous narcotic intended for another patient because of a paperwork mix-up. As a result, the patient’s breathing slowed to the point that he had to be put on a ventilator. “We intubated him and we sent him to the ICU because he got the wrong medication.”
A nurse in a Michigan Ascension hospital ER said a woman with low blood sugar and “altered mental status” went into cardiac arrest and died after staff said they waited four hours for lab results they needed to determine how to treat her, but never received. “If I started having crushing chest pain in the middle of work and thought I was having a big one, I would grab someone to drive me down the street to another hospital,” the same ER nurse said.
Similar concerns reportedly led a travel nurse at an Ascension hospital in Indiana to quit. “I just want to warn those patients that are coming to any of the Ascension facilities that there will be delays in care. There is potential for error and for harm,” Justin Neisser told CBS4 in Indianapolis in May.
Several nurses and doctors at Ascension hospitals said they feared the errors they’ve witnessed since the cyberattack began could threaten their professional licenses. “This is how a RaDonda Vaught happens,” one nurse said, referring to the Tennessee nurse who was convicted of criminally negligent homicide in 2022 for a fatal drug error.
Reporters were not able to review records to verify clinicians’ claims because of privacy laws surrounding patients’ medical information that apply to health care professionals.
Ascension declined to answer questions about claims that care has been affected by the ransomware attack. “As we have made clear throughout this cyber attack which has impacted our system and our dedicated clinical providers, caring for our patients is our highest priority,” Sean Fitzpatrick, Ascension’s vice president of external communications, said via email on June 3. “We are confident that our care providers in our hospitals and facilities continue to provide quality medical care.”
The federal government requires hospitals to protect patients’ sensitive health data, according to cybersecurity experts. However, there are no federal requirements for hospitals to prevent or prepare for cyberattacks that could compromise their electronic systems.
Hospitals: ‘The No.1 Target of Ransomware’
“We’ve started to think about these as public health issues and disasters on the scale of earthquakes or hurricanes,” said Jeff Tully, a co-director of the Center for Healthcare Cybersecurity at the University of California-San Diego. “These types of cybersecurity incidents should be thought of as a matter of when, and not if.”
Josh Corman, a cybersecurity expert and advocate, said ransom crews regard hospitals as the perfect prey: “They have terrible security and they’ll pay. So almost immediately, hospitals went to the No. 1 target of ransomware.”
In 2023, the health sector experienced the largest share of ransomware attacks of 16 infrastructure sectors considered vital to national security or safety, according to an FBI report on internet crimes. In March, the federal Department of Health and Human Services said reported large breaches involving ransomware had jumped by 264% over the past five years.
A cyberattack this year on Change Healthcare, a unit of UnitedHealth Group’s Optum division that processes billions of health care transactions every year, crippled the business of providers, pharmacies, and hospitals.
In May, UnitedHealth Group CEO Andrew Witty told lawmakers the company paid a $22 million ransom as a result of the Change Healthcare attack — which occurred after hackers accessed a company portal that didn’t have multifactor authentication, a basic cybersecurity tool.
The Biden administration in recent months has pushed to bolster health care cybersecurity standards, but it’s not clear which new measures will be required.
In January, HHS nudged companies to improve email security, add multifactor authentication, and institute cybersecurity training and testing, among other voluntary measures. The Centers for Medicare & Medicaid Services is expected to release new requirements for hospitals, but the scope and timing are unclear. The same is true of an update HHS is expected to make to patient privacy regulations.
HHS said the voluntary measures “will inform the creation of new enforceable cybersecurity standards,” department spokesperson Jeff Nesbit said in a statement.
“The recent cyberattack at Ascension only underscores the need for everyone in the health care ecosystem to do their part to secure their systems and protect patients,” Nesbit said.
Meanwhile, lobbyists for the hospital industry contend cybersecurity mandates or penalties are misplaced and would curtail hospitals’ resources to fend off attacks.
“Hospitals and health systems are not the primary source of cyber risk exposure facing the health care sector,” the American Hospital Association, the largest lobbying group for U.S. hospitals, said in an April statement prepared for U.S. House lawmakers. Most large data breaches that hit hospitals in 2023 originated with third-party “business associates” or other health entities, including CMS itself, the AHA statement said.
Hospitals consolidating into large multistate health systems face increased risk of data breaches and ransomware attacks, according to one study. Ascension in 2022 was the third-largest hospital chain in the U.S. by number of beds, according to the most recent data from the federal Agency for Healthcare Research and Quality.
And while cybersecurity regulations can quickly become outdated, they can at least make it clear that if health systems fail to implement basic protections there “should be consequences for that,” Jim Bagian, a former director of the National Center for Patient Safety at the Veterans Health Administration, told Michigan Public’s Stateside.
Patients can pay the price when lapses occur. Those in hospital care face a greater likelihood of death during a cyberattack, according to researchers at the University of Minnesota School of Public Health.
Workers concerned about patient safety at Ascension hospitals in Michigan have called for the company to make changes.
“We implore Ascension to recognize the internal problems that continue to plague its hospitals, both publicly and transparently,” said Dina Carlisle, a nurse and the president of the OPEIU Local 40 union, which represents nurses at Ascension Providence Rochester. At least 125 staff members at that Ascension hospital have signed a petition asking administrators to temporarily reduce elective surgeries and nonemergency patient admissions, like under the protocols many hospitals adopted early in the covid-19 pandemic.
Watson, the Kansas ICU nurse, said in late May that nurses had urged management to bring in more nurses to help manage the workflow. “Everything that we say has fallen on deaf ears,” she said.
“It is very hard to be a nurse at Ascension right now,” Watson said in late May. “It is very hard to be a patient at Ascension right now.”
If you’re a patient or worker at an Ascension hospital and would like to tell KFF Health News about your experiences, click here to share your story with us.
KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.
In the wake of a debilitating cyberattack against one of the nation’s largest health care systems, Marvin Ruckle, a nurse at an Ascension hospital in Wichita, Kansas, said he had a frightening experience: He nearly gave a baby “the wrong dose of narcotic” because of confusing paperwork.
A May 8 ransomware attack against Ascension, a Catholic health system with 140 hospitals in at least 10 states, locked providers out of systems that track and coordinate nearly every aspect of patient care. They include its systems for electronic health records, some phones, and ones “utilized to order certain tests, procedures and medications,” the company said in a May 9 statement.
More than a dozen doctors and nurses who work for the sprawling health system told Michigan Public and KFF Health News that patient care at its hospitals across the nation was compromised in the fallout of the cyberattack over the past several weeks. Clinicians working for hospitals in three states described harrowing lapses, including delayed or lost lab results, medication errors, and an absence of routine safety checks via technology to prevent potentially fatal mistakes.
Despite a precipitous rise in cyberattacks against the health sector in recent years, a weeks-long disruption of this magnitude is beyond what most health systems are prepared for, said John S. Clark, an associate chief pharmacy officer at the University of Michigan health system.
“I don’t believe that anyone is fully prepared,” he said. Most emergency management plans “are designed around long-term downtimes that are into one, two, or three days.”
Ascension in a public statement May 9 said its care teams were “trained for these kinds of disruptions,” but did not respond to questions in early June about whether it had prepared for longer periods of downtime. Ascension said June 14 it had restored access to electronic health records across its network, but that patient “medical records and other information collected between May 8” and when the service was restored “may be temporarily inaccessible as we work to update the portal with information collected during the system downtime.”
Ruckle said he “had no training” for the cyberattack.
Back to Paper
Lisa Watson, an intensive care unit nurse at Ascension Via Christi St. Francis hospital in Wichita, described her own close call. She said she nearly administered the wrong medication to a critically ill patient because she couldn’t scan it as she normally would. “My patient probably would have passed away had I not caught it,” she said.
Watson is no stranger to using paper for patients’ medical charts, saying she did so “for probably half of my career,” before electronic health records became ubiquitous in hospitals. What happened after the cyberattack was “by no means the same.”
“When we paper-charted, we had systems in place to get those orders to other departments in a timely manner,” she said, “and those have all gone away.”
Melissa LaRue, an ICU nurse at Ascension Saint Agnes Hospital in Baltimore, described a close call with “administering the wrong dosage” of a patient’s blood pressure medication. “Luckily,” she said, it was “triple-checked and remedied before that could happen. But I think the potential for harm is there when you have so much information and paperwork that you have to go through.”
Clinicians say their hospitals have relied on slapdash workarounds, using handwritten notes, faxes, sticky notes, and basic computer spreadsheets — many devised on the fly by doctors and nurses — to care for patients.
More than a dozen other nurses and doctors, some of them without union protections, at Ascension hospitals in Michigan recounted situations in which they say patient care was compromised. Those clinicians spoke on the condition that they not be named for fear of retaliation by their employer.
An Ascension hospital emergency room doctor in Detroit said a man on the city’s east side was given a dangerous narcotic intended for another patient because of a paperwork mix-up. As a result, the patient’s breathing slowed to the point that he had to be put on a ventilator. “We intubated him and we sent him to the ICU because he got the wrong medication.”
A nurse in a Michigan Ascension hospital ER said a woman with low blood sugar and “altered mental status” went into cardiac arrest and died after staff said they waited four hours for lab results they needed to determine how to treat her, but never received. “If I started having crushing chest pain in the middle of work and thought I was having a big one, I would grab someone to drive me down the street to another hospital,” the same ER nurse said.
Similar concerns reportedly led a travel nurse at an Ascension hospital in Indiana to quit. “I just want to warn those patients that are coming to any of the Ascension facilities that there will be delays in care. There is potential for error and for harm,” Justin Neisser told CBS4 in Indianapolis in May.
Several nurses and doctors at Ascension hospitals said they feared the errors they’ve witnessed since the cyberattack began could threaten their professional licenses. “This is how a RaDonda Vaught happens,” one nurse said, referring to the Tennessee nurse who was convicted of criminally negligent homicide in 2022 for a fatal drug error.
Reporters were not able to review records to verify clinicians’ claims because of privacy laws surrounding patients’ medical information that apply to health care professionals.
Ascension declined to answer questions about claims that care has been affected by the ransomware attack. “As we have made clear throughout this cyber attack which has impacted our system and our dedicated clinical providers, caring for our patients is our highest priority,” Sean Fitzpatrick, Ascension’s vice president of external communications, said via email on June 3. “We are confident that our care providers in our hospitals and facilities continue to provide quality medical care.”
The federal government requires hospitals to protect patients’ sensitive health data, according to cybersecurity experts. However, there are no federal requirements for hospitals to prevent or prepare for cyberattacks that could compromise their electronic systems.
Hospitals: ‘The No.1 Target of Ransomware’
“We’ve started to think about these as public health issues and disasters on the scale of earthquakes or hurricanes,” said Jeff Tully, a co-director of the Center for Healthcare Cybersecurity at the University of California-San Diego. “These types of cybersecurity incidents should be thought of as a matter of when, and not if.”
Josh Corman, a cybersecurity expert and advocate, said ransom crews regard hospitals as the perfect prey: “They have terrible security and they’ll pay. So almost immediately, hospitals went to the No. 1 target of ransomware.”
In 2023, the health sector experienced the largest share of ransomware attacks of 16 infrastructure sectors considered vital to national security or safety, according to an FBI report on internet crimes. In March, the federal Department of Health and Human Services said reported large breaches involving ransomware had jumped by 264% over the past five years.
A cyberattack this year on Change Healthcare, a unit of UnitedHealth Group’s Optum division that processes billions of health care transactions every year, crippled the business of providers, pharmacies, and hospitals.
In May, UnitedHealth Group CEO Andrew Witty told lawmakers the company paid a $22 million ransom as a result of the Change Healthcare attack — which occurred after hackers accessed a company portal that didn’t have multifactor authentication, a basic cybersecurity tool.
The Biden administration in recent months has pushed to bolster health care cybersecurity standards, but it’s not clear which new measures will be required.
In January, HHS nudged companies to improve email security, add multifactor authentication, and institute cybersecurity training and testing, among other voluntary measures. The Centers for Medicare & Medicaid Services is expected to release new requirements for hospitals, but the scope and timing are unclear. The same is true of an update HHS is expected to make to patient privacy regulations.
HHS said the voluntary measures “will inform the creation of new enforceable cybersecurity standards,” department spokesperson Jeff Nesbit said in a statement.
“The recent cyberattack at Ascension only underscores the need for everyone in the health care ecosystem to do their part to secure their systems and protect patients,” Nesbit said.
Meanwhile, lobbyists for the hospital industry contend cybersecurity mandates or penalties are misplaced and would curtail hospitals’ resources to fend off attacks.
“Hospitals and health systems are not the primary source of cyber risk exposure facing the health care sector,” the American Hospital Association, the largest lobbying group for U.S. hospitals, said in an April statement prepared for U.S. House lawmakers. Most large data breaches that hit hospitals in 2023 originated with third-party “business associates” or other health entities, including CMS itself, the AHA statement said.
Hospitals consolidating into large multistate health systems face increased risk of data breaches and ransomware attacks, according to one study. Ascension in 2022 was the third-largest hospital chain in the U.S. by number of beds, according to the most recent data from the federal Agency for Healthcare Research and Quality.
And while cybersecurity regulations can quickly become outdated, they can at least make it clear that if health systems fail to implement basic protections there “should be consequences for that,” Jim Bagian, a former director of the National Center for Patient Safety at the Veterans Health Administration, told Michigan Public’s Stateside.
Patients can pay the price when lapses occur. Those in hospital care face a greater likelihood of death during a cyberattack, according to researchers at the University of Minnesota School of Public Health.
Workers concerned about patient safety at Ascension hospitals in Michigan have called for the company to make changes.
“We implore Ascension to recognize the internal problems that continue to plague its hospitals, both publicly and transparently,” said Dina Carlisle, a nurse and the president of the OPEIU Local 40 union, which represents nurses at Ascension Providence Rochester. At least 125 staff members at that Ascension hospital have signed a petition asking administrators to temporarily reduce elective surgeries and nonemergency patient admissions, like under the protocols many hospitals adopted early in the covid-19 pandemic.
Watson, the Kansas ICU nurse, said in late May that nurses had urged management to bring in more nurses to help manage the workflow. “Everything that we say has fallen on deaf ears,” she said.
“It is very hard to be a nurse at Ascension right now,” Watson said in late May. “It is very hard to be a patient at Ascension right now.”
If you’re a patient or worker at an Ascension hospital and would like to tell KFF Health News about your experiences, click here to share your story with us.
KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.
Should You Offer Medical Credit Cards?
Editor’s note: This is Dr. Eastern’s last “Managing Your Practice” column for Dermatology News. After his first column was published in 1986, Dr. Eastern continued writing his column monthly until the mid-1990s, resuming in 2005. In total, he has written over 300 columns on topics relevant to medical practice, ranging from hiring employees, selling and merging practices, complying with OSHA, and avoiding embezzlement, to electronic health records, burnout, medical assistants, negative online reviews, artificial intelligence in the office, and more. In the future, he will continue to provide commentary on practice issues with an occasional guest editorial.
Medicare reimbursement cuts, increasing overhead and staff salaries, and inflation have made running a profitable private practice increasingly challenging, particularly for rural and smaller offices. Medical credit cards are an increasingly popular choice to fill this gap.
Traditionally, these cards were used to help cover procedures insurance didn’t cover — such as cosmetic procedures — but over the years, they have been expanded to cover other healthcare charges, mostly for patients who are paying out of pocket due to inadequate insurance or other reasons.
Advantages for physicians include immediate payment from the credit card company and reduced billing and collection costs. Patients are also less likely to delay or defer treatment if they can charge the payment and pay it back in installments.
The first step in offering medical credit cards is signing up with one or more third-party card companies. CareCredit is the most common provider in the medical credit card market. Other vendors include Wells Fargo, AccessOne, Alphaeon Credit, and iCare Financial. (As always, I have no financial interest in any product or service mentioned in this column.) A member of your staff signs patients up, and the credit card company checks their credit. If approved, the card company pays you your fee and assumes responsibility for collecting from the patient.
The interest charge on medical credit cards is often deferred for a period of time, typically between 6 and 24 months. If patients pay off the debt within this time, they can avoid paying interest. But, like other credit cards, if they make late payments or have an unpaid balance once the promotional period ends, they may end up with interest and fees totaling 25%-30% or more. It is important to make it very clear to your patients that payments are interest-free only if they are all made on time and within the promotional period.
According to a Consumer Financial Protection Bureau report released earlier this year, deferred interest medical credit cards or loans were used to pay nearly $23 billion in healthcare expenses from 2018 to 2020. Individuals unable to complete payment during the promotional period paid $1 billion in deferred interest payments during that period.
Despite the growing popularity of medical credit cards among physicians, it is worth noting that some consumer groups view them as predatory financial products, marketed toward people in tough financial situations. A coalition of 60 health advocacy groups has urged the Biden Administration to ban deferred interest medical credit cards. So there is that much more reason to choose candidates for medical credit cards carefully, and to make them fully aware of what obligations they are assuming.
Patients who do not think they can pay off the balance within the interest-free time frame should probably be advised to pursue an alternative payment method, such as using a conventional credit card, taking out a personal or home-equity loan, or borrowing from a retirement savings account. Some physicians are willing to negotiate a reduced fee for patients who agree to pay cash at the time of service.
Those who do choose to apply for a medical credit card should be informed of their options, which can vary considerably depending on the product and the third-party vendor. Some medical credit products can be used only for elective procedures, but some can be used more broadly for various medical expenses. Check to make sure that each patient’s financing option can be used for his or her desired medical service.
Some payment products can only be used at specific practices or groups, while others can be used at a variety of medical offices and hospitals. If a patient arrives with a medical credit card already in hand, confirm that it is one that your office accepts.
Interest rates generally vary with each card and vendor. Make patients aware of when interest rates start accruing and if the plan offers a fixed or variable APR, or if it charges compounding interest. Confirm if there is a deferred interest option, and if so, for how long.
Different medical credit products also have varying fees and payment schedules. See that each patient reads the terms of the agreement to understand when interest may start to accrue or change, as well as when certain fees may apply. Understanding when the payments are due will help them avoid additional fees, including late fees. Some medical payment plans may also have administrative or processing fees. If so, patients should be made aware of them.
Dr. Eastern practices dermatology and dermatologic surgery in Belleville, New Jersey. He is the author of numerous articles and textbook chapters, and is a longtime monthly columnist for Dermatology News. Write to him at [email protected].
Editor’s note: This is Dr. Eastern’s last “Managing Your Practice” column for Dermatology News. After his first column was published in 1986, Dr. Eastern continued writing his column monthly until the mid-1990s, resuming in 2005. In total, he has written over 300 columns on topics relevant to medical practice, ranging from hiring employees, selling and merging practices, complying with OSHA, and avoiding embezzlement, to electronic health records, burnout, medical assistants, negative online reviews, artificial intelligence in the office, and more. In the future, he will continue to provide commentary on practice issues with an occasional guest editorial.
Medicare reimbursement cuts, increasing overhead and staff salaries, and inflation have made running a profitable private practice increasingly challenging, particularly for rural and smaller offices. Medical credit cards are an increasingly popular choice to fill this gap.
Traditionally, these cards were used to help cover procedures insurance didn’t cover — such as cosmetic procedures — but over the years, they have been expanded to cover other healthcare charges, mostly for patients who are paying out of pocket due to inadequate insurance or other reasons.
Advantages for physicians include immediate payment from the credit card company and reduced billing and collection costs. Patients are also less likely to delay or defer treatment if they can charge the payment and pay it back in installments.
The first step in offering medical credit cards is signing up with one or more third-party card companies. CareCredit is the most common provider in the medical credit card market. Other vendors include Wells Fargo, AccessOne, Alphaeon Credit, and iCare Financial. (As always, I have no financial interest in any product or service mentioned in this column.) A member of your staff signs patients up, and the credit card company checks their credit. If approved, the card company pays you your fee and assumes responsibility for collecting from the patient.
The interest charge on medical credit cards is often deferred for a period of time, typically between 6 and 24 months. If patients pay off the debt within this time, they can avoid paying interest. But, like other credit cards, if they make late payments or have an unpaid balance once the promotional period ends, they may end up with interest and fees totaling 25%-30% or more. It is important to make it very clear to your patients that payments are interest-free only if they are all made on time and within the promotional period.
According to a Consumer Financial Protection Bureau report released earlier this year, deferred interest medical credit cards or loans were used to pay nearly $23 billion in healthcare expenses from 2018 to 2020. Individuals unable to complete payment during the promotional period paid $1 billion in deferred interest payments during that period.
Despite the growing popularity of medical credit cards among physicians, it is worth noting that some consumer groups view them as predatory financial products, marketed toward people in tough financial situations. A coalition of 60 health advocacy groups has urged the Biden Administration to ban deferred interest medical credit cards. So there is that much more reason to choose candidates for medical credit cards carefully, and to make them fully aware of what obligations they are assuming.
Patients who do not think they can pay off the balance within the interest-free time frame should probably be advised to pursue an alternative payment method, such as using a conventional credit card, taking out a personal or home-equity loan, or borrowing from a retirement savings account. Some physicians are willing to negotiate a reduced fee for patients who agree to pay cash at the time of service.
Those who do choose to apply for a medical credit card should be informed of their options, which can vary considerably depending on the product and the third-party vendor. Some medical credit products can be used only for elective procedures, but some can be used more broadly for various medical expenses. Check to make sure that each patient’s financing option can be used for his or her desired medical service.
Some payment products can only be used at specific practices or groups, while others can be used at a variety of medical offices and hospitals. If a patient arrives with a medical credit card already in hand, confirm that it is one that your office accepts.
Interest rates generally vary with each card and vendor. Make patients aware of when interest rates start accruing and if the plan offers a fixed or variable APR, or if it charges compounding interest. Confirm if there is a deferred interest option, and if so, for how long.
Different medical credit products also have varying fees and payment schedules. See that each patient reads the terms of the agreement to understand when interest may start to accrue or change, as well as when certain fees may apply. Understanding when the payments are due will help them avoid additional fees, including late fees. Some medical payment plans may also have administrative or processing fees. If so, patients should be made aware of them.
Dr. Eastern practices dermatology and dermatologic surgery in Belleville, New Jersey. He is the author of numerous articles and textbook chapters, and is a longtime monthly columnist for Dermatology News. Write to him at [email protected].
Editor’s note: This is Dr. Eastern’s last “Managing Your Practice” column for Dermatology News. After his first column was published in 1986, Dr. Eastern continued writing his column monthly until the mid-1990s, resuming in 2005. In total, he has written over 300 columns on topics relevant to medical practice, ranging from hiring employees, selling and merging practices, complying with OSHA, and avoiding embezzlement, to electronic health records, burnout, medical assistants, negative online reviews, artificial intelligence in the office, and more. In the future, he will continue to provide commentary on practice issues with an occasional guest editorial.
Medicare reimbursement cuts, increasing overhead and staff salaries, and inflation have made running a profitable private practice increasingly challenging, particularly for rural and smaller offices. Medical credit cards are an increasingly popular choice to fill this gap.
Traditionally, these cards were used to help cover procedures insurance didn’t cover — such as cosmetic procedures — but over the years, they have been expanded to cover other healthcare charges, mostly for patients who are paying out of pocket due to inadequate insurance or other reasons.
Advantages for physicians include immediate payment from the credit card company and reduced billing and collection costs. Patients are also less likely to delay or defer treatment if they can charge the payment and pay it back in installments.
The first step in offering medical credit cards is signing up with one or more third-party card companies. CareCredit is the most common provider in the medical credit card market. Other vendors include Wells Fargo, AccessOne, Alphaeon Credit, and iCare Financial. (As always, I have no financial interest in any product or service mentioned in this column.) A member of your staff signs patients up, and the credit card company checks their credit. If approved, the card company pays you your fee and assumes responsibility for collecting from the patient.
The interest charge on medical credit cards is often deferred for a period of time, typically between 6 and 24 months. If patients pay off the debt within this time, they can avoid paying interest. But, like other credit cards, if they make late payments or have an unpaid balance once the promotional period ends, they may end up with interest and fees totaling 25%-30% or more. It is important to make it very clear to your patients that payments are interest-free only if they are all made on time and within the promotional period.
According to a Consumer Financial Protection Bureau report released earlier this year, deferred interest medical credit cards or loans were used to pay nearly $23 billion in healthcare expenses from 2018 to 2020. Individuals unable to complete payment during the promotional period paid $1 billion in deferred interest payments during that period.
Despite the growing popularity of medical credit cards among physicians, it is worth noting that some consumer groups view them as predatory financial products, marketed toward people in tough financial situations. A coalition of 60 health advocacy groups has urged the Biden Administration to ban deferred interest medical credit cards. So there is that much more reason to choose candidates for medical credit cards carefully, and to make them fully aware of what obligations they are assuming.
Patients who do not think they can pay off the balance within the interest-free time frame should probably be advised to pursue an alternative payment method, such as using a conventional credit card, taking out a personal or home-equity loan, or borrowing from a retirement savings account. Some physicians are willing to negotiate a reduced fee for patients who agree to pay cash at the time of service.
Those who do choose to apply for a medical credit card should be informed of their options, which can vary considerably depending on the product and the third-party vendor. Some medical credit products can be used only for elective procedures, but some can be used more broadly for various medical expenses. Check to make sure that each patient’s financing option can be used for his or her desired medical service.
Some payment products can only be used at specific practices or groups, while others can be used at a variety of medical offices and hospitals. If a patient arrives with a medical credit card already in hand, confirm that it is one that your office accepts.
Interest rates generally vary with each card and vendor. Make patients aware of when interest rates start accruing and if the plan offers a fixed or variable APR, or if it charges compounding interest. Confirm if there is a deferred interest option, and if so, for how long.
Different medical credit products also have varying fees and payment schedules. See that each patient reads the terms of the agreement to understand when interest may start to accrue or change, as well as when certain fees may apply. Understanding when the payments are due will help them avoid additional fees, including late fees. Some medical payment plans may also have administrative or processing fees. If so, patients should be made aware of them.
Dr. Eastern practices dermatology and dermatologic surgery in Belleville, New Jersey. He is the author of numerous articles and textbook chapters, and is a longtime monthly columnist for Dermatology News. Write to him at [email protected].
Intensive Interventions Are Needed for High-BMI Youth
The U.S. Preventive Services Task Force (USPSTF) is recommending that clinicians provide comprehensive, intensive behavioral interventions for children 6 years and older who have a high body mass index (BMI) at or above the 95th percentile (for age and sex) or refer those patients to an appropriate provider.
One in five children (19.7%) and adolescents ages 2-19 in the United States are at or above this range, based on Centers for Disease Control and Prevention growth charts from 2000, the task force wrote in its statement. The rate of BMI increase nearly doubled in this age group during the COVID pandemic, compared with prepandemic levels.
Publishing their recommendations in JAMA, the task force, with lead author Wanda K. Nicholson, MD, MPH, MBA, with the Milken Institute of Public Health, George Washington University, Washington, D.C., also noted that the prevalence of high BMI increases with age and rates are higher among children from lower-income families. Rates are also higher in Hispanic/Latino, Native American/Alaska Native and non-Hispanic Black children.
At Least 26 Hours of Interventions
It is important that children and adolescents 6 years or older with a high BMI receive intensive interventions for at least 26 contact hours for up to a year, as evidence showed that was the threshold for weight loss, the task force said.
Based on its evidence review, the USPSTF assigned this recommendation a B grade indicating “moderate certainty ... of moderate net benefit.” The task force analyzed 50 randomized clinical trials (RCTs) (n = 8,798) that examined behavioral interventions. They also analyzed eight trials that assessed pharmacotherapy interventions: liraglutide (three RCTs), semaglutide (one RCT), orlistat (two RCTs) and phentermine/topiramate (two RCTs). Five trials included behavioral counseling with the medication or placebo.
These new recommendations also reaffirm the task force’s 2010 and 2023 recommendations.
Effective interventions had multiple components. They included interventions targeting both the parent and child (separately, together or both); group sessions; information about healthy eating, information on reading food labels, and safe exercising; and interventions for encouraging behavioral changes, such as monitoring food intake and problem solving, changing physical activity behaviors, and goal setting.
These types of interventions are often delivered by multidisciplinary teams, including pediatricians, exercise physiologists or physical therapists, dietitians, psychologists, social workers, or other behavioral specialists.
Personalizing Treatment for Optimal Benefit
“The time to prevent and intervene on childhood obesity is now, and the need to start with ILT [intensive lifestyle therapy] is clear,” Roohi Y. Kharofa, MD, with the department of pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, and colleagues wrote in a related editorial.
However, the editorialists noted it will be important to personalize the level of interventions as ILT won’t be enough for some to prevent serious outcomes. For such patients, bariatric surgery or pharmacotherapy may need to be considered as well.
Ways to Reach the 26 Hours
Dr. Kharofa and coauthors pointed out that, while the threshold of at least 26 contact hours is associated with significant improvement in BMI (mean BMI difference, –0.8; 95% CI, –1.2 to –0.4), and while it’s important to now have an evidence-based threshold, the number may be disheartening given limits on clinicians, staff, and resources. The key may be prescribing physical activity sessions outside the health system.
For patients not interested in group sports or burdened by participation fees, collaboration with local community organizations, such as the YMCA or the Boys & Girls Club, could be arranged, the authors suggested.
“The inability to attain 26 hours should not deter patients or practitioners from participating in, referring to, or implementing obesity interventions. Rather, clinical teams and families should work together to maximize intervention dose using clinical and community programs synergistically,” they wrote.
They noted that the USPSTF in this 2024 update found “inadequate evidence on the benefits of pharmacotherapy in youth with obesity, encouraging clinicians to use ILT as the primary intervention.”
What About Medications?
New since the previous USPSTF review, several new medications have been approved for weight loss in pediatric populations, Elizabeth A. O’Connor, PhD, with The Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon, and colleagues noted in their updated evidence report.
They noted that the 2023 Clinical Practice Guideline developed by the American Academy of Pediatrics states that clinicians “may offer children ages 8 through 11 years of age with obesity weight loss pharmacotherapy, according to medication indications, risks, and benefits, as an adjunct to health behavior and lifestyle treatment.”
However, Dr. O’Connor and coauthors wrote, the evidence base for each agent is limited and there is no information in the literature supporting their findings on harms of medication use beyond 17 months.
“For pharmacotherapy, when evidence was available on weight maintenance after discontinuation, weight rebounded quickly after medication use ended,” the authors wrote. “This suggests that long-term use is required for weight maintenance and underscores the need for evidence about potential harms from long-term use.”
Changes in Investment, Food, Government Priorities Are Needed
In a separate accompanying editorial, Thomas N. Robinson, MD, MPH, with Stanford University’s Center for Healthy Weight and General Pediatrics Department in Palo Alto, California, and Sarah C. Armstrong, MD, with the Duke Center for Childhood Obesity Research, Chapel Hill, North Carolina, wrote that experience to date has shown that current approaches aren’t working and, in fact, pediatric obesity rates are worsening.
“After nearly 15 years of authoritative, evidence-backed USPSTF recommendations for effective interventions for children with high BMI, it is long past time to implement them,” they wrote.
But changes will need to go far beyond clinicians’ offices and priorities must change at local, state, and federal levels, Dr. Robinson and Dr. Armstrong wrote. A shift in priorities is needed to make screening and behavioral interventions available to all children and teens with obesity.
Public policies, they wrote, must address larger issues, such as food content and availability of healthy foods, transportation innovations, and ways to make active lifestyles available equitably.
The authors said that strategies may include taxing sugary drinks, regulating marketing of unhealthful foods, crafting legislation to regulate the nutritional content of school meals, and creating policies to reduce poverty and address social drivers of health.
“A synergistic combination of effective clinical care, as recommended by the USPSTF, and public policy interventions is critically needed to turn the tide on childhood obesity,” Dr. Robinson and Dr. Armstrong wrote.
The full recommendation statement is available at the USPSTF website or the JAMA website.
One coauthor of the recommendation statement reported receiving publications and federal grand funding to his institution for the relationship between obesity and the potential effect of nutrition policy interventions on cardiovascular disease and cancer and for a meta-analysis of the effect of dietary counseling for weight loss. The authors of the evidence report had no relevant conflicts of interest. Dr. Kharofa reported receiving grants from Rhythm Pharmaceuticals outside the submitted work. Dr. Robinson has served on the scientific advisory board of WW International (through December 2022). Dr. Armstrong has served as chair of the Section on Obesity, American Academy of Pediatrics; and is a coauthor of the Clinical Practice Guidelines for the Evaluation and Treatment of Children and Adolescents with Obesity.
The U.S. Preventive Services Task Force (USPSTF) is recommending that clinicians provide comprehensive, intensive behavioral interventions for children 6 years and older who have a high body mass index (BMI) at or above the 95th percentile (for age and sex) or refer those patients to an appropriate provider.
One in five children (19.7%) and adolescents ages 2-19 in the United States are at or above this range, based on Centers for Disease Control and Prevention growth charts from 2000, the task force wrote in its statement. The rate of BMI increase nearly doubled in this age group during the COVID pandemic, compared with prepandemic levels.
Publishing their recommendations in JAMA, the task force, with lead author Wanda K. Nicholson, MD, MPH, MBA, with the Milken Institute of Public Health, George Washington University, Washington, D.C., also noted that the prevalence of high BMI increases with age and rates are higher among children from lower-income families. Rates are also higher in Hispanic/Latino, Native American/Alaska Native and non-Hispanic Black children.
At Least 26 Hours of Interventions
It is important that children and adolescents 6 years or older with a high BMI receive intensive interventions for at least 26 contact hours for up to a year, as evidence showed that was the threshold for weight loss, the task force said.
Based on its evidence review, the USPSTF assigned this recommendation a B grade indicating “moderate certainty ... of moderate net benefit.” The task force analyzed 50 randomized clinical trials (RCTs) (n = 8,798) that examined behavioral interventions. They also analyzed eight trials that assessed pharmacotherapy interventions: liraglutide (three RCTs), semaglutide (one RCT), orlistat (two RCTs) and phentermine/topiramate (two RCTs). Five trials included behavioral counseling with the medication or placebo.
These new recommendations also reaffirm the task force’s 2010 and 2023 recommendations.
Effective interventions had multiple components. They included interventions targeting both the parent and child (separately, together or both); group sessions; information about healthy eating, information on reading food labels, and safe exercising; and interventions for encouraging behavioral changes, such as monitoring food intake and problem solving, changing physical activity behaviors, and goal setting.
These types of interventions are often delivered by multidisciplinary teams, including pediatricians, exercise physiologists or physical therapists, dietitians, psychologists, social workers, or other behavioral specialists.
Personalizing Treatment for Optimal Benefit
“The time to prevent and intervene on childhood obesity is now, and the need to start with ILT [intensive lifestyle therapy] is clear,” Roohi Y. Kharofa, MD, with the department of pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, and colleagues wrote in a related editorial.
However, the editorialists noted it will be important to personalize the level of interventions as ILT won’t be enough for some to prevent serious outcomes. For such patients, bariatric surgery or pharmacotherapy may need to be considered as well.
Ways to Reach the 26 Hours
Dr. Kharofa and coauthors pointed out that, while the threshold of at least 26 contact hours is associated with significant improvement in BMI (mean BMI difference, –0.8; 95% CI, –1.2 to –0.4), and while it’s important to now have an evidence-based threshold, the number may be disheartening given limits on clinicians, staff, and resources. The key may be prescribing physical activity sessions outside the health system.
For patients not interested in group sports or burdened by participation fees, collaboration with local community organizations, such as the YMCA or the Boys & Girls Club, could be arranged, the authors suggested.
“The inability to attain 26 hours should not deter patients or practitioners from participating in, referring to, or implementing obesity interventions. Rather, clinical teams and families should work together to maximize intervention dose using clinical and community programs synergistically,” they wrote.
They noted that the USPSTF in this 2024 update found “inadequate evidence on the benefits of pharmacotherapy in youth with obesity, encouraging clinicians to use ILT as the primary intervention.”
What About Medications?
New since the previous USPSTF review, several new medications have been approved for weight loss in pediatric populations, Elizabeth A. O’Connor, PhD, with The Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon, and colleagues noted in their updated evidence report.
They noted that the 2023 Clinical Practice Guideline developed by the American Academy of Pediatrics states that clinicians “may offer children ages 8 through 11 years of age with obesity weight loss pharmacotherapy, according to medication indications, risks, and benefits, as an adjunct to health behavior and lifestyle treatment.”
However, Dr. O’Connor and coauthors wrote, the evidence base for each agent is limited and there is no information in the literature supporting their findings on harms of medication use beyond 17 months.
“For pharmacotherapy, when evidence was available on weight maintenance after discontinuation, weight rebounded quickly after medication use ended,” the authors wrote. “This suggests that long-term use is required for weight maintenance and underscores the need for evidence about potential harms from long-term use.”
Changes in Investment, Food, Government Priorities Are Needed
In a separate accompanying editorial, Thomas N. Robinson, MD, MPH, with Stanford University’s Center for Healthy Weight and General Pediatrics Department in Palo Alto, California, and Sarah C. Armstrong, MD, with the Duke Center for Childhood Obesity Research, Chapel Hill, North Carolina, wrote that experience to date has shown that current approaches aren’t working and, in fact, pediatric obesity rates are worsening.
“After nearly 15 years of authoritative, evidence-backed USPSTF recommendations for effective interventions for children with high BMI, it is long past time to implement them,” they wrote.
But changes will need to go far beyond clinicians’ offices and priorities must change at local, state, and federal levels, Dr. Robinson and Dr. Armstrong wrote. A shift in priorities is needed to make screening and behavioral interventions available to all children and teens with obesity.
Public policies, they wrote, must address larger issues, such as food content and availability of healthy foods, transportation innovations, and ways to make active lifestyles available equitably.
The authors said that strategies may include taxing sugary drinks, regulating marketing of unhealthful foods, crafting legislation to regulate the nutritional content of school meals, and creating policies to reduce poverty and address social drivers of health.
“A synergistic combination of effective clinical care, as recommended by the USPSTF, and public policy interventions is critically needed to turn the tide on childhood obesity,” Dr. Robinson and Dr. Armstrong wrote.
The full recommendation statement is available at the USPSTF website or the JAMA website.
One coauthor of the recommendation statement reported receiving publications and federal grand funding to his institution for the relationship between obesity and the potential effect of nutrition policy interventions on cardiovascular disease and cancer and for a meta-analysis of the effect of dietary counseling for weight loss. The authors of the evidence report had no relevant conflicts of interest. Dr. Kharofa reported receiving grants from Rhythm Pharmaceuticals outside the submitted work. Dr. Robinson has served on the scientific advisory board of WW International (through December 2022). Dr. Armstrong has served as chair of the Section on Obesity, American Academy of Pediatrics; and is a coauthor of the Clinical Practice Guidelines for the Evaluation and Treatment of Children and Adolescents with Obesity.
The U.S. Preventive Services Task Force (USPSTF) is recommending that clinicians provide comprehensive, intensive behavioral interventions for children 6 years and older who have a high body mass index (BMI) at or above the 95th percentile (for age and sex) or refer those patients to an appropriate provider.
One in five children (19.7%) and adolescents ages 2-19 in the United States are at or above this range, based on Centers for Disease Control and Prevention growth charts from 2000, the task force wrote in its statement. The rate of BMI increase nearly doubled in this age group during the COVID pandemic, compared with prepandemic levels.
Publishing their recommendations in JAMA, the task force, with lead author Wanda K. Nicholson, MD, MPH, MBA, with the Milken Institute of Public Health, George Washington University, Washington, D.C., also noted that the prevalence of high BMI increases with age and rates are higher among children from lower-income families. Rates are also higher in Hispanic/Latino, Native American/Alaska Native and non-Hispanic Black children.
At Least 26 Hours of Interventions
It is important that children and adolescents 6 years or older with a high BMI receive intensive interventions for at least 26 contact hours for up to a year, as evidence showed that was the threshold for weight loss, the task force said.
Based on its evidence review, the USPSTF assigned this recommendation a B grade indicating “moderate certainty ... of moderate net benefit.” The task force analyzed 50 randomized clinical trials (RCTs) (n = 8,798) that examined behavioral interventions. They also analyzed eight trials that assessed pharmacotherapy interventions: liraglutide (three RCTs), semaglutide (one RCT), orlistat (two RCTs) and phentermine/topiramate (two RCTs). Five trials included behavioral counseling with the medication or placebo.
These new recommendations also reaffirm the task force’s 2010 and 2023 recommendations.
Effective interventions had multiple components. They included interventions targeting both the parent and child (separately, together or both); group sessions; information about healthy eating, information on reading food labels, and safe exercising; and interventions for encouraging behavioral changes, such as monitoring food intake and problem solving, changing physical activity behaviors, and goal setting.
These types of interventions are often delivered by multidisciplinary teams, including pediatricians, exercise physiologists or physical therapists, dietitians, psychologists, social workers, or other behavioral specialists.
Personalizing Treatment for Optimal Benefit
“The time to prevent and intervene on childhood obesity is now, and the need to start with ILT [intensive lifestyle therapy] is clear,” Roohi Y. Kharofa, MD, with the department of pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, and colleagues wrote in a related editorial.
However, the editorialists noted it will be important to personalize the level of interventions as ILT won’t be enough for some to prevent serious outcomes. For such patients, bariatric surgery or pharmacotherapy may need to be considered as well.
Ways to Reach the 26 Hours
Dr. Kharofa and coauthors pointed out that, while the threshold of at least 26 contact hours is associated with significant improvement in BMI (mean BMI difference, –0.8; 95% CI, –1.2 to –0.4), and while it’s important to now have an evidence-based threshold, the number may be disheartening given limits on clinicians, staff, and resources. The key may be prescribing physical activity sessions outside the health system.
For patients not interested in group sports or burdened by participation fees, collaboration with local community organizations, such as the YMCA or the Boys & Girls Club, could be arranged, the authors suggested.
“The inability to attain 26 hours should not deter patients or practitioners from participating in, referring to, or implementing obesity interventions. Rather, clinical teams and families should work together to maximize intervention dose using clinical and community programs synergistically,” they wrote.
They noted that the USPSTF in this 2024 update found “inadequate evidence on the benefits of pharmacotherapy in youth with obesity, encouraging clinicians to use ILT as the primary intervention.”
What About Medications?
New since the previous USPSTF review, several new medications have been approved for weight loss in pediatric populations, Elizabeth A. O’Connor, PhD, with The Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon, and colleagues noted in their updated evidence report.
They noted that the 2023 Clinical Practice Guideline developed by the American Academy of Pediatrics states that clinicians “may offer children ages 8 through 11 years of age with obesity weight loss pharmacotherapy, according to medication indications, risks, and benefits, as an adjunct to health behavior and lifestyle treatment.”
However, Dr. O’Connor and coauthors wrote, the evidence base for each agent is limited and there is no information in the literature supporting their findings on harms of medication use beyond 17 months.
“For pharmacotherapy, when evidence was available on weight maintenance after discontinuation, weight rebounded quickly after medication use ended,” the authors wrote. “This suggests that long-term use is required for weight maintenance and underscores the need for evidence about potential harms from long-term use.”
Changes in Investment, Food, Government Priorities Are Needed
In a separate accompanying editorial, Thomas N. Robinson, MD, MPH, with Stanford University’s Center for Healthy Weight and General Pediatrics Department in Palo Alto, California, and Sarah C. Armstrong, MD, with the Duke Center for Childhood Obesity Research, Chapel Hill, North Carolina, wrote that experience to date has shown that current approaches aren’t working and, in fact, pediatric obesity rates are worsening.
“After nearly 15 years of authoritative, evidence-backed USPSTF recommendations for effective interventions for children with high BMI, it is long past time to implement them,” they wrote.
But changes will need to go far beyond clinicians’ offices and priorities must change at local, state, and federal levels, Dr. Robinson and Dr. Armstrong wrote. A shift in priorities is needed to make screening and behavioral interventions available to all children and teens with obesity.
Public policies, they wrote, must address larger issues, such as food content and availability of healthy foods, transportation innovations, and ways to make active lifestyles available equitably.
The authors said that strategies may include taxing sugary drinks, regulating marketing of unhealthful foods, crafting legislation to regulate the nutritional content of school meals, and creating policies to reduce poverty and address social drivers of health.
“A synergistic combination of effective clinical care, as recommended by the USPSTF, and public policy interventions is critically needed to turn the tide on childhood obesity,” Dr. Robinson and Dr. Armstrong wrote.
The full recommendation statement is available at the USPSTF website or the JAMA website.
One coauthor of the recommendation statement reported receiving publications and federal grand funding to his institution for the relationship between obesity and the potential effect of nutrition policy interventions on cardiovascular disease and cancer and for a meta-analysis of the effect of dietary counseling for weight loss. The authors of the evidence report had no relevant conflicts of interest. Dr. Kharofa reported receiving grants from Rhythm Pharmaceuticals outside the submitted work. Dr. Robinson has served on the scientific advisory board of WW International (through December 2022). Dr. Armstrong has served as chair of the Section on Obesity, American Academy of Pediatrics; and is a coauthor of the Clinical Practice Guidelines for the Evaluation and Treatment of Children and Adolescents with Obesity.
FROM JAMA
Acute Sore Throat in Primary Care: When to Reach for the Antibiotics
This transcript has been edited for clarity.
There is a helpful consensus from experts on the best management of patients with acute sore throat. This is a common problem in primary care, and one for which there is a lot of evidence, opinion, and ultimately overprescribing of antibiotics. This consensus presents a pragmatic clinical approach aimed at decreasing overprescribing, yet detecting which patients are likely to benefit from treatment with antibiotics.
Let’s first go over the evidence that forms the basis for the recommendations, then the recommended approach. First, a sore throat can be caused by many different viruses, as well as group A streptococcus (GAS), the group C streptococcus S dysgalactiae, and fusobacterium. We sometimes think of throat cultures as telling us the definitive etiology of a sore throat. In fact, children commonly are colonized with GAS even when not infected — 35% of the time, when GAS is detected on throat swab in a child, GAS is not the cause of the sore throat. Very few adults are colonized with GAS.
Sore throats are usually self-limited, whether they are treated with antibiotics or not, but occasionally complications can occur. Suppurative complications include peritonsillar abscess, sinusitis and sepsis. Nonsuppurative complications are primarily glomerulonephritis and rheumatic fever, which can lead to rheumatic heart disease.
Antibiotics. Antibiotics have three potential benefits in acute sore throat: to reduce the risk of developing rheumatic heart disease, reduce the duration and severity of symptoms, and treat suppurative complications. The risk for rheumatic heart disease has almost vanished in high-income countries, but not in low-income countries. Thus, antibiotic treatment of acute sore throat due to GAS may benefit those in living in, and those who recently emigrated from, low-income countries.
Patients with suppurative complications should be identified because antibiotics are important for this group. Although antibiotics are prescribed primarily to prevent rheumatic fever in this population, they may be mildly helpful in reducing a patient’s symptoms.
Testing. The sensitivity and specificity of high-quality point-of-care tests (POCTs) are on par with those of cultures, with the advantage that the results are available within minutes. Negative tests reduce unneeded antibiotic prescriptions.
Given this evidence, the authors recommend an approach that puts a lot of emphasis on two major things: the risk for rheumatic fever, and clinical assessment. On the basis of these factors, a decision is made about the utility of POCTs and treatment with antibiotics for GAS. The risk for rheumatic fever is based on epidemiology: If the patient is in a low-income country or has recently immigrated from one, then the risk is high, and if not, the risk is low.
Complicated vs uncomplicated? This is determined by clinical assessment of the severity of the patient’s illness, including general appearance. Uncomplicated sore throat means that the patient:
- Is not getting worse after 3 days of illness
- Has a duration of illness ≤ 5 days or is getting better after day 5
- Has mild to moderate symptom severity (bilateral throat pain, the ability to open the mouth fully, and absence of a sandpaper or scarlatiniform rash or strawberry tongue)
For patients with uncomplicated sore throat and low risk for rheumatic fever, the main goals are to reduce antibiotic use and provide symptomatic relief. For these patients, an assessment such as the Centor score can be done. Those with a low Centor score (0-2) can be treated with analgesics and there is no need for a POCT.
In patients with a higher Centor score, the consensus gives two choices: They can either be tested (and treated if the testing is positive), or it is reasonable to forgo testing and use a wait-and-see strategy, with reevaluation if they are getting worse after day 3 or not improving after day 5 days of their illness. Illnesses that last longer than 5 days with sore throat and fatigue should prompt consideration of alternative diagnoses, such as infectious mononucleosis.
For patients with potentially complicated sore throat — including indicators such as worsening symptoms after 3 days or worsening after initiation of antibiotics, inability to open the mouth fully, unilateral neck pain or swelling, or rigors — should undergo a careful evaluation. The need for further testing in these patients, including labs and imaging, should be decided on a case-by-case basis. If the patient appears seriously ill, don’t rely solely on POCT for GAS, but think about other diagnoses.
Rheumatic fever. The approach is very different in patients at high risk for rheumatic fever. POCT for GAS is recommended irrespective of their clinical score, and antibiotics should be prescribed if it’s positive for GAS. If a POCT is unavailable, then the consensus recommends prescribing antibiotics for all high-risk patients who have acute sore throat.
This approach is sensible and puts a lot of emphasis on clinical evaluation, though it should be noted that this approach is considerably different from that in the 2012 Infectious Diseases Society of America guidelines.
Dr. Skolnik, professor, Department of Family Medicine, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, and associate director, Department of Family Medicine, Abington Jefferson Health, Abington, Pennsylvania, disclosed ties with AstraZeneca, Teva, Eli Lilly and Company, Boehringer Ingelheim, Sanofi, Sanofi Pasteur, GlaxoSmithKline, Merck, and Bayer.
A version of this article appeared on Medscape.com.
This transcript has been edited for clarity.
There is a helpful consensus from experts on the best management of patients with acute sore throat. This is a common problem in primary care, and one for which there is a lot of evidence, opinion, and ultimately overprescribing of antibiotics. This consensus presents a pragmatic clinical approach aimed at decreasing overprescribing, yet detecting which patients are likely to benefit from treatment with antibiotics.
Let’s first go over the evidence that forms the basis for the recommendations, then the recommended approach. First, a sore throat can be caused by many different viruses, as well as group A streptococcus (GAS), the group C streptococcus S dysgalactiae, and fusobacterium. We sometimes think of throat cultures as telling us the definitive etiology of a sore throat. In fact, children commonly are colonized with GAS even when not infected — 35% of the time, when GAS is detected on throat swab in a child, GAS is not the cause of the sore throat. Very few adults are colonized with GAS.
Sore throats are usually self-limited, whether they are treated with antibiotics or not, but occasionally complications can occur. Suppurative complications include peritonsillar abscess, sinusitis and sepsis. Nonsuppurative complications are primarily glomerulonephritis and rheumatic fever, which can lead to rheumatic heart disease.
Antibiotics. Antibiotics have three potential benefits in acute sore throat: to reduce the risk of developing rheumatic heart disease, reduce the duration and severity of symptoms, and treat suppurative complications. The risk for rheumatic heart disease has almost vanished in high-income countries, but not in low-income countries. Thus, antibiotic treatment of acute sore throat due to GAS may benefit those in living in, and those who recently emigrated from, low-income countries.
Patients with suppurative complications should be identified because antibiotics are important for this group. Although antibiotics are prescribed primarily to prevent rheumatic fever in this population, they may be mildly helpful in reducing a patient’s symptoms.
Testing. The sensitivity and specificity of high-quality point-of-care tests (POCTs) are on par with those of cultures, with the advantage that the results are available within minutes. Negative tests reduce unneeded antibiotic prescriptions.
Given this evidence, the authors recommend an approach that puts a lot of emphasis on two major things: the risk for rheumatic fever, and clinical assessment. On the basis of these factors, a decision is made about the utility of POCTs and treatment with antibiotics for GAS. The risk for rheumatic fever is based on epidemiology: If the patient is in a low-income country or has recently immigrated from one, then the risk is high, and if not, the risk is low.
Complicated vs uncomplicated? This is determined by clinical assessment of the severity of the patient’s illness, including general appearance. Uncomplicated sore throat means that the patient:
- Is not getting worse after 3 days of illness
- Has a duration of illness ≤ 5 days or is getting better after day 5
- Has mild to moderate symptom severity (bilateral throat pain, the ability to open the mouth fully, and absence of a sandpaper or scarlatiniform rash or strawberry tongue)
For patients with uncomplicated sore throat and low risk for rheumatic fever, the main goals are to reduce antibiotic use and provide symptomatic relief. For these patients, an assessment such as the Centor score can be done. Those with a low Centor score (0-2) can be treated with analgesics and there is no need for a POCT.
In patients with a higher Centor score, the consensus gives two choices: They can either be tested (and treated if the testing is positive), or it is reasonable to forgo testing and use a wait-and-see strategy, with reevaluation if they are getting worse after day 3 or not improving after day 5 days of their illness. Illnesses that last longer than 5 days with sore throat and fatigue should prompt consideration of alternative diagnoses, such as infectious mononucleosis.
For patients with potentially complicated sore throat — including indicators such as worsening symptoms after 3 days or worsening after initiation of antibiotics, inability to open the mouth fully, unilateral neck pain or swelling, or rigors — should undergo a careful evaluation. The need for further testing in these patients, including labs and imaging, should be decided on a case-by-case basis. If the patient appears seriously ill, don’t rely solely on POCT for GAS, but think about other diagnoses.
Rheumatic fever. The approach is very different in patients at high risk for rheumatic fever. POCT for GAS is recommended irrespective of their clinical score, and antibiotics should be prescribed if it’s positive for GAS. If a POCT is unavailable, then the consensus recommends prescribing antibiotics for all high-risk patients who have acute sore throat.
This approach is sensible and puts a lot of emphasis on clinical evaluation, though it should be noted that this approach is considerably different from that in the 2012 Infectious Diseases Society of America guidelines.
Dr. Skolnik, professor, Department of Family Medicine, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, and associate director, Department of Family Medicine, Abington Jefferson Health, Abington, Pennsylvania, disclosed ties with AstraZeneca, Teva, Eli Lilly and Company, Boehringer Ingelheim, Sanofi, Sanofi Pasteur, GlaxoSmithKline, Merck, and Bayer.
A version of this article appeared on Medscape.com.
This transcript has been edited for clarity.
There is a helpful consensus from experts on the best management of patients with acute sore throat. This is a common problem in primary care, and one for which there is a lot of evidence, opinion, and ultimately overprescribing of antibiotics. This consensus presents a pragmatic clinical approach aimed at decreasing overprescribing, yet detecting which patients are likely to benefit from treatment with antibiotics.
Let’s first go over the evidence that forms the basis for the recommendations, then the recommended approach. First, a sore throat can be caused by many different viruses, as well as group A streptococcus (GAS), the group C streptococcus S dysgalactiae, and fusobacterium. We sometimes think of throat cultures as telling us the definitive etiology of a sore throat. In fact, children commonly are colonized with GAS even when not infected — 35% of the time, when GAS is detected on throat swab in a child, GAS is not the cause of the sore throat. Very few adults are colonized with GAS.
Sore throats are usually self-limited, whether they are treated with antibiotics or not, but occasionally complications can occur. Suppurative complications include peritonsillar abscess, sinusitis and sepsis. Nonsuppurative complications are primarily glomerulonephritis and rheumatic fever, which can lead to rheumatic heart disease.
Antibiotics. Antibiotics have three potential benefits in acute sore throat: to reduce the risk of developing rheumatic heart disease, reduce the duration and severity of symptoms, and treat suppurative complications. The risk for rheumatic heart disease has almost vanished in high-income countries, but not in low-income countries. Thus, antibiotic treatment of acute sore throat due to GAS may benefit those in living in, and those who recently emigrated from, low-income countries.
Patients with suppurative complications should be identified because antibiotics are important for this group. Although antibiotics are prescribed primarily to prevent rheumatic fever in this population, they may be mildly helpful in reducing a patient’s symptoms.
Testing. The sensitivity and specificity of high-quality point-of-care tests (POCTs) are on par with those of cultures, with the advantage that the results are available within minutes. Negative tests reduce unneeded antibiotic prescriptions.
Given this evidence, the authors recommend an approach that puts a lot of emphasis on two major things: the risk for rheumatic fever, and clinical assessment. On the basis of these factors, a decision is made about the utility of POCTs and treatment with antibiotics for GAS. The risk for rheumatic fever is based on epidemiology: If the patient is in a low-income country or has recently immigrated from one, then the risk is high, and if not, the risk is low.
Complicated vs uncomplicated? This is determined by clinical assessment of the severity of the patient’s illness, including general appearance. Uncomplicated sore throat means that the patient:
- Is not getting worse after 3 days of illness
- Has a duration of illness ≤ 5 days or is getting better after day 5
- Has mild to moderate symptom severity (bilateral throat pain, the ability to open the mouth fully, and absence of a sandpaper or scarlatiniform rash or strawberry tongue)
For patients with uncomplicated sore throat and low risk for rheumatic fever, the main goals are to reduce antibiotic use and provide symptomatic relief. For these patients, an assessment such as the Centor score can be done. Those with a low Centor score (0-2) can be treated with analgesics and there is no need for a POCT.
In patients with a higher Centor score, the consensus gives two choices: They can either be tested (and treated if the testing is positive), or it is reasonable to forgo testing and use a wait-and-see strategy, with reevaluation if they are getting worse after day 3 or not improving after day 5 days of their illness. Illnesses that last longer than 5 days with sore throat and fatigue should prompt consideration of alternative diagnoses, such as infectious mononucleosis.
For patients with potentially complicated sore throat — including indicators such as worsening symptoms after 3 days or worsening after initiation of antibiotics, inability to open the mouth fully, unilateral neck pain or swelling, or rigors — should undergo a careful evaluation. The need for further testing in these patients, including labs and imaging, should be decided on a case-by-case basis. If the patient appears seriously ill, don’t rely solely on POCT for GAS, but think about other diagnoses.
Rheumatic fever. The approach is very different in patients at high risk for rheumatic fever. POCT for GAS is recommended irrespective of their clinical score, and antibiotics should be prescribed if it’s positive for GAS. If a POCT is unavailable, then the consensus recommends prescribing antibiotics for all high-risk patients who have acute sore throat.
This approach is sensible and puts a lot of emphasis on clinical evaluation, though it should be noted that this approach is considerably different from that in the 2012 Infectious Diseases Society of America guidelines.
Dr. Skolnik, professor, Department of Family Medicine, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, and associate director, Department of Family Medicine, Abington Jefferson Health, Abington, Pennsylvania, disclosed ties with AstraZeneca, Teva, Eli Lilly and Company, Boehringer Ingelheim, Sanofi, Sanofi Pasteur, GlaxoSmithKline, Merck, and Bayer.
A version of this article appeared on Medscape.com.
Doctors Endorsing Products on X May Not Disclose Company Ties
Lead author Aaron Mitchell, MD, MPH, a medical oncologist at Memorial Sloan Kettering Cancer Center in New York City, told this news organization that he and his colleagues undertook the study in part to see whether physicians were adhering to professional and industry guidelines regarding marketing communications.
The team reviewed posts by physicians on X during 2022, looking for key words that might indicate that the posts were intended as endorsements of a product. The researchers then delved into the Centers for Medicare and Medicaid Services Open Payments database to see how many of those identified as having endorsed a product were paid by the manufacturers.
What Dr. Mitchell found concerned him, he said.
Overall, the researchers identified 28 physician endorsers who received a total of $1.4 million from sponsors in 2022. Among these, 26 physicians (93%) received payments from the product’s manufacturer, totaling $713,976, and 24 physicians (86%) accepted payments related to the endorsed drug or device, totaling $492,098.
While most did disclose that the posts were sponsored — by adding the word “sponsored” or using #sponsored — nine physicians did not.
Although 28 physician endorsers represent a “small fraction” of the overall number of physicians who use X, each endorsement was ultimately posted dozens, if not hundreds of times, said Dr. Mitchell. In fact, he said he saw the same particular endorsement post every time he opened his X app for months.
Overall, Dr. Mitchell noted that it’s less about the fact that the endorsements are occurring on social media and more that there are these paid endorsements taking place at all.
Among the physician specialties promoting a product, urologists and oncologists dominated. Almost one third were urologists, and 57% were oncologists — six medical oncologists, six radiation oncologists, and four gynecologic oncologists. Of the remaining three physicians, two were internists and one was a pulmonary and critical care medicine specialist.
The authors tracked posts from physicians and industry accounts. Many of the posts on industry accounts were physician testimonials, usually videos. Almost half — 8 of 17 — of those testimonials did not disclose that the doctor was being paid by the manufacturer. In another case, a physician did not disclose that they were paid to endorse a white paper.
Fifteen promotional posts were for a Boston Scientific product, followed by six for GlaxoSmithKline, two for Eisai, two for Exelixis, and one each for AstraZeneca, Novartis, and Pfizer.
In general, Dr. Mitchell said, industry guidelines suggest that manufacturer-paid speakers or consultants should have well-regarded expertise in the area they are being asked to weigh in on, but most physician endorsers in the study were not key opinion leaders or experts.
The authors examined the paid endorsers’ H-index — a measure of academic productivity provided by Scopus. Overall, 19 of the 28 physicians had an H-index below 20, which is considered less accomplished, and 14 had no published research related to the endorsed product.
Ten received payments from manufacturers for research purposes, and only one received research payments related to the endorsed product ($224,577).
“Physicians’ participation in industry marketing raises questions regarding professionalism and their responsibilities as patient advocates,” the JAMA authors wrote.
The study was supported by grants from the National Cancer Institute. Dr. Mitchell reported no relevant financial relationships. Coauthors Samer Al Hadidi, MD, reported receiving personal fees from Pfizer, Sanofi, and Janssen during the conduct of the study, and Timothy S. Anderson, MD, reported receiving grants from the National Institute on Aging, the American Heart Association, and the American College of Cardiology, and receiving consulting fees from the American Medical Student Association. Dr. Anderson is also an associate editor of JAMA Internal Medicine.
A version of this article appeared on Medscape.com.
Lead author Aaron Mitchell, MD, MPH, a medical oncologist at Memorial Sloan Kettering Cancer Center in New York City, told this news organization that he and his colleagues undertook the study in part to see whether physicians were adhering to professional and industry guidelines regarding marketing communications.
The team reviewed posts by physicians on X during 2022, looking for key words that might indicate that the posts were intended as endorsements of a product. The researchers then delved into the Centers for Medicare and Medicaid Services Open Payments database to see how many of those identified as having endorsed a product were paid by the manufacturers.
What Dr. Mitchell found concerned him, he said.
Overall, the researchers identified 28 physician endorsers who received a total of $1.4 million from sponsors in 2022. Among these, 26 physicians (93%) received payments from the product’s manufacturer, totaling $713,976, and 24 physicians (86%) accepted payments related to the endorsed drug or device, totaling $492,098.
While most did disclose that the posts were sponsored — by adding the word “sponsored” or using #sponsored — nine physicians did not.
Although 28 physician endorsers represent a “small fraction” of the overall number of physicians who use X, each endorsement was ultimately posted dozens, if not hundreds of times, said Dr. Mitchell. In fact, he said he saw the same particular endorsement post every time he opened his X app for months.
Overall, Dr. Mitchell noted that it’s less about the fact that the endorsements are occurring on social media and more that there are these paid endorsements taking place at all.
Among the physician specialties promoting a product, urologists and oncologists dominated. Almost one third were urologists, and 57% were oncologists — six medical oncologists, six radiation oncologists, and four gynecologic oncologists. Of the remaining three physicians, two were internists and one was a pulmonary and critical care medicine specialist.
The authors tracked posts from physicians and industry accounts. Many of the posts on industry accounts were physician testimonials, usually videos. Almost half — 8 of 17 — of those testimonials did not disclose that the doctor was being paid by the manufacturer. In another case, a physician did not disclose that they were paid to endorse a white paper.
Fifteen promotional posts were for a Boston Scientific product, followed by six for GlaxoSmithKline, two for Eisai, two for Exelixis, and one each for AstraZeneca, Novartis, and Pfizer.
In general, Dr. Mitchell said, industry guidelines suggest that manufacturer-paid speakers or consultants should have well-regarded expertise in the area they are being asked to weigh in on, but most physician endorsers in the study were not key opinion leaders or experts.
The authors examined the paid endorsers’ H-index — a measure of academic productivity provided by Scopus. Overall, 19 of the 28 physicians had an H-index below 20, which is considered less accomplished, and 14 had no published research related to the endorsed product.
Ten received payments from manufacturers for research purposes, and only one received research payments related to the endorsed product ($224,577).
“Physicians’ participation in industry marketing raises questions regarding professionalism and their responsibilities as patient advocates,” the JAMA authors wrote.
The study was supported by grants from the National Cancer Institute. Dr. Mitchell reported no relevant financial relationships. Coauthors Samer Al Hadidi, MD, reported receiving personal fees from Pfizer, Sanofi, and Janssen during the conduct of the study, and Timothy S. Anderson, MD, reported receiving grants from the National Institute on Aging, the American Heart Association, and the American College of Cardiology, and receiving consulting fees from the American Medical Student Association. Dr. Anderson is also an associate editor of JAMA Internal Medicine.
A version of this article appeared on Medscape.com.
Lead author Aaron Mitchell, MD, MPH, a medical oncologist at Memorial Sloan Kettering Cancer Center in New York City, told this news organization that he and his colleagues undertook the study in part to see whether physicians were adhering to professional and industry guidelines regarding marketing communications.
The team reviewed posts by physicians on X during 2022, looking for key words that might indicate that the posts were intended as endorsements of a product. The researchers then delved into the Centers for Medicare and Medicaid Services Open Payments database to see how many of those identified as having endorsed a product were paid by the manufacturers.
What Dr. Mitchell found concerned him, he said.
Overall, the researchers identified 28 physician endorsers who received a total of $1.4 million from sponsors in 2022. Among these, 26 physicians (93%) received payments from the product’s manufacturer, totaling $713,976, and 24 physicians (86%) accepted payments related to the endorsed drug or device, totaling $492,098.
While most did disclose that the posts were sponsored — by adding the word “sponsored” or using #sponsored — nine physicians did not.
Although 28 physician endorsers represent a “small fraction” of the overall number of physicians who use X, each endorsement was ultimately posted dozens, if not hundreds of times, said Dr. Mitchell. In fact, he said he saw the same particular endorsement post every time he opened his X app for months.
Overall, Dr. Mitchell noted that it’s less about the fact that the endorsements are occurring on social media and more that there are these paid endorsements taking place at all.
Among the physician specialties promoting a product, urologists and oncologists dominated. Almost one third were urologists, and 57% were oncologists — six medical oncologists, six radiation oncologists, and four gynecologic oncologists. Of the remaining three physicians, two were internists and one was a pulmonary and critical care medicine specialist.
The authors tracked posts from physicians and industry accounts. Many of the posts on industry accounts were physician testimonials, usually videos. Almost half — 8 of 17 — of those testimonials did not disclose that the doctor was being paid by the manufacturer. In another case, a physician did not disclose that they were paid to endorse a white paper.
Fifteen promotional posts were for a Boston Scientific product, followed by six for GlaxoSmithKline, two for Eisai, two for Exelixis, and one each for AstraZeneca, Novartis, and Pfizer.
In general, Dr. Mitchell said, industry guidelines suggest that manufacturer-paid speakers or consultants should have well-regarded expertise in the area they are being asked to weigh in on, but most physician endorsers in the study were not key opinion leaders or experts.
The authors examined the paid endorsers’ H-index — a measure of academic productivity provided by Scopus. Overall, 19 of the 28 physicians had an H-index below 20, which is considered less accomplished, and 14 had no published research related to the endorsed product.
Ten received payments from manufacturers for research purposes, and only one received research payments related to the endorsed product ($224,577).
“Physicians’ participation in industry marketing raises questions regarding professionalism and their responsibilities as patient advocates,” the JAMA authors wrote.
The study was supported by grants from the National Cancer Institute. Dr. Mitchell reported no relevant financial relationships. Coauthors Samer Al Hadidi, MD, reported receiving personal fees from Pfizer, Sanofi, and Janssen during the conduct of the study, and Timothy S. Anderson, MD, reported receiving grants from the National Institute on Aging, the American Heart Association, and the American College of Cardiology, and receiving consulting fees from the American Medical Student Association. Dr. Anderson is also an associate editor of JAMA Internal Medicine.
A version of this article appeared on Medscape.com.
Lidocaine Effective Against Pediatric Migraine
SAN DIEGO — The treatment has long been used in adults, and frequently in children on the strength of observational evidence.
Prior Research
Most of the studies have been conducted in adults, and these were often in specific settings like the emergency department for status migrainosus, while outpatient studies were generally conducted in chronic migraine, according to presenting author Christina Szperka, MD. “The assumptions were a little bit different,” Dr. Szperka, director of the pediatric headache program at Children’s Hospital of Philadelphia, said in an interview.
Retrospective studies are also fraught with bias. “We’ve tried to look at retrospective data. People don’t necessarily report how they’re doing unless they come back, and so you lose a huge portion of kids,” said Dr. Szperka, who presented the research at the annual meeting of the American Headache Society.
“From a clinical perspective, I think it gives us additional evidence that what we’re doing makes a difference, and I think that will help us in terms of insurance coverage, because that’s really been a major barrier,” said Dr. Szperka.
The study also opens other avenues for research. “Just doing the greater occipital nerves only reduces the pain so much. So what’s the next step? Do I study additional injections? Do I do a study where I compare different medications?”
She previously conducted a study of how providers were using lidocaine injections, and “there was a large amount of variability, both in terms of what nerves are being injected, what medications they were using, the patient population, et cetera,” said Dr. Szperka. Previous observational studies have suggested efficacy in pediatric populations for transition and prevention of migraine, new daily persistent headache, posttraumatic headache, and post-shunt occipital neuralgia.
A Randomized, Controlled Trial
In the new study, 58 adolescents aged 7 to 21 (mean age, 16.0 years; 44 female) were initially treated with lidocaine cream. The patients were “relatively refractory,” said Dr. Szperka, with 25 having received intravenous medications and 6 having been inpatients. After 30 minutes, if they still had pain and consented to further treatment, Dr. Szperka performed bilateral greater occipital nerve injections with lidocaine or a saline placebo, and did additional injections after 30 minutes if there wasn’t sufficient improvement.
There was no significant change in pain after the lidocaine cream treatment, and all patients proceeded to be randomized to lidocaine or placebo injections. The primary outcome of 30-minute reduction in pain score ranked 0-10 favored the lidocaine group (2.3 vs 1.1; P = .013). There was a 2-point reduction in pain scores in 69% of the lidocaine group and 34% of the saline group (P = .009) and a higher frequency of pain relief from moderate/severe to no pain or mild (52% versus 24%; P = .03). There was no significant difference in pain freedom.
After 24 hours, the treatment group was more likely to experience pain relief from moderate/severe to no pain or mild (24% vs 3%; P = .05) and to be free from associated symptoms (48% vs 21%; P = .027). Pain at the injection site was significantly higher in the placebo group (5.4 vs 3.2), prompting a change in plans for future trials. “I don’t think I would do saline again, because I think it hurt them, and I don’t want to cause them harm,” said Dr. Szperka.
Adverse events were common, with all but one patient in the study experiencing at least one. “I think this is a couple of things: One, kids don’t like needles in their head. Nerve blocks hurt. And so it was not surprising in some ways that we had a very high rate of adverse events. We also consented them, and that had a long wait period, and there’s a lot of anxiety in the room. However, most of the adverse events were mild,” said Dr. Szperka.
Important Research in an Understudied Population
Laine Greene, MD, who moderated the session, was asked for comment. “I think it’s an important study. Occipital nerve blocks have been used for a long period of time in management of migraine and other headache disorders. The quality of the evidence has always been brought into question, especially from payers, but also a very important aspect to this is that a lot of clinical trials over time have not specifically been done in children or adolescents, so any work that is done in that age category is significantly helpful to advancing therapeutics,” said Dr. Greene, associate professor of neurology at Mayo Clinic Arizona.
Dr. Szperka has consulted for AbbVie and Teva, and serves on data safety and monitoring boards for Eli Lilly and Upsher-Smith. She has been a principal investigator in trials sponsored by Abbvie, Amgen, Biohaven/Pfizer, Teva, and Theranica. Dr. Greene has no relevant financial disclosures.
SAN DIEGO — The treatment has long been used in adults, and frequently in children on the strength of observational evidence.
Prior Research
Most of the studies have been conducted in adults, and these were often in specific settings like the emergency department for status migrainosus, while outpatient studies were generally conducted in chronic migraine, according to presenting author Christina Szperka, MD. “The assumptions were a little bit different,” Dr. Szperka, director of the pediatric headache program at Children’s Hospital of Philadelphia, said in an interview.
Retrospective studies are also fraught with bias. “We’ve tried to look at retrospective data. People don’t necessarily report how they’re doing unless they come back, and so you lose a huge portion of kids,” said Dr. Szperka, who presented the research at the annual meeting of the American Headache Society.
“From a clinical perspective, I think it gives us additional evidence that what we’re doing makes a difference, and I think that will help us in terms of insurance coverage, because that’s really been a major barrier,” said Dr. Szperka.
The study also opens other avenues for research. “Just doing the greater occipital nerves only reduces the pain so much. So what’s the next step? Do I study additional injections? Do I do a study where I compare different medications?”
She previously conducted a study of how providers were using lidocaine injections, and “there was a large amount of variability, both in terms of what nerves are being injected, what medications they were using, the patient population, et cetera,” said Dr. Szperka. Previous observational studies have suggested efficacy in pediatric populations for transition and prevention of migraine, new daily persistent headache, posttraumatic headache, and post-shunt occipital neuralgia.
A Randomized, Controlled Trial
In the new study, 58 adolescents aged 7 to 21 (mean age, 16.0 years; 44 female) were initially treated with lidocaine cream. The patients were “relatively refractory,” said Dr. Szperka, with 25 having received intravenous medications and 6 having been inpatients. After 30 minutes, if they still had pain and consented to further treatment, Dr. Szperka performed bilateral greater occipital nerve injections with lidocaine or a saline placebo, and did additional injections after 30 minutes if there wasn’t sufficient improvement.
There was no significant change in pain after the lidocaine cream treatment, and all patients proceeded to be randomized to lidocaine or placebo injections. The primary outcome of 30-minute reduction in pain score ranked 0-10 favored the lidocaine group (2.3 vs 1.1; P = .013). There was a 2-point reduction in pain scores in 69% of the lidocaine group and 34% of the saline group (P = .009) and a higher frequency of pain relief from moderate/severe to no pain or mild (52% versus 24%; P = .03). There was no significant difference in pain freedom.
After 24 hours, the treatment group was more likely to experience pain relief from moderate/severe to no pain or mild (24% vs 3%; P = .05) and to be free from associated symptoms (48% vs 21%; P = .027). Pain at the injection site was significantly higher in the placebo group (5.4 vs 3.2), prompting a change in plans for future trials. “I don’t think I would do saline again, because I think it hurt them, and I don’t want to cause them harm,” said Dr. Szperka.
Adverse events were common, with all but one patient in the study experiencing at least one. “I think this is a couple of things: One, kids don’t like needles in their head. Nerve blocks hurt. And so it was not surprising in some ways that we had a very high rate of adverse events. We also consented them, and that had a long wait period, and there’s a lot of anxiety in the room. However, most of the adverse events were mild,” said Dr. Szperka.
Important Research in an Understudied Population
Laine Greene, MD, who moderated the session, was asked for comment. “I think it’s an important study. Occipital nerve blocks have been used for a long period of time in management of migraine and other headache disorders. The quality of the evidence has always been brought into question, especially from payers, but also a very important aspect to this is that a lot of clinical trials over time have not specifically been done in children or adolescents, so any work that is done in that age category is significantly helpful to advancing therapeutics,” said Dr. Greene, associate professor of neurology at Mayo Clinic Arizona.
Dr. Szperka has consulted for AbbVie and Teva, and serves on data safety and monitoring boards for Eli Lilly and Upsher-Smith. She has been a principal investigator in trials sponsored by Abbvie, Amgen, Biohaven/Pfizer, Teva, and Theranica. Dr. Greene has no relevant financial disclosures.
SAN DIEGO — The treatment has long been used in adults, and frequently in children on the strength of observational evidence.
Prior Research
Most of the studies have been conducted in adults, and these were often in specific settings like the emergency department for status migrainosus, while outpatient studies were generally conducted in chronic migraine, according to presenting author Christina Szperka, MD. “The assumptions were a little bit different,” Dr. Szperka, director of the pediatric headache program at Children’s Hospital of Philadelphia, said in an interview.
Retrospective studies are also fraught with bias. “We’ve tried to look at retrospective data. People don’t necessarily report how they’re doing unless they come back, and so you lose a huge portion of kids,” said Dr. Szperka, who presented the research at the annual meeting of the American Headache Society.
“From a clinical perspective, I think it gives us additional evidence that what we’re doing makes a difference, and I think that will help us in terms of insurance coverage, because that’s really been a major barrier,” said Dr. Szperka.
The study also opens other avenues for research. “Just doing the greater occipital nerves only reduces the pain so much. So what’s the next step? Do I study additional injections? Do I do a study where I compare different medications?”
She previously conducted a study of how providers were using lidocaine injections, and “there was a large amount of variability, both in terms of what nerves are being injected, what medications they were using, the patient population, et cetera,” said Dr. Szperka. Previous observational studies have suggested efficacy in pediatric populations for transition and prevention of migraine, new daily persistent headache, posttraumatic headache, and post-shunt occipital neuralgia.
A Randomized, Controlled Trial
In the new study, 58 adolescents aged 7 to 21 (mean age, 16.0 years; 44 female) were initially treated with lidocaine cream. The patients were “relatively refractory,” said Dr. Szperka, with 25 having received intravenous medications and 6 having been inpatients. After 30 minutes, if they still had pain and consented to further treatment, Dr. Szperka performed bilateral greater occipital nerve injections with lidocaine or a saline placebo, and did additional injections after 30 minutes if there wasn’t sufficient improvement.
There was no significant change in pain after the lidocaine cream treatment, and all patients proceeded to be randomized to lidocaine or placebo injections. The primary outcome of 30-minute reduction in pain score ranked 0-10 favored the lidocaine group (2.3 vs 1.1; P = .013). There was a 2-point reduction in pain scores in 69% of the lidocaine group and 34% of the saline group (P = .009) and a higher frequency of pain relief from moderate/severe to no pain or mild (52% versus 24%; P = .03). There was no significant difference in pain freedom.
After 24 hours, the treatment group was more likely to experience pain relief from moderate/severe to no pain or mild (24% vs 3%; P = .05) and to be free from associated symptoms (48% vs 21%; P = .027). Pain at the injection site was significantly higher in the placebo group (5.4 vs 3.2), prompting a change in plans for future trials. “I don’t think I would do saline again, because I think it hurt them, and I don’t want to cause them harm,” said Dr. Szperka.
Adverse events were common, with all but one patient in the study experiencing at least one. “I think this is a couple of things: One, kids don’t like needles in their head. Nerve blocks hurt. And so it was not surprising in some ways that we had a very high rate of adverse events. We also consented them, and that had a long wait period, and there’s a lot of anxiety in the room. However, most of the adverse events were mild,” said Dr. Szperka.
Important Research in an Understudied Population
Laine Greene, MD, who moderated the session, was asked for comment. “I think it’s an important study. Occipital nerve blocks have been used for a long period of time in management of migraine and other headache disorders. The quality of the evidence has always been brought into question, especially from payers, but also a very important aspect to this is that a lot of clinical trials over time have not specifically been done in children or adolescents, so any work that is done in that age category is significantly helpful to advancing therapeutics,” said Dr. Greene, associate professor of neurology at Mayo Clinic Arizona.
Dr. Szperka has consulted for AbbVie and Teva, and serves on data safety and monitoring boards for Eli Lilly and Upsher-Smith. She has been a principal investigator in trials sponsored by Abbvie, Amgen, Biohaven/Pfizer, Teva, and Theranica. Dr. Greene has no relevant financial disclosures.
FROM AHS 2024
Photoprotection: Benefits of Sunscreens With Iron Oxide
CHICAGO — One of the more recent developments in sunscreen technology is the addition of iron oxide to mineral sunscreens.
Iron oxide is “an excellent pigment” that absorbs and blocks visible light, which is particularly important in individuals with Fitzpatrick skin types III-VI, Zoe D. Draelos, MD, consulting professor of dermatology at Duke University, Durham, North Carolina, said at the Pigmentation Disorders Exchange symposium.
Susan C. Taylor, MD, professor of dermatology at the University of Pennsylvania, Philadelphia, who spoke at the conference, also recommended tinted sunscreen with iron oxide for patients with skin of color. “It still needs to be broad spectrum,” she said, “and at least an SPF [Sun Protection Factor] 30.”
When blended with mineral sunscreens, iron oxide can reduce transmission of visible light by 90% and can protect patients from hyperpigmentation. Iron oxide comes in different colors blended together for various degrees of tinting.
Dr. Taylor noted that iron oxide is listed under the inactive ingredients. “The literature indicates a 3% concentration to aim for, but we don’t know the concentration in most of the products,” she added.
During her presentation, Dr. Draelos noted that inorganic sunscreens, such as zinc oxide and titanium oxides, are highly effective but make the skin white and pasty. To address this issue, many companies are now grinding these materials into such small particles that they are transparent.
“That’s great, except the smaller the particle is, the less UV [ultraviolet] radiation it reflects and that lowers the [SPF],” she said.
In addition to providing photoprotection, sunscreens in general provide protection from nanoparticles in tobacco and combustion, such as traffic exhaust, which can harm skin over time. “Moisturizers and sunscreens are the best way to protect against pollution and tobacco nanoparticle damage, which can contribute to inflammation,” she noted. They create a film over the skin and trap the nanoparticles.
Start the Patient Visit With a Photoprotection Talk
At the meeting, Dr. Taylor recommended that for all patients with hypopigmentation and hyperpigmentation disorders, “treatment really begins with photoprotection.”
She acknowledged that photoprotection discussions, including the basics of seeking shade, wearing protective clothing, and avoiding midday sun, often come at the end of the patient visit but she urged dermatologists to make that the first topic instead.
Dr. Taylor said a question often asked of patients of color about prolonged sun exposure — whether their skin turns bright red after too much sun — may get a negative reply. The better question is whether the patient has experienced tender skin after too much sun — which can signify a sunburn, she said.
Dr. Draelos reported no relevant financial relationships. Dr. Taylor reported financial relationships and grant support from multiple pharmaceutical companies.
A version of this article first appeared on Medscape.com.
CHICAGO — One of the more recent developments in sunscreen technology is the addition of iron oxide to mineral sunscreens.
Iron oxide is “an excellent pigment” that absorbs and blocks visible light, which is particularly important in individuals with Fitzpatrick skin types III-VI, Zoe D. Draelos, MD, consulting professor of dermatology at Duke University, Durham, North Carolina, said at the Pigmentation Disorders Exchange symposium.
Susan C. Taylor, MD, professor of dermatology at the University of Pennsylvania, Philadelphia, who spoke at the conference, also recommended tinted sunscreen with iron oxide for patients with skin of color. “It still needs to be broad spectrum,” she said, “and at least an SPF [Sun Protection Factor] 30.”
When blended with mineral sunscreens, iron oxide can reduce transmission of visible light by 90% and can protect patients from hyperpigmentation. Iron oxide comes in different colors blended together for various degrees of tinting.
Dr. Taylor noted that iron oxide is listed under the inactive ingredients. “The literature indicates a 3% concentration to aim for, but we don’t know the concentration in most of the products,” she added.
During her presentation, Dr. Draelos noted that inorganic sunscreens, such as zinc oxide and titanium oxides, are highly effective but make the skin white and pasty. To address this issue, many companies are now grinding these materials into such small particles that they are transparent.
“That’s great, except the smaller the particle is, the less UV [ultraviolet] radiation it reflects and that lowers the [SPF],” she said.
In addition to providing photoprotection, sunscreens in general provide protection from nanoparticles in tobacco and combustion, such as traffic exhaust, which can harm skin over time. “Moisturizers and sunscreens are the best way to protect against pollution and tobacco nanoparticle damage, which can contribute to inflammation,” she noted. They create a film over the skin and trap the nanoparticles.
Start the Patient Visit With a Photoprotection Talk
At the meeting, Dr. Taylor recommended that for all patients with hypopigmentation and hyperpigmentation disorders, “treatment really begins with photoprotection.”
She acknowledged that photoprotection discussions, including the basics of seeking shade, wearing protective clothing, and avoiding midday sun, often come at the end of the patient visit but she urged dermatologists to make that the first topic instead.
Dr. Taylor said a question often asked of patients of color about prolonged sun exposure — whether their skin turns bright red after too much sun — may get a negative reply. The better question is whether the patient has experienced tender skin after too much sun — which can signify a sunburn, she said.
Dr. Draelos reported no relevant financial relationships. Dr. Taylor reported financial relationships and grant support from multiple pharmaceutical companies.
A version of this article first appeared on Medscape.com.
CHICAGO — One of the more recent developments in sunscreen technology is the addition of iron oxide to mineral sunscreens.
Iron oxide is “an excellent pigment” that absorbs and blocks visible light, which is particularly important in individuals with Fitzpatrick skin types III-VI, Zoe D. Draelos, MD, consulting professor of dermatology at Duke University, Durham, North Carolina, said at the Pigmentation Disorders Exchange symposium.
Susan C. Taylor, MD, professor of dermatology at the University of Pennsylvania, Philadelphia, who spoke at the conference, also recommended tinted sunscreen with iron oxide for patients with skin of color. “It still needs to be broad spectrum,” she said, “and at least an SPF [Sun Protection Factor] 30.”
When blended with mineral sunscreens, iron oxide can reduce transmission of visible light by 90% and can protect patients from hyperpigmentation. Iron oxide comes in different colors blended together for various degrees of tinting.
Dr. Taylor noted that iron oxide is listed under the inactive ingredients. “The literature indicates a 3% concentration to aim for, but we don’t know the concentration in most of the products,” she added.
During her presentation, Dr. Draelos noted that inorganic sunscreens, such as zinc oxide and titanium oxides, are highly effective but make the skin white and pasty. To address this issue, many companies are now grinding these materials into such small particles that they are transparent.
“That’s great, except the smaller the particle is, the less UV [ultraviolet] radiation it reflects and that lowers the [SPF],” she said.
In addition to providing photoprotection, sunscreens in general provide protection from nanoparticles in tobacco and combustion, such as traffic exhaust, which can harm skin over time. “Moisturizers and sunscreens are the best way to protect against pollution and tobacco nanoparticle damage, which can contribute to inflammation,” she noted. They create a film over the skin and trap the nanoparticles.
Start the Patient Visit With a Photoprotection Talk
At the meeting, Dr. Taylor recommended that for all patients with hypopigmentation and hyperpigmentation disorders, “treatment really begins with photoprotection.”
She acknowledged that photoprotection discussions, including the basics of seeking shade, wearing protective clothing, and avoiding midday sun, often come at the end of the patient visit but she urged dermatologists to make that the first topic instead.
Dr. Taylor said a question often asked of patients of color about prolonged sun exposure — whether their skin turns bright red after too much sun — may get a negative reply. The better question is whether the patient has experienced tender skin after too much sun — which can signify a sunburn, she said.
Dr. Draelos reported no relevant financial relationships. Dr. Taylor reported financial relationships and grant support from multiple pharmaceutical companies.
A version of this article first appeared on Medscape.com.
Chronic Absenteeism
Among the more unheralded examples of collateral damage of the COVID epidemic is chronic absenteeism. A recent NPR/Ipsos poll found that parents ranked chronic absenteeism last in a list of 12 school-related concerns. Only 5% listed it first.
This is surprising and concerning, given that In fact, in some states the chronic absenteeism rate is 40%. In 2020 8 million students were chronically absent. This number is now over 14 million. Chronic absenteeism is a metric defined as a student absent for 15 days or more, which comes out to around 10% of the school year. Chronic absenteeism has been used as a predictor of the student dropout rate.
The initial contribution of the pandemic is easily explained, as parents were understandably concerned about sending their children into an environment that might cause disease, or at least bring the disease home to a more vulnerable family member. The reasons behind the trend’s persistence are a bit more complicated.
Family schedules initially disrupted by the pandemic have settled back into a pattern that may make it more difficult for a child to get to school. Day care and work schedules may have changed, but not yet readjusted to sync with the school schedule.
In the simplest terms, children and their families may have simply fallen out of the habit of going to school. For children (and maybe their parents) who had always struggled with an unresolved separation anxiety, the time at home — or at least not in school — came as a relief. Which, in turn, meant that any gains in dealing with the anxiety have been undone. The child who was already struggling academically or socially found being at home much less challenging. It’s not surprising that he/she might resist climbing back in the academic saddle.
It is very likely that a significant contributor to the persistent trend in chronic absenteeism is what social scientists call “norm erosion.” Not just children, but families may have developed an attitude that time spent in school just isn’t as valuable as they once believed, or were at least told that it was. There seems to be more parents questioning what their children are being taught in school. The home schooling movement existed before the pandemic. Its roots may be growing under the surface in the form of general skepticism about the importance of school in the bigger scheme of things. The home schooling movement was ready to blossom when the COVID pandemic triggered school closures. We hoped and dreamed that remote learning would be just as good as in-person school. We now realize that, in most cases, that was wishful thinking.
It feels as though a “Perfect Attendance Record” may have lost the cachet it once had. During the pandemic anyone claiming to have never missed a day at school lost that gold star. Did opening your computer every day to watch a remote learning session count for anything?
The threshold for allowing a child to stay home from school may be reaching a historic low. Families seem to regard the school schedule as a guideline that can easily be ignored when planning a vacation. Take little brother out of school to attend big brother’s lacrosse playoff game, not to worry if the youngster misses school days for a trip.
Who is responsible for reversing the trend? Teachers already know it is a serious problem. They view attendance as important. Maybe educators could make school more appealing. But to whom? Sounds like this message should be targeted at the parents. Would stiff penalties for parents whose children are chronically absent help? Would demanding a note from a physician after a certain number of absences help? It might. But, are pediatricians and educators ready to take on one more task in which parents have dropped the ball?
An unknown percentage of chronically absent children are missing school because of a previously unrecognized or inadequately treated mental health condition or learning disability. Involving physicians in a community’s response to chronic absenteeism may be the first step in getting a child back on track. If socioeconomic factors are contributing to a child’s truancy, the involvement of social service agencies may be the answer.
I have a friend who is often asked to address graduating classes at both the high school and college level. One of his standard pieces of advice, whether it be about school or a workplace you may not be in love with, is to at least “show up.” The family that treats school attendance as optional is likely to produce adults who take a similarly nonchalant attitude toward their employment opportunities — with unfortunate results.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at [email protected].
Among the more unheralded examples of collateral damage of the COVID epidemic is chronic absenteeism. A recent NPR/Ipsos poll found that parents ranked chronic absenteeism last in a list of 12 school-related concerns. Only 5% listed it first.
This is surprising and concerning, given that In fact, in some states the chronic absenteeism rate is 40%. In 2020 8 million students were chronically absent. This number is now over 14 million. Chronic absenteeism is a metric defined as a student absent for 15 days or more, which comes out to around 10% of the school year. Chronic absenteeism has been used as a predictor of the student dropout rate.
The initial contribution of the pandemic is easily explained, as parents were understandably concerned about sending their children into an environment that might cause disease, or at least bring the disease home to a more vulnerable family member. The reasons behind the trend’s persistence are a bit more complicated.
Family schedules initially disrupted by the pandemic have settled back into a pattern that may make it more difficult for a child to get to school. Day care and work schedules may have changed, but not yet readjusted to sync with the school schedule.
In the simplest terms, children and their families may have simply fallen out of the habit of going to school. For children (and maybe their parents) who had always struggled with an unresolved separation anxiety, the time at home — or at least not in school — came as a relief. Which, in turn, meant that any gains in dealing with the anxiety have been undone. The child who was already struggling academically or socially found being at home much less challenging. It’s not surprising that he/she might resist climbing back in the academic saddle.
It is very likely that a significant contributor to the persistent trend in chronic absenteeism is what social scientists call “norm erosion.” Not just children, but families may have developed an attitude that time spent in school just isn’t as valuable as they once believed, or were at least told that it was. There seems to be more parents questioning what their children are being taught in school. The home schooling movement existed before the pandemic. Its roots may be growing under the surface in the form of general skepticism about the importance of school in the bigger scheme of things. The home schooling movement was ready to blossom when the COVID pandemic triggered school closures. We hoped and dreamed that remote learning would be just as good as in-person school. We now realize that, in most cases, that was wishful thinking.
It feels as though a “Perfect Attendance Record” may have lost the cachet it once had. During the pandemic anyone claiming to have never missed a day at school lost that gold star. Did opening your computer every day to watch a remote learning session count for anything?
The threshold for allowing a child to stay home from school may be reaching a historic low. Families seem to regard the school schedule as a guideline that can easily be ignored when planning a vacation. Take little brother out of school to attend big brother’s lacrosse playoff game, not to worry if the youngster misses school days for a trip.
Who is responsible for reversing the trend? Teachers already know it is a serious problem. They view attendance as important. Maybe educators could make school more appealing. But to whom? Sounds like this message should be targeted at the parents. Would stiff penalties for parents whose children are chronically absent help? Would demanding a note from a physician after a certain number of absences help? It might. But, are pediatricians and educators ready to take on one more task in which parents have dropped the ball?
An unknown percentage of chronically absent children are missing school because of a previously unrecognized or inadequately treated mental health condition or learning disability. Involving physicians in a community’s response to chronic absenteeism may be the first step in getting a child back on track. If socioeconomic factors are contributing to a child’s truancy, the involvement of social service agencies may be the answer.
I have a friend who is often asked to address graduating classes at both the high school and college level. One of his standard pieces of advice, whether it be about school or a workplace you may not be in love with, is to at least “show up.” The family that treats school attendance as optional is likely to produce adults who take a similarly nonchalant attitude toward their employment opportunities — with unfortunate results.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at [email protected].
Among the more unheralded examples of collateral damage of the COVID epidemic is chronic absenteeism. A recent NPR/Ipsos poll found that parents ranked chronic absenteeism last in a list of 12 school-related concerns. Only 5% listed it first.
This is surprising and concerning, given that In fact, in some states the chronic absenteeism rate is 40%. In 2020 8 million students were chronically absent. This number is now over 14 million. Chronic absenteeism is a metric defined as a student absent for 15 days or more, which comes out to around 10% of the school year. Chronic absenteeism has been used as a predictor of the student dropout rate.
The initial contribution of the pandemic is easily explained, as parents were understandably concerned about sending their children into an environment that might cause disease, or at least bring the disease home to a more vulnerable family member. The reasons behind the trend’s persistence are a bit more complicated.
Family schedules initially disrupted by the pandemic have settled back into a pattern that may make it more difficult for a child to get to school. Day care and work schedules may have changed, but not yet readjusted to sync with the school schedule.
In the simplest terms, children and their families may have simply fallen out of the habit of going to school. For children (and maybe their parents) who had always struggled with an unresolved separation anxiety, the time at home — or at least not in school — came as a relief. Which, in turn, meant that any gains in dealing with the anxiety have been undone. The child who was already struggling academically or socially found being at home much less challenging. It’s not surprising that he/she might resist climbing back in the academic saddle.
It is very likely that a significant contributor to the persistent trend in chronic absenteeism is what social scientists call “norm erosion.” Not just children, but families may have developed an attitude that time spent in school just isn’t as valuable as they once believed, or were at least told that it was. There seems to be more parents questioning what their children are being taught in school. The home schooling movement existed before the pandemic. Its roots may be growing under the surface in the form of general skepticism about the importance of school in the bigger scheme of things. The home schooling movement was ready to blossom when the COVID pandemic triggered school closures. We hoped and dreamed that remote learning would be just as good as in-person school. We now realize that, in most cases, that was wishful thinking.
It feels as though a “Perfect Attendance Record” may have lost the cachet it once had. During the pandemic anyone claiming to have never missed a day at school lost that gold star. Did opening your computer every day to watch a remote learning session count for anything?
The threshold for allowing a child to stay home from school may be reaching a historic low. Families seem to regard the school schedule as a guideline that can easily be ignored when planning a vacation. Take little brother out of school to attend big brother’s lacrosse playoff game, not to worry if the youngster misses school days for a trip.
Who is responsible for reversing the trend? Teachers already know it is a serious problem. They view attendance as important. Maybe educators could make school more appealing. But to whom? Sounds like this message should be targeted at the parents. Would stiff penalties for parents whose children are chronically absent help? Would demanding a note from a physician after a certain number of absences help? It might. But, are pediatricians and educators ready to take on one more task in which parents have dropped the ball?
An unknown percentage of chronically absent children are missing school because of a previously unrecognized or inadequately treated mental health condition or learning disability. Involving physicians in a community’s response to chronic absenteeism may be the first step in getting a child back on track. If socioeconomic factors are contributing to a child’s truancy, the involvement of social service agencies may be the answer.
I have a friend who is often asked to address graduating classes at both the high school and college level. One of his standard pieces of advice, whether it be about school or a workplace you may not be in love with, is to at least “show up.” The family that treats school attendance as optional is likely to produce adults who take a similarly nonchalant attitude toward their employment opportunities — with unfortunate results.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at [email protected].