Rheumatology News

Disparities in health care exist in every specialty. In rheumatology, health disparities look like lack of access to care and lack of education on the part of rheumatologists and their patients, according to a speaker at the 2022 Rheumatology Winter Clinical Symposium.

Health disparities can affect people based on their racial or ethnic group, gender, sexual orientation, a mental or physical disability, socioeconomic status, or religion, Alvin Wells, MD, PhD, director of the department of rheumatology at Advocate Aurora Health in Franklin, Wisc., said in his presentation. But a person’s environment also plays a role – “where you live, work, play, and worship.”

Screenshot RWCS 2022

Social determinants of health can affect short-term and long-term health outcomes, functioning, and quality of life, he noted. “It’s economic stability, it’s access not only to health care, but also to education. And indeed, in my lifetime, as you know, some individuals weren’t allowed to read and write. They weren’t allowed to go to schools. You didn’t get the same type of education, and so that made a dramatic impact in moving forward with future, subsequent generations.”

In a survey of executives, clinical leaders, and clinicians in NEJM Catalyst Innovations in Care Delivery, 48% said widespread disparities in care delivery were present in their organizations. According to the social psychologist James S. House, PhD, some of these disparities like race/ethnicity, socioeconomic status, genetics, and geography are fixed, while others like psychosocial, medical care/insurance, and environmental hazards are modifiable. While factors like education, work, and location might be modifiable for some patients, others don’t have the ability to make these changes, Dr. Wells explained. “It’s not that easy when you think about it.”

Within rheumatology, racial and ethnic disparities exist in rheumatoid arthritis when it comes to disease activity and use of disease-modifying antirheumatic drugs. Disparities in outcomes based on race and geographic location have also been identified for patients with systemic lupus erythematosus, lupus nephritis, and based on race in osteoarthritis and psoriatic arthritis. “Where people live, where they reside, where their zip code is,” makes a difference for patients with rheumatic diseases, Dr. Wells said.

“We’ve heard at this meeting [about] some amazing drugs in treating our patients, both [for] skin and joint disease, but not everybody has the same kind of access,” he said.
 

What actions can medical stakeholders take?

Health equity should be a “desirable goal” for patients who experience health disparities, but it needs to be a “continuous effort,” Dr. Wells said. Focusing on the “how” of eliminating disparities should be a focus rather than checking a box.

Pharmacoequity is also a component of health equity, according to Dr. Wells. Where a person lives can affect their health based on their neighborhood’s level of air pollution, access to green space, and food deserts, but where a person lives also affects what parts of the health system they have access to, according to an editorial published in Circulation: Cardiovascular Quality and Outcomes. When patients aren’t taking their medication, it might be because that person doesn’t have easy access to a pharmacy, noted Dr. Wells. “It really kind of blows you away when you look at the data.”

Different stakeholders in medicine can tackle various aspects of this problem. For example, health care organizations and medical schools can make long-term commitments to prioritizing health equality, Dr. Wells said. “You want to make this a part of your practice, your group, or your university. And then once you get a process in place, don’t just check that box and move on. You want to see it. If you haven’t reached your goal, you need to revamp. If you met your goal, how do [you] improve upon that?”

Medical schools can also do better at improving misconceptions about patients of different races and ethnicities. Dr. Wells cited a striking paper published in Proceedings of the National Academy of Sciences of the U.S.A. that compared false beliefs in biological differences between Black and White people held by White laypeople and medical students. The study found that 58% of laypeople and 40% of first-year medical students believed that Black people have thicker skin than White people. “It’s absolutely amazing when you think about what medical schools can do,” he said.

Increased access to care is another area for improvement, Dr. Wells noted. “If you take people who are uninsured and you look at their health once they get Medicare, the gaps begin to close between the different races.”

In terms of individual actions, Dr. Wells noted that researchers and clinicians can help to make clinical trials better represent the overall population. At your practice, “treat all your patients like a VIP.” Instead of being concerned about the cost of a treatment, ask “is your patient worth it?”

“I have one of my patients on Medicaid. She’s on a biologic drug. And one of the VPs of my hospital is on the same drug. We don’t treat them any differently.”

The private sector is also acting, Dr. Wells said. He cited Novartis’ pledge to partner with 26 historically Black colleges to improve disparities in health and education. “We need to see more of that done from corporate America.”

Are there any short-term solutions?

Eric Ruderman, MD, professor of rheumatology at Northwestern University, Chicago, commented that institutions have been forming committees and focus groups, but “not a lot of action.”

“They’re checking boxes,” he said, “which is very frustrating.” What can rheumatologists do in the short term, he asked?

Dr. Wells noted that there has been some success in using a “carrot” model of using payment models to reduce racial disparities. For example, a recent study analyzing the effects of the Comprehensive Care for Joint Replacement model highlighted the need for payment reform that incentivizes clinicians to spend wisely on patient treatment. Under a payment model that rewards clinicians for treating patients cost effectively, “if I do a great job cost effectively, I could just have more of that money back to my group,” he said.

George Martin, MD, a clinical dermatologist practicing in Maui, recalled the disparity in health care he observed as a child growing up in Philadelphia. “There’s really, within the city, there’s two different levels of health care,” he said. “There’s a tremendous disparity in the quality of the physician in hospital, and way out in the community. Because that’s the point of contact. That’s when either you’re going to prescribe a biologic, or [you’re] going to give them some aspirin and tell them go home. That’s where it starts, point of contact.”

Dr. Wells agreed that it is a big challenge, noting that cities also contribute to pollution, crowding, and other factors that adversely impact health care.

“It’s a shared responsibility. How do we solve that?” Dr. Martin asked. “And if you tell me, I’m going to give you a Nobel Prize.”

Dr. Wells reported he is a reviewer for the Journal of Racial and Ethnic Disparities.

Disparities in health care exist in every specialty. In rheumatology, health disparities look like lack of access to care and lack of education on the part of rheumatologists and their patients, according to a speaker at the 2022 Rheumatology Winter Clinical Symposium.

Health disparities can affect people based on their racial or ethnic group, gender, sexual orientation, a mental or physical disability, socioeconomic status, or religion, Alvin Wells, MD, PhD, director of the department of rheumatology at Advocate Aurora Health in Franklin, Wisc., said in his presentation. But a person’s environment also plays a role – “where you live, work, play, and worship.”

Screenshot RWCS 2022

Social determinants of health can affect short-term and long-term health outcomes, functioning, and quality of life, he noted. “It’s economic stability, it’s access not only to health care, but also to education. And indeed, in my lifetime, as you know, some individuals weren’t allowed to read and write. They weren’t allowed to go to schools. You didn’t get the same type of education, and so that made a dramatic impact in moving forward with future, subsequent generations.”

In a survey of executives, clinical leaders, and clinicians in NEJM Catalyst Innovations in Care Delivery, 48% said widespread disparities in care delivery were present in their organizations. According to the social psychologist James S. House, PhD, some of these disparities like race/ethnicity, socioeconomic status, genetics, and geography are fixed, while others like psychosocial, medical care/insurance, and environmental hazards are modifiable. While factors like education, work, and location might be modifiable for some patients, others don’t have the ability to make these changes, Dr. Wells explained. “It’s not that easy when you think about it.”

Within rheumatology, racial and ethnic disparities exist in rheumatoid arthritis when it comes to disease activity and use of disease-modifying antirheumatic drugs. Disparities in outcomes based on race and geographic location have also been identified for patients with systemic lupus erythematosus, lupus nephritis, and based on race in osteoarthritis and psoriatic arthritis. “Where people live, where they reside, where their zip code is,” makes a difference for patients with rheumatic diseases, Dr. Wells said.

“We’ve heard at this meeting [about] some amazing drugs in treating our patients, both [for] skin and joint disease, but not everybody has the same kind of access,” he said.
 

What actions can medical stakeholders take?

Health equity should be a “desirable goal” for patients who experience health disparities, but it needs to be a “continuous effort,” Dr. Wells said. Focusing on the “how” of eliminating disparities should be a focus rather than checking a box.

Pharmacoequity is also a component of health equity, according to Dr. Wells. Where a person lives can affect their health based on their neighborhood’s level of air pollution, access to green space, and food deserts, but where a person lives also affects what parts of the health system they have access to, according to an editorial published in Circulation: Cardiovascular Quality and Outcomes. When patients aren’t taking their medication, it might be because that person doesn’t have easy access to a pharmacy, noted Dr. Wells. “It really kind of blows you away when you look at the data.”

Different stakeholders in medicine can tackle various aspects of this problem. For example, health care organizations and medical schools can make long-term commitments to prioritizing health equality, Dr. Wells said. “You want to make this a part of your practice, your group, or your university. And then once you get a process in place, don’t just check that box and move on. You want to see it. If you haven’t reached your goal, you need to revamp. If you met your goal, how do [you] improve upon that?”

Medical schools can also do better at improving misconceptions about patients of different races and ethnicities. Dr. Wells cited a striking paper published in Proceedings of the National Academy of Sciences of the U.S.A. that compared false beliefs in biological differences between Black and White people held by White laypeople and medical students. The study found that 58% of laypeople and 40% of first-year medical students believed that Black people have thicker skin than White people. “It’s absolutely amazing when you think about what medical schools can do,” he said.

Increased access to care is another area for improvement, Dr. Wells noted. “If you take people who are uninsured and you look at their health once they get Medicare, the gaps begin to close between the different races.”

In terms of individual actions, Dr. Wells noted that researchers and clinicians can help to make clinical trials better represent the overall population. At your practice, “treat all your patients like a VIP.” Instead of being concerned about the cost of a treatment, ask “is your patient worth it?”

“I have one of my patients on Medicaid. She’s on a biologic drug. And one of the VPs of my hospital is on the same drug. We don’t treat them any differently.”

The private sector is also acting, Dr. Wells said. He cited Novartis’ pledge to partner with 26 historically Black colleges to improve disparities in health and education. “We need to see more of that done from corporate America.”

Are there any short-term solutions?

Eric Ruderman, MD, professor of rheumatology at Northwestern University, Chicago, commented that institutions have been forming committees and focus groups, but “not a lot of action.”

“They’re checking boxes,” he said, “which is very frustrating.” What can rheumatologists do in the short term, he asked?

Dr. Wells noted that there has been some success in using a “carrot” model of using payment models to reduce racial disparities. For example, a recent study analyzing the effects of the Comprehensive Care for Joint Replacement model highlighted the need for payment reform that incentivizes clinicians to spend wisely on patient treatment. Under a payment model that rewards clinicians for treating patients cost effectively, “if I do a great job cost effectively, I could just have more of that money back to my group,” he said.

George Martin, MD, a clinical dermatologist practicing in Maui, recalled the disparity in health care he observed as a child growing up in Philadelphia. “There’s really, within the city, there’s two different levels of health care,” he said. “There’s a tremendous disparity in the quality of the physician in hospital, and way out in the community. Because that’s the point of contact. That’s when either you’re going to prescribe a biologic, or [you’re] going to give them some aspirin and tell them go home. That’s where it starts, point of contact.”

Dr. Wells agreed that it is a big challenge, noting that cities also contribute to pollution, crowding, and other factors that adversely impact health care.

“It’s a shared responsibility. How do we solve that?” Dr. Martin asked. “And if you tell me, I’m going to give you a Nobel Prize.”

Dr. Wells reported he is a reviewer for the Journal of Racial and Ethnic Disparities.

Disparities in health care exist in every specialty. In rheumatology, health disparities look like lack of access to care and lack of education on the part of rheumatologists and their patients, according to a speaker at the 2022 Rheumatology Winter Clinical Symposium.

Health disparities can affect people based on their racial or ethnic group, gender, sexual orientation, a mental or physical disability, socioeconomic status, or religion, Alvin Wells, MD, PhD, director of the department of rheumatology at Advocate Aurora Health in Franklin, Wisc., said in his presentation. But a person’s environment also plays a role – “where you live, work, play, and worship.”

Screenshot RWCS 2022

Social determinants of health can affect short-term and long-term health outcomes, functioning, and quality of life, he noted. “It’s economic stability, it’s access not only to health care, but also to education. And indeed, in my lifetime, as you know, some individuals weren’t allowed to read and write. They weren’t allowed to go to schools. You didn’t get the same type of education, and so that made a dramatic impact in moving forward with future, subsequent generations.”

In a survey of executives, clinical leaders, and clinicians in NEJM Catalyst Innovations in Care Delivery, 48% said widespread disparities in care delivery were present in their organizations. According to the social psychologist James S. House, PhD, some of these disparities like race/ethnicity, socioeconomic status, genetics, and geography are fixed, while others like psychosocial, medical care/insurance, and environmental hazards are modifiable. While factors like education, work, and location might be modifiable for some patients, others don’t have the ability to make these changes, Dr. Wells explained. “It’s not that easy when you think about it.”

Within rheumatology, racial and ethnic disparities exist in rheumatoid arthritis when it comes to disease activity and use of disease-modifying antirheumatic drugs. Disparities in outcomes based on race and geographic location have also been identified for patients with systemic lupus erythematosus, lupus nephritis, and based on race in osteoarthritis and psoriatic arthritis. “Where people live, where they reside, where their zip code is,” makes a difference for patients with rheumatic diseases, Dr. Wells said.

“We’ve heard at this meeting [about] some amazing drugs in treating our patients, both [for] skin and joint disease, but not everybody has the same kind of access,” he said.
 

What actions can medical stakeholders take?

Health equity should be a “desirable goal” for patients who experience health disparities, but it needs to be a “continuous effort,” Dr. Wells said. Focusing on the “how” of eliminating disparities should be a focus rather than checking a box.

Pharmacoequity is also a component of health equity, according to Dr. Wells. Where a person lives can affect their health based on their neighborhood’s level of air pollution, access to green space, and food deserts, but where a person lives also affects what parts of the health system they have access to, according to an editorial published in Circulation: Cardiovascular Quality and Outcomes. When patients aren’t taking their medication, it might be because that person doesn’t have easy access to a pharmacy, noted Dr. Wells. “It really kind of blows you away when you look at the data.”

Different stakeholders in medicine can tackle various aspects of this problem. For example, health care organizations and medical schools can make long-term commitments to prioritizing health equality, Dr. Wells said. “You want to make this a part of your practice, your group, or your university. And then once you get a process in place, don’t just check that box and move on. You want to see it. If you haven’t reached your goal, you need to revamp. If you met your goal, how do [you] improve upon that?”

Medical schools can also do better at improving misconceptions about patients of different races and ethnicities. Dr. Wells cited a striking paper published in Proceedings of the National Academy of Sciences of the U.S.A. that compared false beliefs in biological differences between Black and White people held by White laypeople and medical students. The study found that 58% of laypeople and 40% of first-year medical students believed that Black people have thicker skin than White people. “It’s absolutely amazing when you think about what medical schools can do,” he said.

Increased access to care is another area for improvement, Dr. Wells noted. “If you take people who are uninsured and you look at their health once they get Medicare, the gaps begin to close between the different races.”

In terms of individual actions, Dr. Wells noted that researchers and clinicians can help to make clinical trials better represent the overall population. At your practice, “treat all your patients like a VIP.” Instead of being concerned about the cost of a treatment, ask “is your patient worth it?”

“I have one of my patients on Medicaid. She’s on a biologic drug. And one of the VPs of my hospital is on the same drug. We don’t treat them any differently.”

The private sector is also acting, Dr. Wells said. He cited Novartis’ pledge to partner with 26 historically Black colleges to improve disparities in health and education. “We need to see more of that done from corporate America.”

Are there any short-term solutions?

Eric Ruderman, MD, professor of rheumatology at Northwestern University, Chicago, commented that institutions have been forming committees and focus groups, but “not a lot of action.”

“They’re checking boxes,” he said, “which is very frustrating.” What can rheumatologists do in the short term, he asked?

Dr. Wells noted that there has been some success in using a “carrot” model of using payment models to reduce racial disparities. For example, a recent study analyzing the effects of the Comprehensive Care for Joint Replacement model highlighted the need for payment reform that incentivizes clinicians to spend wisely on patient treatment. Under a payment model that rewards clinicians for treating patients cost effectively, “if I do a great job cost effectively, I could just have more of that money back to my group,” he said.

George Martin, MD, a clinical dermatologist practicing in Maui, recalled the disparity in health care he observed as a child growing up in Philadelphia. “There’s really, within the city, there’s two different levels of health care,” he said. “There’s a tremendous disparity in the quality of the physician in hospital, and way out in the community. Because that’s the point of contact. That’s when either you’re going to prescribe a biologic, or [you’re] going to give them some aspirin and tell them go home. That’s where it starts, point of contact.”

Dr. Wells agreed that it is a big challenge, noting that cities also contribute to pollution, crowding, and other factors that adversely impact health care.

“It’s a shared responsibility. How do we solve that?” Dr. Martin asked. “And if you tell me, I’m going to give you a Nobel Prize.”

Dr. Wells reported he is a reviewer for the Journal of Racial and Ethnic Disparities.

Anecdotal reports have linked the vaccines against COVID-19 to the sudden loss of hearing in some people. But a new study has found no evidence for such a connection with any of the three approved shots. 

The analysis of data from the Centers for Disease Control and Prevention’s Vaccine Adverse Event Reporting System (VAERS) found that the incidence of sudden onset hearing loss was not elevated – and might even be a bit lower than expected – in the first few weeks after the injections.

“We’re not finding a signal,” said Eric J. Formeister, MD, a neurotology fellow at the Johns Hopkins University, Baltimore, and the first author of the U.S. study, which appeared Feb. 24 in JAMA Otolaryngology – Head and Neck Surgery.

Dr. Formeister and colleagues undertook the study in response to reports of hearing problems, including hearing loss and tinnitus, that occurred soon after COVID-19 vaccination.

They analyzed reports of sudden hearing loss, experienced within 21 days of vaccination, logged in VAERS. Anyone can report a potential event to the database, which does not require medical documentation in support of the adverse event. To minimize potential misdiagnoses, Dr. Formeister and colleagues reviewed only those reports that indicated that a doctor had diagnosed sudden hearing loss, leaving 555 cases (305 in women; mean age 54 years) between December 2020 and July 2021.

Dividing these reports by the total doses of vaccines administered in the United States during that period yielded an incidence rate of 0.6 cases of sudden hearing loss for every 100,000 people, Dr. Formeister and colleagues reported.

When the researchers divided all cases of hearing loss in the VAERS database (2,170) by the number of people who had received two doses of vaccine, the incidence rate increased to 28 per 100,000 people. For comparison, the authors reported, the incidence of sudden hearing loss within the United States population is between 11 and 77 per 100,000 people, depending on age.

“There was not an increase in cases of sudden [sensorineural] hearing loss associated with COVID-19 vaccination compared to previously published reports before the COVID-19 vaccination era,” study coauthor Elliott D. Kozin, MD, assistant professor of otolaryngology–head and neck surgery at Harvard Medical School, Boston, said in an interview.

Another reassuring sign: If hearing loss were linked to the vaccines, the researchers said, they would expect to see an increase in the number of complaints in lockstep with an increase in the number of doses administered. However, the opposite was true. “[T]he rate of reports per 100,000 doses decreased across the vaccination period, despite large concomitant increases in the absolute number of vaccine doses administered per week,” the researchers reported.

They also looked at case reports of 21 men and women who had experienced sudden hearing loss after having received COVID-19 vaccines, to see if they could discern any clinically relevant signs of people most likely to experience the adverse event. However, the group had a range of preexisting conditions and varying times after receiving a vaccine when their hearing loss occurred, leading Dr. Formeister’s team to conclude that they could find no clear markers of risk.

“When we examined patients across several institutions, there was no obvious pattern. The patient demographics and clinical findings were variable,” Dr. Kozin said. A provisional interpretation of this data, he added, is that no link exists between COVID-19 vaccination and predictable hearing deficits, although the analysis covered a small number of patients.

“Association does not necessarily imply a causal relationship,” said Michael Brenner, MD, FACS, associate professor of otolaryngology–head and neck surgery at the University of Michigan, Ann Arbor. Dr. Brenner, who was not involved in the study, said any hearing loss attributed to the COVID-19 vaccines could have had other causes besides the injections.

But a second study, also published in JAMA Otolaryngology – Head and Neck Surgery on Feb. 24, leaves open the possibility of a link. Researchers in Israel looked for increases in steroid prescriptions used to treat sudden hearing loss as vaccination with the Pfizer version of the shot became widespread in that country. Their conclusion: The vaccine might be associated with a slightly increased risk of sudden hearing loss, although if so, that risk is likely “very small” and the benefits of vaccination “outweigh its potential association” with the side effect.

Dr. Brenner agreed. “The evidence supports [the] clear public health benefit of COVID-19 vaccination, and the scale of those benefits dwarfs associations with hearing, which are of uncertain significance,” he said.

A version of this article first appeared on Medscape.com.

Anecdotal reports have linked the vaccines against COVID-19 to the sudden loss of hearing in some people. But a new study has found no evidence for such a connection with any of the three approved shots. 

The analysis of data from the Centers for Disease Control and Prevention’s Vaccine Adverse Event Reporting System (VAERS) found that the incidence of sudden onset hearing loss was not elevated – and might even be a bit lower than expected – in the first few weeks after the injections.

“We’re not finding a signal,” said Eric J. Formeister, MD, a neurotology fellow at the Johns Hopkins University, Baltimore, and the first author of the U.S. study, which appeared Feb. 24 in JAMA Otolaryngology – Head and Neck Surgery.

Dr. Formeister and colleagues undertook the study in response to reports of hearing problems, including hearing loss and tinnitus, that occurred soon after COVID-19 vaccination.

They analyzed reports of sudden hearing loss, experienced within 21 days of vaccination, logged in VAERS. Anyone can report a potential event to the database, which does not require medical documentation in support of the adverse event. To minimize potential misdiagnoses, Dr. Formeister and colleagues reviewed only those reports that indicated that a doctor had diagnosed sudden hearing loss, leaving 555 cases (305 in women; mean age 54 years) between December 2020 and July 2021.

Dividing these reports by the total doses of vaccines administered in the United States during that period yielded an incidence rate of 0.6 cases of sudden hearing loss for every 100,000 people, Dr. Formeister and colleagues reported.

When the researchers divided all cases of hearing loss in the VAERS database (2,170) by the number of people who had received two doses of vaccine, the incidence rate increased to 28 per 100,000 people. For comparison, the authors reported, the incidence of sudden hearing loss within the United States population is between 11 and 77 per 100,000 people, depending on age.

“There was not an increase in cases of sudden [sensorineural] hearing loss associated with COVID-19 vaccination compared to previously published reports before the COVID-19 vaccination era,” study coauthor Elliott D. Kozin, MD, assistant professor of otolaryngology–head and neck surgery at Harvard Medical School, Boston, said in an interview.

Another reassuring sign: If hearing loss were linked to the vaccines, the researchers said, they would expect to see an increase in the number of complaints in lockstep with an increase in the number of doses administered. However, the opposite was true. “[T]he rate of reports per 100,000 doses decreased across the vaccination period, despite large concomitant increases in the absolute number of vaccine doses administered per week,” the researchers reported.

They also looked at case reports of 21 men and women who had experienced sudden hearing loss after having received COVID-19 vaccines, to see if they could discern any clinically relevant signs of people most likely to experience the adverse event. However, the group had a range of preexisting conditions and varying times after receiving a vaccine when their hearing loss occurred, leading Dr. Formeister’s team to conclude that they could find no clear markers of risk.

“When we examined patients across several institutions, there was no obvious pattern. The patient demographics and clinical findings were variable,” Dr. Kozin said. A provisional interpretation of this data, he added, is that no link exists between COVID-19 vaccination and predictable hearing deficits, although the analysis covered a small number of patients.

“Association does not necessarily imply a causal relationship,” said Michael Brenner, MD, FACS, associate professor of otolaryngology–head and neck surgery at the University of Michigan, Ann Arbor. Dr. Brenner, who was not involved in the study, said any hearing loss attributed to the COVID-19 vaccines could have had other causes besides the injections.

But a second study, also published in JAMA Otolaryngology – Head and Neck Surgery on Feb. 24, leaves open the possibility of a link. Researchers in Israel looked for increases in steroid prescriptions used to treat sudden hearing loss as vaccination with the Pfizer version of the shot became widespread in that country. Their conclusion: The vaccine might be associated with a slightly increased risk of sudden hearing loss, although if so, that risk is likely “very small” and the benefits of vaccination “outweigh its potential association” with the side effect.

Dr. Brenner agreed. “The evidence supports [the] clear public health benefit of COVID-19 vaccination, and the scale of those benefits dwarfs associations with hearing, which are of uncertain significance,” he said.

A version of this article first appeared on Medscape.com.

Anecdotal reports have linked the vaccines against COVID-19 to the sudden loss of hearing in some people. But a new study has found no evidence for such a connection with any of the three approved shots. 

The analysis of data from the Centers for Disease Control and Prevention’s Vaccine Adverse Event Reporting System (VAERS) found that the incidence of sudden onset hearing loss was not elevated – and might even be a bit lower than expected – in the first few weeks after the injections.

“We’re not finding a signal,” said Eric J. Formeister, MD, a neurotology fellow at the Johns Hopkins University, Baltimore, and the first author of the U.S. study, which appeared Feb. 24 in JAMA Otolaryngology – Head and Neck Surgery.

Dr. Formeister and colleagues undertook the study in response to reports of hearing problems, including hearing loss and tinnitus, that occurred soon after COVID-19 vaccination.

They analyzed reports of sudden hearing loss, experienced within 21 days of vaccination, logged in VAERS. Anyone can report a potential event to the database, which does not require medical documentation in support of the adverse event. To minimize potential misdiagnoses, Dr. Formeister and colleagues reviewed only those reports that indicated that a doctor had diagnosed sudden hearing loss, leaving 555 cases (305 in women; mean age 54 years) between December 2020 and July 2021.

Dividing these reports by the total doses of vaccines administered in the United States during that period yielded an incidence rate of 0.6 cases of sudden hearing loss for every 100,000 people, Dr. Formeister and colleagues reported.

When the researchers divided all cases of hearing loss in the VAERS database (2,170) by the number of people who had received two doses of vaccine, the incidence rate increased to 28 per 100,000 people. For comparison, the authors reported, the incidence of sudden hearing loss within the United States population is between 11 and 77 per 100,000 people, depending on age.

“There was not an increase in cases of sudden [sensorineural] hearing loss associated with COVID-19 vaccination compared to previously published reports before the COVID-19 vaccination era,” study coauthor Elliott D. Kozin, MD, assistant professor of otolaryngology–head and neck surgery at Harvard Medical School, Boston, said in an interview.

Another reassuring sign: If hearing loss were linked to the vaccines, the researchers said, they would expect to see an increase in the number of complaints in lockstep with an increase in the number of doses administered. However, the opposite was true. “[T]he rate of reports per 100,000 doses decreased across the vaccination period, despite large concomitant increases in the absolute number of vaccine doses administered per week,” the researchers reported.

They also looked at case reports of 21 men and women who had experienced sudden hearing loss after having received COVID-19 vaccines, to see if they could discern any clinically relevant signs of people most likely to experience the adverse event. However, the group had a range of preexisting conditions and varying times after receiving a vaccine when their hearing loss occurred, leading Dr. Formeister’s team to conclude that they could find no clear markers of risk.

“When we examined patients across several institutions, there was no obvious pattern. The patient demographics and clinical findings were variable,” Dr. Kozin said. A provisional interpretation of this data, he added, is that no link exists between COVID-19 vaccination and predictable hearing deficits, although the analysis covered a small number of patients.

“Association does not necessarily imply a causal relationship,” said Michael Brenner, MD, FACS, associate professor of otolaryngology–head and neck surgery at the University of Michigan, Ann Arbor. Dr. Brenner, who was not involved in the study, said any hearing loss attributed to the COVID-19 vaccines could have had other causes besides the injections.

But a second study, also published in JAMA Otolaryngology – Head and Neck Surgery on Feb. 24, leaves open the possibility of a link. Researchers in Israel looked for increases in steroid prescriptions used to treat sudden hearing loss as vaccination with the Pfizer version of the shot became widespread in that country. Their conclusion: The vaccine might be associated with a slightly increased risk of sudden hearing loss, although if so, that risk is likely “very small” and the benefits of vaccination “outweigh its potential association” with the side effect.

Dr. Brenner agreed. “The evidence supports [the] clear public health benefit of COVID-19 vaccination, and the scale of those benefits dwarfs associations with hearing, which are of uncertain significance,” he said.

A version of this article first appeared on Medscape.com.

I have a secret. It’s one I think many physicians and nurses share. Sometimes, when I’m stretched too thin — overbooked, hungry, tired, fielding yet another appeal to an insurance company in the middle of a clinic day — I find myself momentarily resenting the patients on my schedule.

As soon as this happens, I feel immediate guilt. These are the worst moments of my day. Why the heck would I resent my patients? They’re the entire reason I’m there. I wouldn’t be a physician without patients to care for. I became a physician, and completed subspecialty training, to help patients. People.

Recently, I started thinking more about this emotion of resentment. What exactly is it, and where does it come from? Is what I’m feeling actually resentment? Or is it something else?

Two books I’ve recently read have helped me explore the complicated emotion of resentment and how it might play a role in burnout for both physicians and nurses.

First, Brené Brown’s most recent book, Atlas of the Heart: Mapping Meaningful Connection and the Language of Human Experience, provides a roadmap for 87 of our human emotions. (That’s right — 87!)

One emotion of the 87 that she shares has been a particular struggle for her has been our good old friend, resentment.

In her book, Dr Brown shares that she initially considered resentment to belong to the anger family of emotion. As I read this, I agreed. When I feel resentful, I associate that with feeling angry.

But she then writes about her discovery that resentment, in fact, belongs to the envy family. She explains how this discovery shook her world. I had to close the book for a moment at this point.

Wait a minute, I thought. If resentment is in the envy family, why do we (physicians) often find ourselves resenting patients who take up our time? What are we envious of?

I took some time to think about how this might be true. Could it be that I’m envious they have the time I don’t have? I want to have all the time in the world to answer their questions, but the reality is I don’t.

Or maybe it’s because sometimes I feel the patient is expecting me to offer them something more than is available. A cure when there might be none.

But is this actually true? Or is this my unrealistic expectation of myself?

Here’s how Brené Brown defines resentment in her book: “Resentment is the feeling of frustration, judgment, anger, ‘better than,’ and/or hidden envy related to perceived unfairness or injustice. It’s an emotion that we often experience when we fail to set boundaries or ask for what we need, or when expectations let us down because they were based on things we can’t control, like what other people think, what they feel, or how they’re going to react.”

Wow, I thought, Healthcare checks all of these boxes.

• Perceived unfairness of work schedules? Check.
• Perceived injustice? Of course — we see that in our dealings with insurance company denials every day.

But those are both extrinsic. What about the intrinsic factors she’s calling us out on here?

• Do we, as physicians, fail to set boundaries?
• Do we fail to ask for what we need?

Hard yes and yes. (Do we even know, as physicians, what our own boundaries are?)

And the last one:

• Do our expectations of how our clinic day will go let us down every day because they’re based on things we can’t control?

My brain had to repeat the critical parts of that: Expectations let us down when they’re based on things we can’t control.

But wait, my brain argued back; I’m the physician, I thought I was supposed to get to control things.

Next, the revelation: Could it be that a key to experiencing less resentment is accepting how much control we don’t have in a typical day?

And a corollary: How much does resentment factor into burnout? (To read more on my personal journey with burnout, see this piece).

It so happens that around this same time, I was reading another excellent book, Changing How We Think About Difficult Patients: A Guide for Physicians and Healthcare Professionals, by Joan Naidorf, DO.

Dr Naidorf is an emergency medicine physician of 30 years who wrote the book to “provid[e] insight and tools to manage our negative thoughts about difficult patients” and help “beleaguered colleagues…return to their benevolent guiding principles and find more enjoyment in their vitally important careers.”

As I read Dr Naidorf’s book, I thus did so with the mindset of wanting to further understand for myself where this specific emotion of resentment toward our “difficult” patients could come from and how to best understand it in order to get past it.

Dr. Naidorf writes, “Challenging patients will never stop appearing… You cannot change them or control them—the only person you can control is you.”

I wondered how much the resentment we might involuntarily feel at being asked to see a “difficult” patient has nothing to do with the patient but everything to do with it making us feel not in control of the situation.

Dr. Naidorf also writes, “Negative thoughts about challenging patients can cause, in otherwise capable clinicians, a sense of inadequacy and incompetence.”

Do we perhaps resent our challenging patients because of the negative thoughts they sometimes trigger in us? If so, how does this relate to envy, as Dr. Brown asserts resentment is tied to? Is it triggering us to feel inadequate?

“[Difficult patients] often make us question ourselves,” Dr. Naidorf writes, “and we need to feel comfortable with the answers.”

Again, the discrepancy between expectations and reality creates the negative emotion.

Or, as Dr. Naidorf writes, “What if you could stop judging others so harshly and accept them exactly as they are?”

Hmmm, I thought, then the cessation of harsh judgment and implementation of acceptance would have to apply to us too. The elusive concept of self-compassion.

Maybe the resentment/envy comes from us not allowing ourselves to behave in this way because to do so would allow too much vulnerability. Something most of us were conditioned to avoid to survive medical training.

Dr. Brown also writes about an “aha” moment she had in her struggle to understand resentment. “I’m not mad because you’re resting. I’m mad because I’m so bone tired and I want to rest. But, unlike you, I’m going to pretend that I don’t need to.”

I felt all too seen in that passage. Could it be my old nemesis, perfectionism, creeping its way back in? Is resentment the ugly stepsister to perfectionism?

Perhaps challenging patients can engender resentment because they make us feel like we’re not living up to our own unrealistic expectations. And in that case, we need to change our unrealistic expectations for ourselves.

Dr Naidorf’s book explores much more on the complex matter of what makes a “difficult” patient, but I chose to focus here only on the resentment piece as a tie-in to Dr. Brown’s book. I highly recommend both books for further reading to help physicians and nurses navigate the complex emotions our jobs can trigger.

Most importantly, recognizing that we have these transient negative emotions does not make us bad people or healthcare professionals. It only makes us human.

Dr. Lycette is medical director, Providence Oncology and Hematology Care Clinic, Seaside, Ore. She has disclosed having no relevant financial relationships.

A version of this article first appeared on Medscape.com.

I have a secret. It’s one I think many physicians and nurses share. Sometimes, when I’m stretched too thin — overbooked, hungry, tired, fielding yet another appeal to an insurance company in the middle of a clinic day — I find myself momentarily resenting the patients on my schedule.

As soon as this happens, I feel immediate guilt. These are the worst moments of my day. Why the heck would I resent my patients? They’re the entire reason I’m there. I wouldn’t be a physician without patients to care for. I became a physician, and completed subspecialty training, to help patients. People.

Recently, I started thinking more about this emotion of resentment. What exactly is it, and where does it come from? Is what I’m feeling actually resentment? Or is it something else?

Two books I’ve recently read have helped me explore the complicated emotion of resentment and how it might play a role in burnout for both physicians and nurses.

First, Brené Brown’s most recent book, Atlas of the Heart: Mapping Meaningful Connection and the Language of Human Experience, provides a roadmap for 87 of our human emotions. (That’s right — 87!)

One emotion of the 87 that she shares has been a particular struggle for her has been our good old friend, resentment.

In her book, Dr Brown shares that she initially considered resentment to belong to the anger family of emotion. As I read this, I agreed. When I feel resentful, I associate that with feeling angry.

But she then writes about her discovery that resentment, in fact, belongs to the envy family. She explains how this discovery shook her world. I had to close the book for a moment at this point.

Wait a minute, I thought. If resentment is in the envy family, why do we (physicians) often find ourselves resenting patients who take up our time? What are we envious of?

I took some time to think about how this might be true. Could it be that I’m envious they have the time I don’t have? I want to have all the time in the world to answer their questions, but the reality is I don’t.

Or maybe it’s because sometimes I feel the patient is expecting me to offer them something more than is available. A cure when there might be none.

But is this actually true? Or is this my unrealistic expectation of myself?

Here’s how Brené Brown defines resentment in her book: “Resentment is the feeling of frustration, judgment, anger, ‘better than,’ and/or hidden envy related to perceived unfairness or injustice. It’s an emotion that we often experience when we fail to set boundaries or ask for what we need, or when expectations let us down because they were based on things we can’t control, like what other people think, what they feel, or how they’re going to react.”

Wow, I thought, Healthcare checks all of these boxes.

• Perceived unfairness of work schedules? Check.
• Perceived injustice? Of course — we see that in our dealings with insurance company denials every day.

But those are both extrinsic. What about the intrinsic factors she’s calling us out on here?

• Do we, as physicians, fail to set boundaries?
• Do we fail to ask for what we need?

Hard yes and yes. (Do we even know, as physicians, what our own boundaries are?)

And the last one:

• Do our expectations of how our clinic day will go let us down every day because they’re based on things we can’t control?

My brain had to repeat the critical parts of that: Expectations let us down when they’re based on things we can’t control.

But wait, my brain argued back; I’m the physician, I thought I was supposed to get to control things.

Next, the revelation: Could it be that a key to experiencing less resentment is accepting how much control we don’t have in a typical day?

And a corollary: How much does resentment factor into burnout? (To read more on my personal journey with burnout, see this piece).

It so happens that around this same time, I was reading another excellent book, Changing How We Think About Difficult Patients: A Guide for Physicians and Healthcare Professionals, by Joan Naidorf, DO.

Dr Naidorf is an emergency medicine physician of 30 years who wrote the book to “provid[e] insight and tools to manage our negative thoughts about difficult patients” and help “beleaguered colleagues…return to their benevolent guiding principles and find more enjoyment in their vitally important careers.”

As I read Dr Naidorf’s book, I thus did so with the mindset of wanting to further understand for myself where this specific emotion of resentment toward our “difficult” patients could come from and how to best understand it in order to get past it.

Dr. Naidorf writes, “Challenging patients will never stop appearing… You cannot change them or control them—the only person you can control is you.”

I wondered how much the resentment we might involuntarily feel at being asked to see a “difficult” patient has nothing to do with the patient but everything to do with it making us feel not in control of the situation.

Dr. Naidorf also writes, “Negative thoughts about challenging patients can cause, in otherwise capable clinicians, a sense of inadequacy and incompetence.”

Do we perhaps resent our challenging patients because of the negative thoughts they sometimes trigger in us? If so, how does this relate to envy, as Dr. Brown asserts resentment is tied to? Is it triggering us to feel inadequate?

“[Difficult patients] often make us question ourselves,” Dr. Naidorf writes, “and we need to feel comfortable with the answers.”

Again, the discrepancy between expectations and reality creates the negative emotion.

Or, as Dr. Naidorf writes, “What if you could stop judging others so harshly and accept them exactly as they are?”

Hmmm, I thought, then the cessation of harsh judgment and implementation of acceptance would have to apply to us too. The elusive concept of self-compassion.

Maybe the resentment/envy comes from us not allowing ourselves to behave in this way because to do so would allow too much vulnerability. Something most of us were conditioned to avoid to survive medical training.

Dr. Brown also writes about an “aha” moment she had in her struggle to understand resentment. “I’m not mad because you’re resting. I’m mad because I’m so bone tired and I want to rest. But, unlike you, I’m going to pretend that I don’t need to.”

I felt all too seen in that passage. Could it be my old nemesis, perfectionism, creeping its way back in? Is resentment the ugly stepsister to perfectionism?

Perhaps challenging patients can engender resentment because they make us feel like we’re not living up to our own unrealistic expectations. And in that case, we need to change our unrealistic expectations for ourselves.

Dr Naidorf’s book explores much more on the complex matter of what makes a “difficult” patient, but I chose to focus here only on the resentment piece as a tie-in to Dr. Brown’s book. I highly recommend both books for further reading to help physicians and nurses navigate the complex emotions our jobs can trigger.

Most importantly, recognizing that we have these transient negative emotions does not make us bad people or healthcare professionals. It only makes us human.

Dr. Lycette is medical director, Providence Oncology and Hematology Care Clinic, Seaside, Ore. She has disclosed having no relevant financial relationships.

A version of this article first appeared on Medscape.com.

I have a secret. It’s one I think many physicians and nurses share. Sometimes, when I’m stretched too thin — overbooked, hungry, tired, fielding yet another appeal to an insurance company in the middle of a clinic day — I find myself momentarily resenting the patients on my schedule.

As soon as this happens, I feel immediate guilt. These are the worst moments of my day. Why the heck would I resent my patients? They’re the entire reason I’m there. I wouldn’t be a physician without patients to care for. I became a physician, and completed subspecialty training, to help patients. People.

Recently, I started thinking more about this emotion of resentment. What exactly is it, and where does it come from? Is what I’m feeling actually resentment? Or is it something else?

Two books I’ve recently read have helped me explore the complicated emotion of resentment and how it might play a role in burnout for both physicians and nurses.

First, Brené Brown’s most recent book, Atlas of the Heart: Mapping Meaningful Connection and the Language of Human Experience, provides a roadmap for 87 of our human emotions. (That’s right — 87!)

One emotion of the 87 that she shares has been a particular struggle for her has been our good old friend, resentment.

In her book, Dr Brown shares that she initially considered resentment to belong to the anger family of emotion. As I read this, I agreed. When I feel resentful, I associate that with feeling angry.

But she then writes about her discovery that resentment, in fact, belongs to the envy family. She explains how this discovery shook her world. I had to close the book for a moment at this point.

Wait a minute, I thought. If resentment is in the envy family, why do we (physicians) often find ourselves resenting patients who take up our time? What are we envious of?

I took some time to think about how this might be true. Could it be that I’m envious they have the time I don’t have? I want to have all the time in the world to answer their questions, but the reality is I don’t.

Or maybe it’s because sometimes I feel the patient is expecting me to offer them something more than is available. A cure when there might be none.

But is this actually true? Or is this my unrealistic expectation of myself?

Here’s how Brené Brown defines resentment in her book: “Resentment is the feeling of frustration, judgment, anger, ‘better than,’ and/or hidden envy related to perceived unfairness or injustice. It’s an emotion that we often experience when we fail to set boundaries or ask for what we need, or when expectations let us down because they were based on things we can’t control, like what other people think, what they feel, or how they’re going to react.”

Wow, I thought, Healthcare checks all of these boxes.

• Perceived unfairness of work schedules? Check.
• Perceived injustice? Of course — we see that in our dealings with insurance company denials every day.

But those are both extrinsic. What about the intrinsic factors she’s calling us out on here?

• Do we, as physicians, fail to set boundaries?
• Do we fail to ask for what we need?

Hard yes and yes. (Do we even know, as physicians, what our own boundaries are?)

And the last one:

• Do our expectations of how our clinic day will go let us down every day because they’re based on things we can’t control?

My brain had to repeat the critical parts of that: Expectations let us down when they’re based on things we can’t control.

But wait, my brain argued back; I’m the physician, I thought I was supposed to get to control things.

Next, the revelation: Could it be that a key to experiencing less resentment is accepting how much control we don’t have in a typical day?

And a corollary: How much does resentment factor into burnout? (To read more on my personal journey with burnout, see this piece).

It so happens that around this same time, I was reading another excellent book, Changing How We Think About Difficult Patients: A Guide for Physicians and Healthcare Professionals, by Joan Naidorf, DO.

Dr Naidorf is an emergency medicine physician of 30 years who wrote the book to “provid[e] insight and tools to manage our negative thoughts about difficult patients” and help “beleaguered colleagues…return to their benevolent guiding principles and find more enjoyment in their vitally important careers.”

As I read Dr Naidorf’s book, I thus did so with the mindset of wanting to further understand for myself where this specific emotion of resentment toward our “difficult” patients could come from and how to best understand it in order to get past it.

Dr. Naidorf writes, “Challenging patients will never stop appearing… You cannot change them or control them—the only person you can control is you.”

I wondered how much the resentment we might involuntarily feel at being asked to see a “difficult” patient has nothing to do with the patient but everything to do with it making us feel not in control of the situation.

Dr. Naidorf also writes, “Negative thoughts about challenging patients can cause, in otherwise capable clinicians, a sense of inadequacy and incompetence.”

Do we perhaps resent our challenging patients because of the negative thoughts they sometimes trigger in us? If so, how does this relate to envy, as Dr. Brown asserts resentment is tied to? Is it triggering us to feel inadequate?

“[Difficult patients] often make us question ourselves,” Dr. Naidorf writes, “and we need to feel comfortable with the answers.”

Again, the discrepancy between expectations and reality creates the negative emotion.

Or, as Dr. Naidorf writes, “What if you could stop judging others so harshly and accept them exactly as they are?”

Hmmm, I thought, then the cessation of harsh judgment and implementation of acceptance would have to apply to us too. The elusive concept of self-compassion.

Maybe the resentment/envy comes from us not allowing ourselves to behave in this way because to do so would allow too much vulnerability. Something most of us were conditioned to avoid to survive medical training.

Dr. Brown also writes about an “aha” moment she had in her struggle to understand resentment. “I’m not mad because you’re resting. I’m mad because I’m so bone tired and I want to rest. But, unlike you, I’m going to pretend that I don’t need to.”

I felt all too seen in that passage. Could it be my old nemesis, perfectionism, creeping its way back in? Is resentment the ugly stepsister to perfectionism?

Perhaps challenging patients can engender resentment because they make us feel like we’re not living up to our own unrealistic expectations. And in that case, we need to change our unrealistic expectations for ourselves.

Dr Naidorf’s book explores much more on the complex matter of what makes a “difficult” patient, but I chose to focus here only on the resentment piece as a tie-in to Dr. Brown’s book. I highly recommend both books for further reading to help physicians and nurses navigate the complex emotions our jobs can trigger.

Most importantly, recognizing that we have these transient negative emotions does not make us bad people or healthcare professionals. It only makes us human.

Dr. Lycette is medical director, Providence Oncology and Hematology Care Clinic, Seaside, Ore. She has disclosed having no relevant financial relationships.

A version of this article first appeared on Medscape.com.

Nasogastric tubes. Foley catheter kits. Hydrogel anti-burn bandages and transfusion bags. Heparin, atropine, tramadol.

These items are just a few of some two dozen critical medical supplies that physicians in Ukraine desperately need, according to Leo Wolansky, MD, a Ukrainian-American radiologist and president of the Ukrainian Medical Association of North America (UMANA).

Dr. Wolansky founded a teaching program with an organization called Friends of Radiology in Ukraine in 1996 and has been running courses for specialists there ever since. He last visited the country in 2019, before the COVID-19 pandemic, but has remained in contact with his medical colleagues by phone and email. Over the weekend of Feb. 26-27, UMANA held a fundraiser for Ukraine, raising more than $17,000.

This news organization spoke with Dr. Wolansky about the situation for his fellow physicians in the war-torn country.

Question: Where is your family from, and do you have relatives in the country now?

Dr. Wolansky: My family is from two different parts of Ukraine. My mother was from central Ukraine. Her father, Ivan Sharyj, was part of the students’ militia that fought at the famous battle of Kruty in 1918. Four hundred Ukrainian militia fought against 5,000 professional Russian soldiers and were massacred. He later wrote the first eye-witness account. Afterwards, he had the opportunity to flee Ukraine but chose to stay under a pseudonym. Eventually, during Stalin’s purges [1929-1933], the regime found him, arrested him, tortured him, and executed him. My mother was seven when she saw her father arrested, never to return home. My father was from Western Ukraine, which did not have a long history of Russian occupation. His mother’s family was very patriotic; her first cousin, Stepan Vytvytskyi, eventually became the president of Ukraine in exile from 1955-1964.

I have second and more distant cousins in Kyiv. My wife has first cousins in Western Ukraine. They and my doctor colleagues are suffering greatly but are ready to die for their freedom.

Question: The Russian invasion of Ukraine has put tremendous stress on the Ukrainian people, including the country’s medical professionals. How do doctors in these kinds of situations handle casualties they can’t prevent? How do they work around that sense that everything is out of their control?

Dr. Wolansky: A lot of infrastructural things are being disrupted; there are limitations that you wouldn’t normally encounter. Ukraine has been developing a lot of sophisticated medical technology, but it still has room to grow. Under these circumstances, when there are bombs going off and transportation is being disrupted, it creates very new and significant obstacles to surmount. It still has not risen to massive casualties, and we can just pray that it does not, but in times of war, a very different kind of medicine is practiced.

But remember, Ukraine has been at war since 2014, when Russia took Crimea and invaded the Eastern provinces. The doctors there are not unfamiliar with war injuries. At our conferences in Ukraine, I have seen radiological presentations of injuries sustained in war – gunshots, fractures, and amputations – as well as other kinds of traumatic injuries. You’re going for a kind of more emergent treatment: to transfuse, to maintain peoples’ blood pressure, put bandages on, sterilize and sanitize wounds to prevent infections. I imagine there will be many field hospitals set up between now and the next few weeks to deal with the acute injuries.

Question: Ukraine has struggled with high rates of HIV and multidrug-resistant tuberculosis, as well as a lack of resources for treating patients with mental illness. Meanwhile, the country has had more that 5 million cases of COVID-19 and an estimated 112,000 deaths from the disease. Are you concerned about an exacerbation of infection rates, including of COVID, particularly among refugees and those who become homeless?

Dr. Wolansky: Because COVID ran pretty rampant in Ukraine, I think that – at a high cost – there is a level of natural immunity in the population. And the weather is going to be getting warmer soon, and respiratory viruses are cyclic in nature, so I don’t know if that’s going to be a big complicating factor. However, people get sick all the time, and the prognosis for them is going to be much worse than it otherwise might be. If you have a heart attack, your chances were way better when the roads were clear and people weren’t shooting at you.

Right now, it’s very regional where the infrastructure is being destroyed. The West, where I used to go, is in much better shape than the East because it has not been the focus of Russian attacks. But Kyiv could turn into a very big humanitarian crisis very quickly if there’s no electricity, no water. All sorts of medical conditions could be greatly exacerbated, and some new health crises could arise from water contamination, bombs causing buildings to collapse, and other problems. Whatever the illness is, it’s going to be harder to take care of it.

Questions: Doctors Without Borders announced that it was suspending its operations in Ukraine because of the invasion – missions that included HIV care in Severodonetsk, tuberculosis care in Zhytomyr, and improving health care access in Donetsk in eastern Ukraine, according to the aid group. What do doctors in Ukraine need most acutely now, other than peace?

Dr. Wolansky: Obviously, money is valuable, and military protection, which would prevent additional damage to their infrastructure. One thing that bears mentioning. There’s been a fair amount of coverage of this, but I’ve witnessed it first-hand: The Ukrainian people are fiercely patriotic, and there’s really no way their spirit can be conquered. The USSR invaded Afghanistan, and after years of thinking they were in command, they left because they could no longer take the guerilla warfare and the constant sniper attacks. Ukraine’s population is many times larger than Afghanistan’s; there’s no way they can be subdued. And remember, the Ukrainian people have been free for 30 years – generations of young people have known no other way of life. They are not going to give that up.

A version of this article first appeared on Medscape.com.

Nasogastric tubes. Foley catheter kits. Hydrogel anti-burn bandages and transfusion bags. Heparin, atropine, tramadol.

These items are just a few of some two dozen critical medical supplies that physicians in Ukraine desperately need, according to Leo Wolansky, MD, a Ukrainian-American radiologist and president of the Ukrainian Medical Association of North America (UMANA).

Dr. Wolansky founded a teaching program with an organization called Friends of Radiology in Ukraine in 1996 and has been running courses for specialists there ever since. He last visited the country in 2019, before the COVID-19 pandemic, but has remained in contact with his medical colleagues by phone and email. Over the weekend of Feb. 26-27, UMANA held a fundraiser for Ukraine, raising more than $17,000.

This news organization spoke with Dr. Wolansky about the situation for his fellow physicians in the war-torn country.

Question: Where is your family from, and do you have relatives in the country now?

Dr. Wolansky: My family is from two different parts of Ukraine. My mother was from central Ukraine. Her father, Ivan Sharyj, was part of the students’ militia that fought at the famous battle of Kruty in 1918. Four hundred Ukrainian militia fought against 5,000 professional Russian soldiers and were massacred. He later wrote the first eye-witness account. Afterwards, he had the opportunity to flee Ukraine but chose to stay under a pseudonym. Eventually, during Stalin’s purges [1929-1933], the regime found him, arrested him, tortured him, and executed him. My mother was seven when she saw her father arrested, never to return home. My father was from Western Ukraine, which did not have a long history of Russian occupation. His mother’s family was very patriotic; her first cousin, Stepan Vytvytskyi, eventually became the president of Ukraine in exile from 1955-1964.

I have second and more distant cousins in Kyiv. My wife has first cousins in Western Ukraine. They and my doctor colleagues are suffering greatly but are ready to die for their freedom.

Question: The Russian invasion of Ukraine has put tremendous stress on the Ukrainian people, including the country’s medical professionals. How do doctors in these kinds of situations handle casualties they can’t prevent? How do they work around that sense that everything is out of their control?

Dr. Wolansky: A lot of infrastructural things are being disrupted; there are limitations that you wouldn’t normally encounter. Ukraine has been developing a lot of sophisticated medical technology, but it still has room to grow. Under these circumstances, when there are bombs going off and transportation is being disrupted, it creates very new and significant obstacles to surmount. It still has not risen to massive casualties, and we can just pray that it does not, but in times of war, a very different kind of medicine is practiced.

But remember, Ukraine has been at war since 2014, when Russia took Crimea and invaded the Eastern provinces. The doctors there are not unfamiliar with war injuries. At our conferences in Ukraine, I have seen radiological presentations of injuries sustained in war – gunshots, fractures, and amputations – as well as other kinds of traumatic injuries. You’re going for a kind of more emergent treatment: to transfuse, to maintain peoples’ blood pressure, put bandages on, sterilize and sanitize wounds to prevent infections. I imagine there will be many field hospitals set up between now and the next few weeks to deal with the acute injuries.

Question: Ukraine has struggled with high rates of HIV and multidrug-resistant tuberculosis, as well as a lack of resources for treating patients with mental illness. Meanwhile, the country has had more that 5 million cases of COVID-19 and an estimated 112,000 deaths from the disease. Are you concerned about an exacerbation of infection rates, including of COVID, particularly among refugees and those who become homeless?

Dr. Wolansky: Because COVID ran pretty rampant in Ukraine, I think that – at a high cost – there is a level of natural immunity in the population. And the weather is going to be getting warmer soon, and respiratory viruses are cyclic in nature, so I don’t know if that’s going to be a big complicating factor. However, people get sick all the time, and the prognosis for them is going to be much worse than it otherwise might be. If you have a heart attack, your chances were way better when the roads were clear and people weren’t shooting at you.

Right now, it’s very regional where the infrastructure is being destroyed. The West, where I used to go, is in much better shape than the East because it has not been the focus of Russian attacks. But Kyiv could turn into a very big humanitarian crisis very quickly if there’s no electricity, no water. All sorts of medical conditions could be greatly exacerbated, and some new health crises could arise from water contamination, bombs causing buildings to collapse, and other problems. Whatever the illness is, it’s going to be harder to take care of it.

Questions: Doctors Without Borders announced that it was suspending its operations in Ukraine because of the invasion – missions that included HIV care in Severodonetsk, tuberculosis care in Zhytomyr, and improving health care access in Donetsk in eastern Ukraine, according to the aid group. What do doctors in Ukraine need most acutely now, other than peace?

Dr. Wolansky: Obviously, money is valuable, and military protection, which would prevent additional damage to their infrastructure. One thing that bears mentioning. There’s been a fair amount of coverage of this, but I’ve witnessed it first-hand: The Ukrainian people are fiercely patriotic, and there’s really no way their spirit can be conquered. The USSR invaded Afghanistan, and after years of thinking they were in command, they left because they could no longer take the guerilla warfare and the constant sniper attacks. Ukraine’s population is many times larger than Afghanistan’s; there’s no way they can be subdued. And remember, the Ukrainian people have been free for 30 years – generations of young people have known no other way of life. They are not going to give that up.

A version of this article first appeared on Medscape.com.

Nasogastric tubes. Foley catheter kits. Hydrogel anti-burn bandages and transfusion bags. Heparin, atropine, tramadol.

These items are just a few of some two dozen critical medical supplies that physicians in Ukraine desperately need, according to Leo Wolansky, MD, a Ukrainian-American radiologist and president of the Ukrainian Medical Association of North America (UMANA).

Dr. Wolansky founded a teaching program with an organization called Friends of Radiology in Ukraine in 1996 and has been running courses for specialists there ever since. He last visited the country in 2019, before the COVID-19 pandemic, but has remained in contact with his medical colleagues by phone and email. Over the weekend of Feb. 26-27, UMANA held a fundraiser for Ukraine, raising more than $17,000.

This news organization spoke with Dr. Wolansky about the situation for his fellow physicians in the war-torn country.

Question: Where is your family from, and do you have relatives in the country now?

Dr. Wolansky: My family is from two different parts of Ukraine. My mother was from central Ukraine. Her father, Ivan Sharyj, was part of the students’ militia that fought at the famous battle of Kruty in 1918. Four hundred Ukrainian militia fought against 5,000 professional Russian soldiers and were massacred. He later wrote the first eye-witness account. Afterwards, he had the opportunity to flee Ukraine but chose to stay under a pseudonym. Eventually, during Stalin’s purges [1929-1933], the regime found him, arrested him, tortured him, and executed him. My mother was seven when she saw her father arrested, never to return home. My father was from Western Ukraine, which did not have a long history of Russian occupation. His mother’s family was very patriotic; her first cousin, Stepan Vytvytskyi, eventually became the president of Ukraine in exile from 1955-1964.

I have second and more distant cousins in Kyiv. My wife has first cousins in Western Ukraine. They and my doctor colleagues are suffering greatly but are ready to die for their freedom.

Question: The Russian invasion of Ukraine has put tremendous stress on the Ukrainian people, including the country’s medical professionals. How do doctors in these kinds of situations handle casualties they can’t prevent? How do they work around that sense that everything is out of their control?

Dr. Wolansky: A lot of infrastructural things are being disrupted; there are limitations that you wouldn’t normally encounter. Ukraine has been developing a lot of sophisticated medical technology, but it still has room to grow. Under these circumstances, when there are bombs going off and transportation is being disrupted, it creates very new and significant obstacles to surmount. It still has not risen to massive casualties, and we can just pray that it does not, but in times of war, a very different kind of medicine is practiced.

But remember, Ukraine has been at war since 2014, when Russia took Crimea and invaded the Eastern provinces. The doctors there are not unfamiliar with war injuries. At our conferences in Ukraine, I have seen radiological presentations of injuries sustained in war – gunshots, fractures, and amputations – as well as other kinds of traumatic injuries. You’re going for a kind of more emergent treatment: to transfuse, to maintain peoples’ blood pressure, put bandages on, sterilize and sanitize wounds to prevent infections. I imagine there will be many field hospitals set up between now and the next few weeks to deal with the acute injuries.

Question: Ukraine has struggled with high rates of HIV and multidrug-resistant tuberculosis, as well as a lack of resources for treating patients with mental illness. Meanwhile, the country has had more that 5 million cases of COVID-19 and an estimated 112,000 deaths from the disease. Are you concerned about an exacerbation of infection rates, including of COVID, particularly among refugees and those who become homeless?

Dr. Wolansky: Because COVID ran pretty rampant in Ukraine, I think that – at a high cost – there is a level of natural immunity in the population. And the weather is going to be getting warmer soon, and respiratory viruses are cyclic in nature, so I don’t know if that’s going to be a big complicating factor. However, people get sick all the time, and the prognosis for them is going to be much worse than it otherwise might be. If you have a heart attack, your chances were way better when the roads were clear and people weren’t shooting at you.

Right now, it’s very regional where the infrastructure is being destroyed. The West, where I used to go, is in much better shape than the East because it has not been the focus of Russian attacks. But Kyiv could turn into a very big humanitarian crisis very quickly if there’s no electricity, no water. All sorts of medical conditions could be greatly exacerbated, and some new health crises could arise from water contamination, bombs causing buildings to collapse, and other problems. Whatever the illness is, it’s going to be harder to take care of it.

Questions: Doctors Without Borders announced that it was suspending its operations in Ukraine because of the invasion – missions that included HIV care in Severodonetsk, tuberculosis care in Zhytomyr, and improving health care access in Donetsk in eastern Ukraine, according to the aid group. What do doctors in Ukraine need most acutely now, other than peace?

Dr. Wolansky: Obviously, money is valuable, and military protection, which would prevent additional damage to their infrastructure. One thing that bears mentioning. There’s been a fair amount of coverage of this, but I’ve witnessed it first-hand: The Ukrainian people are fiercely patriotic, and there’s really no way their spirit can be conquered. The USSR invaded Afghanistan, and after years of thinking they were in command, they left because they could no longer take the guerilla warfare and the constant sniper attacks. Ukraine’s population is many times larger than Afghanistan’s; there’s no way they can be subdued. And remember, the Ukrainian people have been free for 30 years – generations of young people have known no other way of life. They are not going to give that up.

A version of this article first appeared on Medscape.com.

Payments to rheumatologists by pharmaceutical companies, whether through food and beverages or consulting fees, are linked with a higher likelihood of prescribing drugs and higher Medicare spending, according to a new study published Feb. 2 in Mayo Clinic Proceedings.

Alí Duarte-García, MD, of the division of rheumatology in the department of medicine at the Mayo Clinic in Rochester, Minn., led the study.

Courtesy Mayo Clinic

Researchers conducted a cross-sectional analysis of Medicare Part B Public Use File, Medicare Part D Public Use File, and Open Payments data for 2013-2015. They included prescription drugs that accounted for 80% of the total Medicare pharmaceutical expenditures in rheumatology.

They then calculated annual average drug cost per beneficiary per year, the percentage of rheumatologists who received payments, and the average payment per physician per drug per year. Industry payments were categorized as either food/beverage or consulting/compensation.

Multivariable regression models were used to assess links between industry payments, prescribing patterns, and prescription drug spending.
 

‘Directly associated’ with prescribing probability

The authors concluded that “pharmaceutical company payments to rheumatologists were directly associated with the probability of the physician’s prescribing a drug marketed by that company, the proportion of prescriptions that are for that drug, and the resulting Medicare expenditures.”

Thinkstock

The authors noted that food and beverage payments were associated with increased Medicare reimbursement amounts for all drugs except rituximab.

The article includes examples that help quantify the link between payments and prescribing.

The authors wrote that for each $100 in food/beverage payments, Medicare reimbursement increased 6% to 44%. The increases were particularly high for infliximab and rACTH (repository corticotropin injection), “whereby a payment of $100 to a prescriber of these drugs was associated with increases of approximately $72,000 and $30,000 in Medicare reimbursements, respectively. For most of the other drugs, for every $100 in payments, the Medicare reimbursement increased by $8,000 to $13,000.”

The associations were strongest for food and beverage payments even though those were for lower dollar amounts.

The researchers found that every $100 in food and beverage payments, which also include gifts, entertainment, or educational materials, was linked with more than twofold higher probability of prescribing and higher Medicare reimbursements than for every $1,000 paid in consulting fees and compensation.

That finding and findings from previous studies, they say, “suggest that the current approach to regulating industry influence, which focuses on disclosure of large payments, may be inadequate.”

Aaron P. Mitchell, MD, a medical oncologist and health services researcher with Memorial Sloan Kettering Cancer Center in New York, told this news organization that the findings regarding rACTH show the potential harm of industry payments that are linked with prescribing.

Memorial Sloan Kettering Cancer Center

The drug is a naturally produced hormone used for both rheumatologic and neurologic conditions. “Since it is an unpatentable drug – really just a hormone – it’s kind of grandfathered in and never had to get [Food and Drug Administration] approval for its current indications,” Dr. Mitchell said.

The drug, which costs nearly $230,000 per Medicare beneficiary, hasn’t been tested head to head in large randomized trials against much cheaper rheumatology drugs, such as prednisone.

In the case of infliximab, he noted, for every $100 in food/beverage payments, there was an increase of $72,000 in Medicare spending.

Dr. Mitchell studies industry influence in a variety of specialties and said rheumatology follows the universal pattern, although the drugs used in the specialty are more expensive than in many specialties.

He agrees with the authors that focusing on disclosures to address the problem is probably not enough.

“We’ve been in this period of full and open disclosure for going on 10 years, and we haven’t really seen a decline in these payments,” he said.
 

Results won’t surprise rheumatologists

Karen Onel, MD, a pediatric rheumatologist at the Hospital for Special Surgery, New York, and chair of the American College of Rheumatology’s Ethics and Conflict of Interest Committee, who said she was speaking only for herself and not on behalf of the committee, told this news organization that the study will not be surprising to rheumatologists or to physicians in other specialties who are aware of the plethora of studies that concluded that industry payments influence prescribing.*

Physicians are well aware of the problem, but “they all think it’s not them,” she said.

She said a shortcoming of this study is that it is unclear what the payments were for, because many things are lumped together in the categories. In the case of food and beverage payments, she said that could include payments physicians don’t realize are going on their open payments profile.

Dr. Onel gives a personal example. When she goes to a medical conference, she says, “I don’t eat on pharma’s dime.” But because badge numbers are scanned, it appears she accepted the food provided by the pharmaceutical sponsor when she enters a room where food or coffee is being served.

She said that although there are outliers like rACTH that often get highlighted, “the numbers are very low of the physicians who had [industry] money, and the change in prescribing patterns actually was very low.”

She pointed to an important limitation that the authors list: The study was limited to patients with fee-for-service Medicare coverage and did not include those with private insurance.

“For example, Aetna, Cigna, and UnitedHealthcare have restricted reimbursement for rACTH in recent years, citing its lack of proven efficacy and the availability of more affordable options, and rACTH is not in the Veterans Affairs formulary,” the authors wrote.
 

Rapid development of specialty drugs

Still, the authors wrote, the associations described in this article are of high interest because even though rheumatologists make up a small proportion of the physician workforce, they have among the highest costs per prescription in Medicare drug claims.

“Rheumatology, second only to oncology, has entered an era of rapid development of specialty drugs, including biologic disease-modifying antirheumatic drugs (DMARDs),” the authors wrote.

The complex drugs are expensive to produce and require expertise in handling. Most are under patent with no generic or approved biosimilar equivalent.

Nearly half of all U.S. rheumatologists received some payment from a pharmaceutical company in the study period, and most payments to rheumatologists were for low dollar amounts.

The highest per-year annual expenditures were attributed to etanercept ($741 million), adalimumab ($620 million), and infliximab ($539 million).

These drugs were expensive per beneficiary ($20,728 for etanercept, $21,492 for adalimumab, and $15,941 for infliximab) and were prescribed by a large number of rheumatologists (4,068, 3,872, and 1,349, respectively).

Addressing the problem

Dr. Mitchell says the leaders of individual societies need to fill the gaps that leave busy clinicians searching for easy ways to get up-to-date information on drugs.

He says in all specialties, “Industry should not be the most easily and readily available source of information.

“We’re in the age of Zoom now,” he said. “There’s no reason you have to be sitting for an hour at lunch with a sales rep and not a brown-bag lunch getting a 1-hour update from a society on a new drug indication.

“We will get higher-quality information if we’re doing the education ourselves, and we’d be removing the sense of obligation to pay back the industry gift givers,” Dr. Mitchell said.

Dr. Onel said among the most critical work is making sure that the leadership of ACR is free of conflicts of interest.

“They are making decisions for the entire organization. We need to feel safe and comfortable that they are acting in the best interest of the rheumatologists and patients versus corporate partners,” she said.

Guidelines must strictly follow the standards from the Institute of Medicine that fewer than 50% of the regular guideline committee members may have commercial conflicts, Dr. Onel said.

She added that training on real or apparent conflicts of interest must start in medical school, residency, and fellowship, before physicians start to think they know their own practice patterns and that the results don’t apply to them.

However, the reality is that the industry and physicians will always need each other, she said.

Dr. Onel describes a tension between rheumatologists needing industry’s help for research and education, especially when federal money for research can be difficult to get, and managing those relationships to avoid real or apparent conflicts.

“We want the public’s trust,” she said.

A study coauthor has served on advisory boards of Boehringer Ingelheim (> $10,000) and Gilead Sciences (> $10,000); has served on speakers bureaus for Simply Speaking (> $10,000) and Boehringer Ingelheim (< $10,000); and has received royalties from UpToDate (> $10,000). Dr. Mitchell and Dr. Onel reported no relevant financial relationships.

* Update, 2/25/22: This article, which originally attributed comments to Dr. Karen Onel personally, has been updated to further emphasize that these comments were not on behalf of the committee that she leads.

A version of this article first appeared on Medscape.com.

Payments to rheumatologists by pharmaceutical companies, whether through food and beverages or consulting fees, are linked with a higher likelihood of prescribing drugs and higher Medicare spending, according to a new study published Feb. 2 in Mayo Clinic Proceedings.

Alí Duarte-García, MD, of the division of rheumatology in the department of medicine at the Mayo Clinic in Rochester, Minn., led the study.

Courtesy Mayo Clinic

Researchers conducted a cross-sectional analysis of Medicare Part B Public Use File, Medicare Part D Public Use File, and Open Payments data for 2013-2015. They included prescription drugs that accounted for 80% of the total Medicare pharmaceutical expenditures in rheumatology.

They then calculated annual average drug cost per beneficiary per year, the percentage of rheumatologists who received payments, and the average payment per physician per drug per year. Industry payments were categorized as either food/beverage or consulting/compensation.

Multivariable regression models were used to assess links between industry payments, prescribing patterns, and prescription drug spending.
 

‘Directly associated’ with prescribing probability

The authors concluded that “pharmaceutical company payments to rheumatologists were directly associated with the probability of the physician’s prescribing a drug marketed by that company, the proportion of prescriptions that are for that drug, and the resulting Medicare expenditures.”

Thinkstock

The authors noted that food and beverage payments were associated with increased Medicare reimbursement amounts for all drugs except rituximab.

The article includes examples that help quantify the link between payments and prescribing.

The authors wrote that for each $100 in food/beverage payments, Medicare reimbursement increased 6% to 44%. The increases were particularly high for infliximab and rACTH (repository corticotropin injection), “whereby a payment of $100 to a prescriber of these drugs was associated with increases of approximately $72,000 and $30,000 in Medicare reimbursements, respectively. For most of the other drugs, for every $100 in payments, the Medicare reimbursement increased by $8,000 to $13,000.”

The associations were strongest for food and beverage payments even though those were for lower dollar amounts.

The researchers found that every $100 in food and beverage payments, which also include gifts, entertainment, or educational materials, was linked with more than twofold higher probability of prescribing and higher Medicare reimbursements than for every $1,000 paid in consulting fees and compensation.

That finding and findings from previous studies, they say, “suggest that the current approach to regulating industry influence, which focuses on disclosure of large payments, may be inadequate.”

Aaron P. Mitchell, MD, a medical oncologist and health services researcher with Memorial Sloan Kettering Cancer Center in New York, told this news organization that the findings regarding rACTH show the potential harm of industry payments that are linked with prescribing.

Memorial Sloan Kettering Cancer Center

The drug is a naturally produced hormone used for both rheumatologic and neurologic conditions. “Since it is an unpatentable drug – really just a hormone – it’s kind of grandfathered in and never had to get [Food and Drug Administration] approval for its current indications,” Dr. Mitchell said.

The drug, which costs nearly $230,000 per Medicare beneficiary, hasn’t been tested head to head in large randomized trials against much cheaper rheumatology drugs, such as prednisone.

In the case of infliximab, he noted, for every $100 in food/beverage payments, there was an increase of $72,000 in Medicare spending.

Dr. Mitchell studies industry influence in a variety of specialties and said rheumatology follows the universal pattern, although the drugs used in the specialty are more expensive than in many specialties.

He agrees with the authors that focusing on disclosures to address the problem is probably not enough.

“We’ve been in this period of full and open disclosure for going on 10 years, and we haven’t really seen a decline in these payments,” he said.
 

Results won’t surprise rheumatologists

Karen Onel, MD, a pediatric rheumatologist at the Hospital for Special Surgery, New York, and chair of the American College of Rheumatology’s Ethics and Conflict of Interest Committee, who said she was speaking only for herself and not on behalf of the committee, told this news organization that the study will not be surprising to rheumatologists or to physicians in other specialties who are aware of the plethora of studies that concluded that industry payments influence prescribing.*

Physicians are well aware of the problem, but “they all think it’s not them,” she said.

She said a shortcoming of this study is that it is unclear what the payments were for, because many things are lumped together in the categories. In the case of food and beverage payments, she said that could include payments physicians don’t realize are going on their open payments profile.

Dr. Onel gives a personal example. When she goes to a medical conference, she says, “I don’t eat on pharma’s dime.” But because badge numbers are scanned, it appears she accepted the food provided by the pharmaceutical sponsor when she enters a room where food or coffee is being served.

She said that although there are outliers like rACTH that often get highlighted, “the numbers are very low of the physicians who had [industry] money, and the change in prescribing patterns actually was very low.”

She pointed to an important limitation that the authors list: The study was limited to patients with fee-for-service Medicare coverage and did not include those with private insurance.

“For example, Aetna, Cigna, and UnitedHealthcare have restricted reimbursement for rACTH in recent years, citing its lack of proven efficacy and the availability of more affordable options, and rACTH is not in the Veterans Affairs formulary,” the authors wrote.
 

Rapid development of specialty drugs

Still, the authors wrote, the associations described in this article are of high interest because even though rheumatologists make up a small proportion of the physician workforce, they have among the highest costs per prescription in Medicare drug claims.

“Rheumatology, second only to oncology, has entered an era of rapid development of specialty drugs, including biologic disease-modifying antirheumatic drugs (DMARDs),” the authors wrote.

The complex drugs are expensive to produce and require expertise in handling. Most are under patent with no generic or approved biosimilar equivalent.

Nearly half of all U.S. rheumatologists received some payment from a pharmaceutical company in the study period, and most payments to rheumatologists were for low dollar amounts.

The highest per-year annual expenditures were attributed to etanercept ($741 million), adalimumab ($620 million), and infliximab ($539 million).

These drugs were expensive per beneficiary ($20,728 for etanercept, $21,492 for adalimumab, and $15,941 for infliximab) and were prescribed by a large number of rheumatologists (4,068, 3,872, and 1,349, respectively).

Addressing the problem

Dr. Mitchell says the leaders of individual societies need to fill the gaps that leave busy clinicians searching for easy ways to get up-to-date information on drugs.

He says in all specialties, “Industry should not be the most easily and readily available source of information.

“We’re in the age of Zoom now,” he said. “There’s no reason you have to be sitting for an hour at lunch with a sales rep and not a brown-bag lunch getting a 1-hour update from a society on a new drug indication.

“We will get higher-quality information if we’re doing the education ourselves, and we’d be removing the sense of obligation to pay back the industry gift givers,” Dr. Mitchell said.

Dr. Onel said among the most critical work is making sure that the leadership of ACR is free of conflicts of interest.

“They are making decisions for the entire organization. We need to feel safe and comfortable that they are acting in the best interest of the rheumatologists and patients versus corporate partners,” she said.

Guidelines must strictly follow the standards from the Institute of Medicine that fewer than 50% of the regular guideline committee members may have commercial conflicts, Dr. Onel said.

She added that training on real or apparent conflicts of interest must start in medical school, residency, and fellowship, before physicians start to think they know their own practice patterns and that the results don’t apply to them.

However, the reality is that the industry and physicians will always need each other, she said.

Dr. Onel describes a tension between rheumatologists needing industry’s help for research and education, especially when federal money for research can be difficult to get, and managing those relationships to avoid real or apparent conflicts.

“We want the public’s trust,” she said.

A study coauthor has served on advisory boards of Boehringer Ingelheim (> $10,000) and Gilead Sciences (> $10,000); has served on speakers bureaus for Simply Speaking (> $10,000) and Boehringer Ingelheim (< $10,000); and has received royalties from UpToDate (> $10,000). Dr. Mitchell and Dr. Onel reported no relevant financial relationships.

* Update, 2/25/22: This article, which originally attributed comments to Dr. Karen Onel personally, has been updated to further emphasize that these comments were not on behalf of the committee that she leads.

A version of this article first appeared on Medscape.com.

Payments to rheumatologists by pharmaceutical companies, whether through food and beverages or consulting fees, are linked with a higher likelihood of prescribing drugs and higher Medicare spending, according to a new study published Feb. 2 in Mayo Clinic Proceedings.

Alí Duarte-García, MD, of the division of rheumatology in the department of medicine at the Mayo Clinic in Rochester, Minn., led the study.

Courtesy Mayo Clinic

Researchers conducted a cross-sectional analysis of Medicare Part B Public Use File, Medicare Part D Public Use File, and Open Payments data for 2013-2015. They included prescription drugs that accounted for 80% of the total Medicare pharmaceutical expenditures in rheumatology.

They then calculated annual average drug cost per beneficiary per year, the percentage of rheumatologists who received payments, and the average payment per physician per drug per year. Industry payments were categorized as either food/beverage or consulting/compensation.

Multivariable regression models were used to assess links between industry payments, prescribing patterns, and prescription drug spending.
 

‘Directly associated’ with prescribing probability

The authors concluded that “pharmaceutical company payments to rheumatologists were directly associated with the probability of the physician’s prescribing a drug marketed by that company, the proportion of prescriptions that are for that drug, and the resulting Medicare expenditures.”

Thinkstock

The authors noted that food and beverage payments were associated with increased Medicare reimbursement amounts for all drugs except rituximab.

The article includes examples that help quantify the link between payments and prescribing.

The authors wrote that for each $100 in food/beverage payments, Medicare reimbursement increased 6% to 44%. The increases were particularly high for infliximab and rACTH (repository corticotropin injection), “whereby a payment of $100 to a prescriber of these drugs was associated with increases of approximately $72,000 and $30,000 in Medicare reimbursements, respectively. For most of the other drugs, for every $100 in payments, the Medicare reimbursement increased by $8,000 to $13,000.”

The associations were strongest for food and beverage payments even though those were for lower dollar amounts.

The researchers found that every $100 in food and beverage payments, which also include gifts, entertainment, or educational materials, was linked with more than twofold higher probability of prescribing and higher Medicare reimbursements than for every $1,000 paid in consulting fees and compensation.

That finding and findings from previous studies, they say, “suggest that the current approach to regulating industry influence, which focuses on disclosure of large payments, may be inadequate.”

Aaron P. Mitchell, MD, a medical oncologist and health services researcher with Memorial Sloan Kettering Cancer Center in New York, told this news organization that the findings regarding rACTH show the potential harm of industry payments that are linked with prescribing.

Memorial Sloan Kettering Cancer Center

The drug is a naturally produced hormone used for both rheumatologic and neurologic conditions. “Since it is an unpatentable drug – really just a hormone – it’s kind of grandfathered in and never had to get [Food and Drug Administration] approval for its current indications,” Dr. Mitchell said.

The drug, which costs nearly $230,000 per Medicare beneficiary, hasn’t been tested head to head in large randomized trials against much cheaper rheumatology drugs, such as prednisone.

In the case of infliximab, he noted, for every $100 in food/beverage payments, there was an increase of $72,000 in Medicare spending.

Dr. Mitchell studies industry influence in a variety of specialties and said rheumatology follows the universal pattern, although the drugs used in the specialty are more expensive than in many specialties.

He agrees with the authors that focusing on disclosures to address the problem is probably not enough.

“We’ve been in this period of full and open disclosure for going on 10 years, and we haven’t really seen a decline in these payments,” he said.
 

Results won’t surprise rheumatologists

Karen Onel, MD, a pediatric rheumatologist at the Hospital for Special Surgery, New York, and chair of the American College of Rheumatology’s Ethics and Conflict of Interest Committee, who said she was speaking only for herself and not on behalf of the committee, told this news organization that the study will not be surprising to rheumatologists or to physicians in other specialties who are aware of the plethora of studies that concluded that industry payments influence prescribing.*

Physicians are well aware of the problem, but “they all think it’s not them,” she said.

She said a shortcoming of this study is that it is unclear what the payments were for, because many things are lumped together in the categories. In the case of food and beverage payments, she said that could include payments physicians don’t realize are going on their open payments profile.

Dr. Onel gives a personal example. When she goes to a medical conference, she says, “I don’t eat on pharma’s dime.” But because badge numbers are scanned, it appears she accepted the food provided by the pharmaceutical sponsor when she enters a room where food or coffee is being served.

She said that although there are outliers like rACTH that often get highlighted, “the numbers are very low of the physicians who had [industry] money, and the change in prescribing patterns actually was very low.”

She pointed to an important limitation that the authors list: The study was limited to patients with fee-for-service Medicare coverage and did not include those with private insurance.

“For example, Aetna, Cigna, and UnitedHealthcare have restricted reimbursement for rACTH in recent years, citing its lack of proven efficacy and the availability of more affordable options, and rACTH is not in the Veterans Affairs formulary,” the authors wrote.
 

Rapid development of specialty drugs

Still, the authors wrote, the associations described in this article are of high interest because even though rheumatologists make up a small proportion of the physician workforce, they have among the highest costs per prescription in Medicare drug claims.

“Rheumatology, second only to oncology, has entered an era of rapid development of specialty drugs, including biologic disease-modifying antirheumatic drugs (DMARDs),” the authors wrote.

The complex drugs are expensive to produce and require expertise in handling. Most are under patent with no generic or approved biosimilar equivalent.

Nearly half of all U.S. rheumatologists received some payment from a pharmaceutical company in the study period, and most payments to rheumatologists were for low dollar amounts.

The highest per-year annual expenditures were attributed to etanercept ($741 million), adalimumab ($620 million), and infliximab ($539 million).

These drugs were expensive per beneficiary ($20,728 for etanercept, $21,492 for adalimumab, and $15,941 for infliximab) and were prescribed by a large number of rheumatologists (4,068, 3,872, and 1,349, respectively).

Addressing the problem

Dr. Mitchell says the leaders of individual societies need to fill the gaps that leave busy clinicians searching for easy ways to get up-to-date information on drugs.

He says in all specialties, “Industry should not be the most easily and readily available source of information.

“We’re in the age of Zoom now,” he said. “There’s no reason you have to be sitting for an hour at lunch with a sales rep and not a brown-bag lunch getting a 1-hour update from a society on a new drug indication.

“We will get higher-quality information if we’re doing the education ourselves, and we’d be removing the sense of obligation to pay back the industry gift givers,” Dr. Mitchell said.

Dr. Onel said among the most critical work is making sure that the leadership of ACR is free of conflicts of interest.

“They are making decisions for the entire organization. We need to feel safe and comfortable that they are acting in the best interest of the rheumatologists and patients versus corporate partners,” she said.

Guidelines must strictly follow the standards from the Institute of Medicine that fewer than 50% of the regular guideline committee members may have commercial conflicts, Dr. Onel said.

She added that training on real or apparent conflicts of interest must start in medical school, residency, and fellowship, before physicians start to think they know their own practice patterns and that the results don’t apply to them.

However, the reality is that the industry and physicians will always need each other, she said.

Dr. Onel describes a tension between rheumatologists needing industry’s help for research and education, especially when federal money for research can be difficult to get, and managing those relationships to avoid real or apparent conflicts.

“We want the public’s trust,” she said.

A study coauthor has served on advisory boards of Boehringer Ingelheim (> $10,000) and Gilead Sciences (> $10,000); has served on speakers bureaus for Simply Speaking (> $10,000) and Boehringer Ingelheim (< $10,000); and has received royalties from UpToDate (> $10,000). Dr. Mitchell and Dr. Onel reported no relevant financial relationships.

* Update, 2/25/22: This article, which originally attributed comments to Dr. Karen Onel personally, has been updated to further emphasize that these comments were not on behalf of the committee that she leads.

A version of this article first appeared on Medscape.com.

Have you experienced malpractice?

No, I’m not asking whether you have experienced litigation. I’m asking whether you, as a physician, have actually experienced substandard care from a colleague. I have heard many such experiences over the years, and mistreatment doesn’t seem to be getting any less frequent.

It seems to me that physicians may be especially prone to receiving substandard care. If true, there could be several explanations. The first is that, unlike the Pope, who has a dedicated confessor trained to minister to his spiritual needs, no one formally trains physicians to treat physicians. As a result, most of us feel slightly uneasy at treating other physicians. We naturally wish to keep our colleagues well, but at the same time realize that our clinical skills are being very closely scrutinized. What if they are found to be wanting? This discomfiture can make a physician treating a physician overly compulsive, or worse, overtly dismissive.

Second, we physicians are famously poor patients. We pretend we don’t need the advice we give others, to monitor our health and promptly seek care when something feels amiss. And, for the period during which we delay a medical encounter, we often attempt to diagnose and treat ourselves.

Sometimes we are successful, which reinforces this approach. Other times, we fail at being our own caregiver and present to someone else either too late, or with avoidable complications. In the former instance, we congratulate ourselves and learn nothing from the experience. In the latter, we may heap shame upon ourselves for our folly, and we may learn; but it could be a lethal lesson. In the worst scenario, our colleague gives in to frustration (or angst), and heaps even more shame onto their late-presenting physician patient.

Third, when we do submit to being a patient, we often demand VIP treatment. This is probably in response to our anxiety that some of the worst things we have seen happen to patients might happen to us if we are not vigilant to ensure we receive a higher level of care. But of course, such hypervigilance can lead to excessive care and testing, with all the attendant hazards, or alternatively to dilution of care if our caregivers decide we are just too much trouble.

Fourth, as a fifth-generation physician myself, I am convinced that physicians and physician family members are either prone to unusual manifestations of common diseases or unusual diseases, or that rare disease entities and complications are actually more common than literature suggests, and they simply aren’t pursued or diagnosed in nonphysician families.

No matter how we may have arrived in a position to need medical care, how often is such care substandard? And how do we respond when we suspect, or know, this to be the case? Are physicians more, or less, likely to take legal action in the face of it?

I certainly don’t know any statistics. Physicians are in an excellent position to take such action, because judges and juries will likely believe that a doctor can recognize negligence when we fall victim to it. But we may also be reluctant to publicly admit the way (or ways) in which we may have contributed to substandard care or outcome.

Based on decades of working with physician clients who have been sued, and having been sued myself (thus witnessing and also experiencing the effects of litigation), I am probably more reluctant than normal patients or physicians to consider taking legal action. This, despite the fact that I am also a lawyer and (through organized medicine) know many colleagues in all specialties who might serve as expert witnesses.

I have experienced serial substandard care, which has left me highly conflicted about the efficacy of my chosen profession. As a resident, I had my first odd pain condition and consulted an “elder statesperson” from my institution, whom I assumed to be a “doctor’s doctor” because he was a superb teacher (wrong!)

He completely missed the diagnosis and further belittled (indeed, libeled) me in the medical record. (Some years later, I learned that, during that period, he was increasingly demented and tended to view all female patients as having “wandering uterus” equivalents.) Fortunately, I found a better diagnostician, or at least one more willing to lend credence to my complaints, who successfully removed the first of several “zebra” lesions I have experienced.

As a young faculty member, I had an odd presentation of a recurring gynecologic condition, which was treated surgically, successfully, except that my fertility was cut in half – a possibility about which I had not been informed when giving operative consent. Would I have sued this fellow faculty member for that? Never, because she invariably treated me with respect as a colleague.

Later in my career after leaving academia, the same condition recurred in a new location. My old-school gynecologist desired to do an extensive procedure, to which I demurred unless specific pathology was found intraoperatively. Affronted, he subjected me to laparoscopy, did nothing but look, and then left the hospital leaving me and the PACU nurse to try to decipher his instructions (which said, basically, “I didn’t find anything; don’t bother me again.”). Several years of pain later, a younger gynecologist performed the correct procedure to address my problem, which has never recurred. Would I have sued him? No, because I believe he had a disability.

At age 59, I developed a new mole. My beloved general practitioner, in the waning years of his practice, forgot to consult a colleague to remove it for several months. When I forced the issue, the mole was removed and turned out to be a rare pediatric condition considered a precursor to melanoma. The same general practitioner had told me I needn’t worry about my “mild hypercalcemia.”

Ten years later I diagnosed my own parathyroid adenoma, in the interim losing 10% of my bone density. Would I have sued him? No, for he always showed he cared. (Though maybe, if I had fractured my spine or hip.)

If you have been the victim of physician malpractice, how did you respond?

Do we serve our profession well by how we handle substandard care – upon ourselves (or our loved ones)?

Dr. Andrew is a former assistant professor in the department of emergency medicine, Johns Hopkins University, Baltimore, and founder and principal of MDMentor, Victoria, B.C.

A version of this article first appeared on Medscape.com.

Have you experienced malpractice?

No, I’m not asking whether you have experienced litigation. I’m asking whether you, as a physician, have actually experienced substandard care from a colleague. I have heard many such experiences over the years, and mistreatment doesn’t seem to be getting any less frequent.

It seems to me that physicians may be especially prone to receiving substandard care. If true, there could be several explanations. The first is that, unlike the Pope, who has a dedicated confessor trained to minister to his spiritual needs, no one formally trains physicians to treat physicians. As a result, most of us feel slightly uneasy at treating other physicians. We naturally wish to keep our colleagues well, but at the same time realize that our clinical skills are being very closely scrutinized. What if they are found to be wanting? This discomfiture can make a physician treating a physician overly compulsive, or worse, overtly dismissive.

Second, we physicians are famously poor patients. We pretend we don’t need the advice we give others, to monitor our health and promptly seek care when something feels amiss. And, for the period during which we delay a medical encounter, we often attempt to diagnose and treat ourselves.

Sometimes we are successful, which reinforces this approach. Other times, we fail at being our own caregiver and present to someone else either too late, or with avoidable complications. In the former instance, we congratulate ourselves and learn nothing from the experience. In the latter, we may heap shame upon ourselves for our folly, and we may learn; but it could be a lethal lesson. In the worst scenario, our colleague gives in to frustration (or angst), and heaps even more shame onto their late-presenting physician patient.

Third, when we do submit to being a patient, we often demand VIP treatment. This is probably in response to our anxiety that some of the worst things we have seen happen to patients might happen to us if we are not vigilant to ensure we receive a higher level of care. But of course, such hypervigilance can lead to excessive care and testing, with all the attendant hazards, or alternatively to dilution of care if our caregivers decide we are just too much trouble.

Fourth, as a fifth-generation physician myself, I am convinced that physicians and physician family members are either prone to unusual manifestations of common diseases or unusual diseases, or that rare disease entities and complications are actually more common than literature suggests, and they simply aren’t pursued or diagnosed in nonphysician families.

No matter how we may have arrived in a position to need medical care, how often is such care substandard? And how do we respond when we suspect, or know, this to be the case? Are physicians more, or less, likely to take legal action in the face of it?

I certainly don’t know any statistics. Physicians are in an excellent position to take such action, because judges and juries will likely believe that a doctor can recognize negligence when we fall victim to it. But we may also be reluctant to publicly admit the way (or ways) in which we may have contributed to substandard care or outcome.

Based on decades of working with physician clients who have been sued, and having been sued myself (thus witnessing and also experiencing the effects of litigation), I am probably more reluctant than normal patients or physicians to consider taking legal action. This, despite the fact that I am also a lawyer and (through organized medicine) know many colleagues in all specialties who might serve as expert witnesses.

I have experienced serial substandard care, which has left me highly conflicted about the efficacy of my chosen profession. As a resident, I had my first odd pain condition and consulted an “elder statesperson” from my institution, whom I assumed to be a “doctor’s doctor” because he was a superb teacher (wrong!)

He completely missed the diagnosis and further belittled (indeed, libeled) me in the medical record. (Some years later, I learned that, during that period, he was increasingly demented and tended to view all female patients as having “wandering uterus” equivalents.) Fortunately, I found a better diagnostician, or at least one more willing to lend credence to my complaints, who successfully removed the first of several “zebra” lesions I have experienced.

As a young faculty member, I had an odd presentation of a recurring gynecologic condition, which was treated surgically, successfully, except that my fertility was cut in half – a possibility about which I had not been informed when giving operative consent. Would I have sued this fellow faculty member for that? Never, because she invariably treated me with respect as a colleague.

Later in my career after leaving academia, the same condition recurred in a new location. My old-school gynecologist desired to do an extensive procedure, to which I demurred unless specific pathology was found intraoperatively. Affronted, he subjected me to laparoscopy, did nothing but look, and then left the hospital leaving me and the PACU nurse to try to decipher his instructions (which said, basically, “I didn’t find anything; don’t bother me again.”). Several years of pain later, a younger gynecologist performed the correct procedure to address my problem, which has never recurred. Would I have sued him? No, because I believe he had a disability.

At age 59, I developed a new mole. My beloved general practitioner, in the waning years of his practice, forgot to consult a colleague to remove it for several months. When I forced the issue, the mole was removed and turned out to be a rare pediatric condition considered a precursor to melanoma. The same general practitioner had told me I needn’t worry about my “mild hypercalcemia.”

Ten years later I diagnosed my own parathyroid adenoma, in the interim losing 10% of my bone density. Would I have sued him? No, for he always showed he cared. (Though maybe, if I had fractured my spine or hip.)

If you have been the victim of physician malpractice, how did you respond?

Do we serve our profession well by how we handle substandard care – upon ourselves (or our loved ones)?

Dr. Andrew is a former assistant professor in the department of emergency medicine, Johns Hopkins University, Baltimore, and founder and principal of MDMentor, Victoria, B.C.

A version of this article first appeared on Medscape.com.

Have you experienced malpractice?

No, I’m not asking whether you have experienced litigation. I’m asking whether you, as a physician, have actually experienced substandard care from a colleague. I have heard many such experiences over the years, and mistreatment doesn’t seem to be getting any less frequent.

It seems to me that physicians may be especially prone to receiving substandard care. If true, there could be several explanations. The first is that, unlike the Pope, who has a dedicated confessor trained to minister to his spiritual needs, no one formally trains physicians to treat physicians. As a result, most of us feel slightly uneasy at treating other physicians. We naturally wish to keep our colleagues well, but at the same time realize that our clinical skills are being very closely scrutinized. What if they are found to be wanting? This discomfiture can make a physician treating a physician overly compulsive, or worse, overtly dismissive.

Second, we physicians are famously poor patients. We pretend we don’t need the advice we give others, to monitor our health and promptly seek care when something feels amiss. And, for the period during which we delay a medical encounter, we often attempt to diagnose and treat ourselves.

Sometimes we are successful, which reinforces this approach. Other times, we fail at being our own caregiver and present to someone else either too late, or with avoidable complications. In the former instance, we congratulate ourselves and learn nothing from the experience. In the latter, we may heap shame upon ourselves for our folly, and we may learn; but it could be a lethal lesson. In the worst scenario, our colleague gives in to frustration (or angst), and heaps even more shame onto their late-presenting physician patient.

Third, when we do submit to being a patient, we often demand VIP treatment. This is probably in response to our anxiety that some of the worst things we have seen happen to patients might happen to us if we are not vigilant to ensure we receive a higher level of care. But of course, such hypervigilance can lead to excessive care and testing, with all the attendant hazards, or alternatively to dilution of care if our caregivers decide we are just too much trouble.

Fourth, as a fifth-generation physician myself, I am convinced that physicians and physician family members are either prone to unusual manifestations of common diseases or unusual diseases, or that rare disease entities and complications are actually more common than literature suggests, and they simply aren’t pursued or diagnosed in nonphysician families.

No matter how we may have arrived in a position to need medical care, how often is such care substandard? And how do we respond when we suspect, or know, this to be the case? Are physicians more, or less, likely to take legal action in the face of it?

I certainly don’t know any statistics. Physicians are in an excellent position to take such action, because judges and juries will likely believe that a doctor can recognize negligence when we fall victim to it. But we may also be reluctant to publicly admit the way (or ways) in which we may have contributed to substandard care or outcome.

Based on decades of working with physician clients who have been sued, and having been sued myself (thus witnessing and also experiencing the effects of litigation), I am probably more reluctant than normal patients or physicians to consider taking legal action. This, despite the fact that I am also a lawyer and (through organized medicine) know many colleagues in all specialties who might serve as expert witnesses.

I have experienced serial substandard care, which has left me highly conflicted about the efficacy of my chosen profession. As a resident, I had my first odd pain condition and consulted an “elder statesperson” from my institution, whom I assumed to be a “doctor’s doctor” because he was a superb teacher (wrong!)

He completely missed the diagnosis and further belittled (indeed, libeled) me in the medical record. (Some years later, I learned that, during that period, he was increasingly demented and tended to view all female patients as having “wandering uterus” equivalents.) Fortunately, I found a better diagnostician, or at least one more willing to lend credence to my complaints, who successfully removed the first of several “zebra” lesions I have experienced.

As a young faculty member, I had an odd presentation of a recurring gynecologic condition, which was treated surgically, successfully, except that my fertility was cut in half – a possibility about which I had not been informed when giving operative consent. Would I have sued this fellow faculty member for that? Never, because she invariably treated me with respect as a colleague.

Later in my career after leaving academia, the same condition recurred in a new location. My old-school gynecologist desired to do an extensive procedure, to which I demurred unless specific pathology was found intraoperatively. Affronted, he subjected me to laparoscopy, did nothing but look, and then left the hospital leaving me and the PACU nurse to try to decipher his instructions (which said, basically, “I didn’t find anything; don’t bother me again.”). Several years of pain later, a younger gynecologist performed the correct procedure to address my problem, which has never recurred. Would I have sued him? No, because I believe he had a disability.

At age 59, I developed a new mole. My beloved general practitioner, in the waning years of his practice, forgot to consult a colleague to remove it for several months. When I forced the issue, the mole was removed and turned out to be a rare pediatric condition considered a precursor to melanoma. The same general practitioner had told me I needn’t worry about my “mild hypercalcemia.”

Ten years later I diagnosed my own parathyroid adenoma, in the interim losing 10% of my bone density. Would I have sued him? No, for he always showed he cared. (Though maybe, if I had fractured my spine or hip.)

If you have been the victim of physician malpractice, how did you respond?

Do we serve our profession well by how we handle substandard care – upon ourselves (or our loved ones)?

Dr. Andrew is a former assistant professor in the department of emergency medicine, Johns Hopkins University, Baltimore, and founder and principal of MDMentor, Victoria, B.C.

A version of this article first appeared on Medscape.com.

Although there is a lack of evidence for use of cannabidiol (CBD) products and cannabis in rheumatology, many patients are using them anyway and want to discuss the use of these products with their rheumatologists, according to a speaker at the 2022 Rheumatology Winter Clinical Symposium.

While cannabis is still regulated as a Schedule I drug in the United States, CBD products are “all over the place,” Orrin Troum, MD, a rheumatologist at the University of Southern California, Los Angeles, said in his presentation. “You can get it at the pharmacy; you can get it at the dispensaries.”

Patients in rheumatology are also increasingly using cannabis across the United States, Dr. Troum said. In an abstract from the 2019 American College of Rheumatology annual meeting, researchers examined data from FORWARD, the National Databank for Rheumatic Diseases, and found 17.6% of 11,006 respondents reported using cannabis in 2017, an increase from 6.3% of respondents in 2014.

“Putting your personal biases aside, you have to be able to discuss this, and I try to do that openly with my patients,” he said.

According to a 2018 report from the World Health Organization, CBD is “generally well tolerated with a good safety profile.” While CBD itself is safe, CBD products offered over the counter as pills, lotions, foods, drinks, shampoos, cosmetics, oils, and other products carry the risk of being manufactured with “unverified contents” because they are not subject to regulatory oversight.

“There may be heavy metals, pesticides, microbes, [and] mycotoxins that are in these substances that you’re recommending to patients,” Dr. Troum said. There may also be tetrahydrocannabinol (THC) in certain CBD products, he added. Other concerns about CBD products include potential drug-drug interactions with medications used in rheumatology, and potential inhibition of drug metabolism through the CYP450 pathway.

Rheumatologists should be careful when recommending CBD products for this reason, Dr. Troum cautioned. In the absence of products approved by the Food and Drug Administration, “try to get at least products that have a good manufacturing practices certification.”

RWCS 2022 screenshot

Dr. Troum highlighted the additional problem of dispensaries recommending specific products, and emphasized that treatment shouldn’t be managed by dispensary personnel without a medical background. “Our patients are being promoted this, either from the dispensaries or even in some clinicians’ offices, without the real true knowledge as to what we’re dealing with,” he said.
 

Evidence of health effects of CBD, cannabis

When it comes to actual evidence of clinical benefit, “I can tell you there’s lacking data for the majority of what we’re being asked every day in our practices,” Dr. Troum said.

The greatest evidence for the health benefits of cannabinoids appears to be for chronic pain, according to a 2017 report from the National Academies of Sciences, Engineering, and Medicine. Within rheumatology, a position statement released by the Canadian Rheumatology Association in 2019 found insufficient evidence to recommend cannabinoids for use in fibromyalgia, osteoarthritis, RA, or back pain, but acknowledged medical cannabis may relieve symptoms based on evidence from other conditions.

There is some preliminary evidence that cannabis can be used as a substitute for opioids when treating chronic pain, to improve symptoms of fibromyalgia and inflammatory bowel disease, and although a trial of patients with Crohn’s disease failed its primary outcome of disease remission, 10 of 11 patients who smoked cigarettes with THC saw significant improvements in clinical outcomes (P = .028).

In RA, “clinical research focusing on the cannabinoids’ disease-modifying qualities is still lacking,” Dr. Troum said, although an active randomized, controlled trial led by researchers at the University of California, Los Angeles, is testing patients for clinical response to CBD. A separate randomized, double-blind, placebo-controlled trial in Denmark is evaluating whether CBD, followed by open-label add-on of THC, improves chronic pain for patients with RA or ankylosing spondylitis.

The lack of data in this area largely has to do with how cannabis is regulated at the federal level and the differing regulations between U.S. states. “There’s a lot of hurdles you have to go through, and therefore, I think, really has decreased the availability of good studies,” he said.

Overarching principles for medical cannabis in rheumatology

For the rheumatologist counseling a patient who either is self-medicating or wants to start using medical cannabis, the Canadian Rheumatology Association created overarching principles as part of their position statement to guide decision-making for clinicians.

First, clinicians should know that cannabis shouldn’t be used as an alternative treatment for standard of care in rheumatology, and the CRA noted that patients aged under 25 years should not use cannabis. CRA also recommended that clinicians try currently available treatment strategies for common reasons patients seek to use medical cannabis, such as pain relief or a sleep aid, before attempting to use medical cannabis. The CRA noted long-term effects of medical cannabis are not known for patients with rheumatic diseases.

In an interview, Arthur Kavanaugh, MD, professor of medicine at the University of California, San Diego, and director of RWCS, said that CBD and cannabis “come up quite frequently” at his clinic. “Many patients have already tried CBD, especially the topical formulation, prior to discussing it with me. In general, I do not dissuade patients from trying CBD, especially topical.”

Typically, he said his practice situation gives him access to a counselor from the anesthesia department with “significant expertise” in dosing and formulations. “It would be great if there were proper controlled trials of specific formulations to allow us to have real scientific data that may help the patients make optimal choices.”

One issue that is brought up by patients is cost. “These preparations can be relatively expensive,” Dr. Kavanaugh said, but noted that this is also a consideration when patients decide to use any therapy.

Dr. Troum reported having financial relationships with eight pharmaceutical companies.

Although there is a lack of evidence for use of cannabidiol (CBD) products and cannabis in rheumatology, many patients are using them anyway and want to discuss the use of these products with their rheumatologists, according to a speaker at the 2022 Rheumatology Winter Clinical Symposium.

While cannabis is still regulated as a Schedule I drug in the United States, CBD products are “all over the place,” Orrin Troum, MD, a rheumatologist at the University of Southern California, Los Angeles, said in his presentation. “You can get it at the pharmacy; you can get it at the dispensaries.”

Patients in rheumatology are also increasingly using cannabis across the United States, Dr. Troum said. In an abstract from the 2019 American College of Rheumatology annual meeting, researchers examined data from FORWARD, the National Databank for Rheumatic Diseases, and found 17.6% of 11,006 respondents reported using cannabis in 2017, an increase from 6.3% of respondents in 2014.

“Putting your personal biases aside, you have to be able to discuss this, and I try to do that openly with my patients,” he said.

According to a 2018 report from the World Health Organization, CBD is “generally well tolerated with a good safety profile.” While CBD itself is safe, CBD products offered over the counter as pills, lotions, foods, drinks, shampoos, cosmetics, oils, and other products carry the risk of being manufactured with “unverified contents” because they are not subject to regulatory oversight.

“There may be heavy metals, pesticides, microbes, [and] mycotoxins that are in these substances that you’re recommending to patients,” Dr. Troum said. There may also be tetrahydrocannabinol (THC) in certain CBD products, he added. Other concerns about CBD products include potential drug-drug interactions with medications used in rheumatology, and potential inhibition of drug metabolism through the CYP450 pathway.

Rheumatologists should be careful when recommending CBD products for this reason, Dr. Troum cautioned. In the absence of products approved by the Food and Drug Administration, “try to get at least products that have a good manufacturing practices certification.”

RWCS 2022 screenshot

Dr. Troum highlighted the additional problem of dispensaries recommending specific products, and emphasized that treatment shouldn’t be managed by dispensary personnel without a medical background. “Our patients are being promoted this, either from the dispensaries or even in some clinicians’ offices, without the real true knowledge as to what we’re dealing with,” he said.
 

Evidence of health effects of CBD, cannabis

When it comes to actual evidence of clinical benefit, “I can tell you there’s lacking data for the majority of what we’re being asked every day in our practices,” Dr. Troum said.

The greatest evidence for the health benefits of cannabinoids appears to be for chronic pain, according to a 2017 report from the National Academies of Sciences, Engineering, and Medicine. Within rheumatology, a position statement released by the Canadian Rheumatology Association in 2019 found insufficient evidence to recommend cannabinoids for use in fibromyalgia, osteoarthritis, RA, or back pain, but acknowledged medical cannabis may relieve symptoms based on evidence from other conditions.

There is some preliminary evidence that cannabis can be used as a substitute for opioids when treating chronic pain, to improve symptoms of fibromyalgia and inflammatory bowel disease, and although a trial of patients with Crohn’s disease failed its primary outcome of disease remission, 10 of 11 patients who smoked cigarettes with THC saw significant improvements in clinical outcomes (P = .028).

In RA, “clinical research focusing on the cannabinoids’ disease-modifying qualities is still lacking,” Dr. Troum said, although an active randomized, controlled trial led by researchers at the University of California, Los Angeles, is testing patients for clinical response to CBD. A separate randomized, double-blind, placebo-controlled trial in Denmark is evaluating whether CBD, followed by open-label add-on of THC, improves chronic pain for patients with RA or ankylosing spondylitis.

The lack of data in this area largely has to do with how cannabis is regulated at the federal level and the differing regulations between U.S. states. “There’s a lot of hurdles you have to go through, and therefore, I think, really has decreased the availability of good studies,” he said.

Overarching principles for medical cannabis in rheumatology

For the rheumatologist counseling a patient who either is self-medicating or wants to start using medical cannabis, the Canadian Rheumatology Association created overarching principles as part of their position statement to guide decision-making for clinicians.

First, clinicians should know that cannabis shouldn’t be used as an alternative treatment for standard of care in rheumatology, and the CRA noted that patients aged under 25 years should not use cannabis. CRA also recommended that clinicians try currently available treatment strategies for common reasons patients seek to use medical cannabis, such as pain relief or a sleep aid, before attempting to use medical cannabis. The CRA noted long-term effects of medical cannabis are not known for patients with rheumatic diseases.

In an interview, Arthur Kavanaugh, MD, professor of medicine at the University of California, San Diego, and director of RWCS, said that CBD and cannabis “come up quite frequently” at his clinic. “Many patients have already tried CBD, especially the topical formulation, prior to discussing it with me. In general, I do not dissuade patients from trying CBD, especially topical.”

Typically, he said his practice situation gives him access to a counselor from the anesthesia department with “significant expertise” in dosing and formulations. “It would be great if there were proper controlled trials of specific formulations to allow us to have real scientific data that may help the patients make optimal choices.”

One issue that is brought up by patients is cost. “These preparations can be relatively expensive,” Dr. Kavanaugh said, but noted that this is also a consideration when patients decide to use any therapy.

Dr. Troum reported having financial relationships with eight pharmaceutical companies.

Although there is a lack of evidence for use of cannabidiol (CBD) products and cannabis in rheumatology, many patients are using them anyway and want to discuss the use of these products with their rheumatologists, according to a speaker at the 2022 Rheumatology Winter Clinical Symposium.

While cannabis is still regulated as a Schedule I drug in the United States, CBD products are “all over the place,” Orrin Troum, MD, a rheumatologist at the University of Southern California, Los Angeles, said in his presentation. “You can get it at the pharmacy; you can get it at the dispensaries.”

Patients in rheumatology are also increasingly using cannabis across the United States, Dr. Troum said. In an abstract from the 2019 American College of Rheumatology annual meeting, researchers examined data from FORWARD, the National Databank for Rheumatic Diseases, and found 17.6% of 11,006 respondents reported using cannabis in 2017, an increase from 6.3% of respondents in 2014.

“Putting your personal biases aside, you have to be able to discuss this, and I try to do that openly with my patients,” he said.

According to a 2018 report from the World Health Organization, CBD is “generally well tolerated with a good safety profile.” While CBD itself is safe, CBD products offered over the counter as pills, lotions, foods, drinks, shampoos, cosmetics, oils, and other products carry the risk of being manufactured with “unverified contents” because they are not subject to regulatory oversight.

“There may be heavy metals, pesticides, microbes, [and] mycotoxins that are in these substances that you’re recommending to patients,” Dr. Troum said. There may also be tetrahydrocannabinol (THC) in certain CBD products, he added. Other concerns about CBD products include potential drug-drug interactions with medications used in rheumatology, and potential inhibition of drug metabolism through the CYP450 pathway.

Rheumatologists should be careful when recommending CBD products for this reason, Dr. Troum cautioned. In the absence of products approved by the Food and Drug Administration, “try to get at least products that have a good manufacturing practices certification.”

RWCS 2022 screenshot

Dr. Troum highlighted the additional problem of dispensaries recommending specific products, and emphasized that treatment shouldn’t be managed by dispensary personnel without a medical background. “Our patients are being promoted this, either from the dispensaries or even in some clinicians’ offices, without the real true knowledge as to what we’re dealing with,” he said.
 

Evidence of health effects of CBD, cannabis

When it comes to actual evidence of clinical benefit, “I can tell you there’s lacking data for the majority of what we’re being asked every day in our practices,” Dr. Troum said.

The greatest evidence for the health benefits of cannabinoids appears to be for chronic pain, according to a 2017 report from the National Academies of Sciences, Engineering, and Medicine. Within rheumatology, a position statement released by the Canadian Rheumatology Association in 2019 found insufficient evidence to recommend cannabinoids for use in fibromyalgia, osteoarthritis, RA, or back pain, but acknowledged medical cannabis may relieve symptoms based on evidence from other conditions.

There is some preliminary evidence that cannabis can be used as a substitute for opioids when treating chronic pain, to improve symptoms of fibromyalgia and inflammatory bowel disease, and although a trial of patients with Crohn’s disease failed its primary outcome of disease remission, 10 of 11 patients who smoked cigarettes with THC saw significant improvements in clinical outcomes (P = .028).

In RA, “clinical research focusing on the cannabinoids’ disease-modifying qualities is still lacking,” Dr. Troum said, although an active randomized, controlled trial led by researchers at the University of California, Los Angeles, is testing patients for clinical response to CBD. A separate randomized, double-blind, placebo-controlled trial in Denmark is evaluating whether CBD, followed by open-label add-on of THC, improves chronic pain for patients with RA or ankylosing spondylitis.

The lack of data in this area largely has to do with how cannabis is regulated at the federal level and the differing regulations between U.S. states. “There’s a lot of hurdles you have to go through, and therefore, I think, really has decreased the availability of good studies,” he said.

Overarching principles for medical cannabis in rheumatology

For the rheumatologist counseling a patient who either is self-medicating or wants to start using medical cannabis, the Canadian Rheumatology Association created overarching principles as part of their position statement to guide decision-making for clinicians.

First, clinicians should know that cannabis shouldn’t be used as an alternative treatment for standard of care in rheumatology, and the CRA noted that patients aged under 25 years should not use cannabis. CRA also recommended that clinicians try currently available treatment strategies for common reasons patients seek to use medical cannabis, such as pain relief or a sleep aid, before attempting to use medical cannabis. The CRA noted long-term effects of medical cannabis are not known for patients with rheumatic diseases.

In an interview, Arthur Kavanaugh, MD, professor of medicine at the University of California, San Diego, and director of RWCS, said that CBD and cannabis “come up quite frequently” at his clinic. “Many patients have already tried CBD, especially the topical formulation, prior to discussing it with me. In general, I do not dissuade patients from trying CBD, especially topical.”

Typically, he said his practice situation gives him access to a counselor from the anesthesia department with “significant expertise” in dosing and formulations. “It would be great if there were proper controlled trials of specific formulations to allow us to have real scientific data that may help the patients make optimal choices.”

One issue that is brought up by patients is cost. “These preparations can be relatively expensive,” Dr. Kavanaugh said, but noted that this is also a consideration when patients decide to use any therapy.

Dr. Troum reported having financial relationships with eight pharmaceutical companies.

New recommendations from the European Alliance of Associations for Rheumatology provide both broad and detailed advice for cardiovascular risk management in various rheumatic and musculoskeletal diseases (RMDs), many of which can lead to an increased possibility of cardiovascular disease (CVD).

“The panel believes that these recommendations will enable health care providers and patients to mutually engage in a long-term care pathway tailored to patients’ needs and expectations for improving cardiovascular health in RMDs,” write George C. Drosos, National and Kapodistrian University of Athens, and colleagues. The recommendations were published in February in Annals of the Rheumatic Diseases).

EULAR assembled a task force to generate best practices for preventing CVD in patients with gout, vasculitis, systemic sclerosis (SSc), myositis, mixed connective tissue disease (MCTD), Sjögren syndrome (SS), systemic lupus erythematosus (SLE), and antiphospholipid syndrome (APS).

The cardiovascular risk management of patients with rheumatoid arthritis, ankylosing spondylitis, and psoriatic arthritis was covered in prior EULAR recommendations.

The task force included 20 members from 11 European countries, including 12 rheumatologists, 2 cardiologists, 1 metabolic medicine physician, 1 health care professional, 2 patient representatives, and 2 EMEUNET (Emerging EULAR Network) members. One group of task force members conducted a systematic literature review of 105 articles about gout, vasculitis, SSc, myositis, MCTD, and SS, and another group evaluated 75 articles about SLE and APS. Together, they decided on four overarching principles:

Clinicians need to be aware of increased cardiovascular risk in patients with RMDs, with disease reduction likely decreasing risk.

Rheumatologists – in tandem with other health care providers – are responsible for their patients’ cardiovascular risk assessment and management.

Screening for cardiovascular risk should be performed regularly in all patients with RMDs, with an emphasis on factors like smoking and blood pressure management.

Patient education and counseling on cardiovascular risk, including important lifestyle modifications, is key for RMD patients.

Specific recommendations from the gout, vasculitis, SSc, myositis, MCTD, and SS group include deploying existing cardiovascular prediction tools as they are used in the general population, with the European Vasculitis Society model suggesting to supplement the Framingham Risk Score for patients with antineutrophil cytoplasmic antibody–associated vasculitis. They also recommended avoiding diuretics in patients with gout and beta-blockers in patients with SSc, as well as following the same blood pressure and lipid management strategies that are used among the general population.

Recommendations from the SLE and APS group include thoroughly assessing traditional cardiovascular risk factors in all patients, following typical blood pressure management strategies in patients with APS, and setting a blood pressure target of less than 130/80 mm Hg in patients with SLE. They also recommended administering the lowest possible glucocorticoid dose in patients with SLE, along with treatment with hydroxychloroquine – unless contraindicated – and even common preventive strategies like low-dose aspirin if it suits their cardiovascular risk profile.

As for next steps, the task force noted several areas where additional focus is needed, such as identifying patient subgroups with increased cardiovascular risk. This could include patients with a longer disease duration or more flare-ups, older patients, and those with certain disease characteristics like antiphospholipid positivity in SLE.

Can EULAR’s recommendations be implemented in U.S. rheumatology practices?

“We have been hearing for years that patients with rheumatic diseases have an increased risk of cardiovascular disease,” Ali A. Duarte Garcia, MD, a rheumatologist at the Mayo Clinic in Rochester, Minn., told this news organization. “That has been consistently published for more than a decade now. But any further guidance about it has not been issued. I think there was a void there.”

“Certainly, cardiovascular disease risk in rheumatoid and psoriatic arthritis has been front of mind for the last decade or so,” Christie M. Bartels, MD, chief of the division of rheumatology at the University of Wisconsin, Madison, said when asked to comment on the recommendations. “But in some of these other conditions, it hasn’t been.”

When asked if rheumatologists would be ready and willing to implement these recommendations, Dr. Duarte Garcia acknowledged that it could be challenging for some.

“It’s a different workflow,” he said. “You’ve been trained traditionally to assess inflammation, to keep the disease under control, which is something they recommend, by the way. If you control the disease, patients do better. But I think lipid screening, for example, and testing for cholesterol, smoking cessation, those well-established programs are harder to bring to a rheumatology clinic. It’s doable, but it’s something that needs to be implemented within the current workflows and could take a few years to take hold.”

Dr. Bartels, however, noted that her group has done extensive work over the last 5 years incorporating certain interventions into practice, including sending patients with high blood pressure back to primary care.

“It’s a sustainable intervention in our clinic that basically our medical assistants and nurses do as a routine operation,” she said. “Our primary care providers are grateful to get these patients back. Our patients are grateful because otherwise when they come to the rheumatologist, get their blood pressure measured, and don’t get feedback, they assume they’re OK. So, we’re giving them a false signal.

“We have a similar intervention with smoking,” she added. “Often our patients aren’t even aware that they’re at increased risk of cardiovascular disease or that smoking might make their rheumatic disease and their cardiovascular outcomes worse. No one has had that conversation with them. They really welcome engaging in those discussions.

“Our tobacco intervention takes 90 seconds at point of care. Our blood pressure intervention at point of care, we’ve timed it, takes 3 minutes. There are ways that we can hardwire this into care.”

Along those lines, Dr. Duarte Garcia stated that the recommendations – although released by EULAR – are largely intuitive and should be very adaptable to an American health care context. He also recognized this moment as an opportunity for rheumatologists to consider patient outcomes beyond what they usually encounter firsthand.

“I don’t think we have many rheumatologists with patients who get a stroke or heart attack because if that happens, it’s in a hospital context or they go see a cardiologist,” he said. “You may see it once it happens if they survive and come and see you – or perhaps if you’re in a more integrated practice – but I don’t think it’s as apparent in our clinics because it is a predominantly outpatient practice and many times those are emergencies or inpatient complications.

“The bottom line,” he added, “is these are practical guidelines. It’s a push in the right direction, but there is still work to be done. And hopefully some of the recommendations, like measuring high blood pressure and addressing it just as in the general population, are something we can start to implement.”

Dr. Duarte Garcia reported receiving grant funding from the Rheumatology Research Foundation and the Centers for Disease Control and Prevention. Dr. Bartels reported that her group’s tobacco cessation work is funded by Pfizer’s Independent Grants for Learning and Change.

A version of this article first appeared on Medscape.com.