User login
For MD-IQ use only
Syracuse Hemoglobinopathy Presenting With Tophaceous Gout: A Case Report
Hemoglobinopathies are inherited disorders of hemoglobin that alter oxygen binding capacity by affecting the production of a specific subset of globin chains or their structure.1 A lesser-known subtype, Syracuse hemoglobinopathy (SH), was first identified in 4 generations of a family in the 1970s.2 As with other disorders of hemoglobin structure, there is an inherent risk of increased cell breakdown and turnover. This case discusses the presentation of gout in a patient with a history of SH.
Case presentation
A 44-year-old man with known SH, tobacco use disorder, and shoulder osteoarthritis presented with pain and palpable nodular masses on bilateral elbows, metacarpophalangeal joints, and feet progressively over 5 years. Of note, he was initially misdiagnosed with polycythemia vera after an incidental finding of elevated hematocrit more than 10 years prior. His mother, maternal aunt, and maternal grandmother have all been treated for polycythemia vera.
On examination, there were irregular palpable masses of varying sizes, erythema, and tenderness over the second metacarpophalangeal joint of the left hand, bilateral elbows, and bilateral metatarsophalangeal joints. Laboratory studies were remarkable for 19.8 g/dL hemoglobin (reference range, 12.0-16.0 g/dL); 63.4% hematocrit (reference range, 37.0%-47.0%); 219 × 103 µL platelets (reference range, 150-450 × 103 µL); 79.3 fL mean corpuscular volume (reference range, 81.0-99.0 fL); 14 mg/dL blood urea nitrogen (reference range, 8-27 mg/dL); 1.18 mg/dL creatinine (reference range, 0.60-1.60 mg/dL); 3 mmol/h erythrocyte sedimentation rate (reference range, 0-30 mmol/h); 88 IU/L alkaline phosphatase (reference range, 34-130 IU/L); and 11.3 mg/dL uric acid (reference range, 2.4-7.9 mg/dL). Hemoglobin electrophoresis studies showed a 49% hemoglobin A1 (reference range, 95%-98%); 3.0% hemoglobin A2 (reference range, 2%-3%); 3.1% hemoglobin F (reference range, < 0.6%); and 44.9% hemoglobin Syracuse (reference range, absent). It was negative for JAK2 V617F mutation. An X-ray of the bilateral feet showed irregularity/erosion involving the medial border of the great toe metatarsal head, joint effusions, and sclerotic margins (Figure 1). A prominent plantar calcaneal spur was present (Figure 2). Synovial fluid analysis detected the presence of negatively birefringent needle-shaped urate crystals.
Per the Clinical Gout Diagnosis tool, which has a sensitivity of 97%, this patient scored high given the findings of greater than one attack of acute arthritis, mono/oligoarthritic attacks, podagra, erythema, probable tophi, and hyperuricemia. This raised the likelihood of his presentation being an acute flare of tophaceous gout.3 He was treated with colchicine and prednisone for acute exacerbation. Once the exacerbation subsided, the colchicine was discontinued, and allopurinol was added. The uric acid goal was < 6 mg/dL and was consistently maintained. Over the subsequent months, he reported mild joint pain if he stopped taking allopurinol but did not report a recurrence in disease exacerbation.
Discussion
Hemoglobin Syracuse was first identified in the early 1970s after the discovery of similar familial hemoglobinopathies unique for their high oxygen affinity hemoglobin.1 High oxygen affinity hemoglobin functions by causing a leftward shift in the hemoglobin dissociation curve and therefore slower off-loading of oxygen into tissues.4 The hypoxic state at the tissue level created by the hemoglobin binding tightly to oxygen promotes the production of erythropoietin, increasing red blood cell and hemoglobin production.5 A study looking at uric acid levels in patients living at high altitudes (which can imitate the low-oxygen state seen in high affinity hemoglobinopathy) theorized that increased erythroblast turnover in the setting of polycythemia involves increased purine metabolism and consequently, uric acid as a breakdown product.6 Uric acid levels have also been used as a marker for hypoxia in studies regarding sleep apnea. Tissue hypoxia can increase adenosine triphosphate breakdown. One byproduct of this breakdown is hypoxanthine, which is further metabolized by xanthine oxidase, which, in turn, produces uric acid.7
The relationship between elevated uric acid and gout was first studied in the mid-nineteenth century after Alfred Barring Garrod identified urate deposits in the articular cartilage of patients with gout.1 These urate deposits garner a proinflammatory response with the activation of the complement cascade, resulting in the recruitment of neutrophils, macrophages, and lymphocytes. Recurrent gout flares eventually result in a chronic granulomatous inflammatory response to the deposited crystals resulting in the classic tophi.8 A study looking at patients with thalassemia showed that while elevated serum uric acid levels were common in these patients, only 6% developed gout. Significant risk factors were noted to be intact spleen and inefficient urinary excretion of urea due to chronic kidney disease.9
Current treatment of gout flares consistsof pain control in the acute phase and prevention in the long-term setting. The first-line treatment for acute gout attack is colchicine, prednisone, or nonsteroidal anti-inflammatory drugs. Clinicians can consider switching or combining these therapies if ineffective or in the event of severe exacerbation. Prophylactic therapy involves urate-lowering agents, such as allopurinol and febuxostat.10
Conclusions
This case illustrates how a rare disorder of high oxygen affinity hemoglobin, SH, can present itself with findings of elevated serum uric acid and tophaceous gout. Most patients with hyperuricemia never develop gout, but having a condition that increases their serum levels of uric acid can increase their chances.11 It is important for clinicians to consider this increased risk when a patient with hemoglobinopathy presents with joint pain.
1. Garrod AB. The Nature and Treatment of Gout and Rheumatic Gout. 2nd ed. Walton and Maberly; 1859.
2. Jensen M, Oski FA, Nathan DG, Bunn HF. Hemoglobin Syracuse (alpha2beta2-143(H21)His leads to Pro), a new high-affinity variant detected by special electrophoretic methods. Observations on the auto-oxidation of normal and variant hemoglobins. J Clin Invest. 1975;55(3):469-477. doi:10.1172/JCI107953
3. Vázquez-Mellado J, Hernández-Cuevas CB, Alvarez-Hernández E, et al. The diagnostic value of the proposal for clinical gout diagnosis (CGD). Clin Rheumatol. 2012;31(3):429-434. doi:10.1007/s10067-011-1873-4
4. Kaufman DP, Kandle PF, Murray IV, et al. Physiology, Oxyhemoglobin Dissociation Curve. [Updated 2023 Jul 31]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK499818/
5. Yudin J, Verhovsek M. How we diagnose and manage altered oxygen affinity hemoglobin variants. Am J Hematol. 2019;94(5):597-603. doi:10.1002/ajh.25425
6. Jefferson JA, Escudero E, Hurtado ME, et al. Hyperuricemia, hypertension, and proteinuria associated with high-altitude polycythemia. Am J Kidney Dis. 2002;39(6):1135-1142. doi:10.1053/ajkd.2002.33380
7. Hirotsu C, Tufik S, Guindalini C, Mazzotti DR, Bittencourt LR, Andersen ML. Association between uric acid levels and obstructive sleep apnea syndrome in a large epidemiological sample. PLoS One. 2013;8(6):e66891. Published 2013 Jun 24. doi:10.1371/journal.pone.0066891
8. Dalbeth N, Phipps-Green A, Frampton C, Neogi T, Taylor WJ, Merriman TR. Relationship between serum urate concentration and clinically evident incident gout: an individual participant data analysis. Ann Rheum Dis. 2018;77(7):1048-1052. doi:10.1136/annrheumdis-2017-212288
9. Ballou SP, Khan MA, Kushner I, Harris JW. Secondary gout in hemoglobinopathies: report of two cases and review of the literature. Am J Hematol. 1977;2(4):397-402. doi:10.1002/ajh.2830020410
10. Khanna D, Khanna PP, Fitzgerald JD, et al. 2012 American College of Rheumatology guidelines for management of gout. Part 2: therapy and antiinflammatory prophylaxis of acute gouty arthritis. Arthritis Care Res (Hoboken). 2012;64(10):1447-1461. doi:10.1002/acr.21773
11. Dalbeth N, Choi HK, Joosten LAB, et al. Gout. Nat Rev Dis Primers. 2019;5(1):69. Published 2019 Sep 26. doi:10.1038/s41572-019-0115-y
Hemoglobinopathies are inherited disorders of hemoglobin that alter oxygen binding capacity by affecting the production of a specific subset of globin chains or their structure.1 A lesser-known subtype, Syracuse hemoglobinopathy (SH), was first identified in 4 generations of a family in the 1970s.2 As with other disorders of hemoglobin structure, there is an inherent risk of increased cell breakdown and turnover. This case discusses the presentation of gout in a patient with a history of SH.
Case presentation
A 44-year-old man with known SH, tobacco use disorder, and shoulder osteoarthritis presented with pain and palpable nodular masses on bilateral elbows, metacarpophalangeal joints, and feet progressively over 5 years. Of note, he was initially misdiagnosed with polycythemia vera after an incidental finding of elevated hematocrit more than 10 years prior. His mother, maternal aunt, and maternal grandmother have all been treated for polycythemia vera.
On examination, there were irregular palpable masses of varying sizes, erythema, and tenderness over the second metacarpophalangeal joint of the left hand, bilateral elbows, and bilateral metatarsophalangeal joints. Laboratory studies were remarkable for 19.8 g/dL hemoglobin (reference range, 12.0-16.0 g/dL); 63.4% hematocrit (reference range, 37.0%-47.0%); 219 × 103 µL platelets (reference range, 150-450 × 103 µL); 79.3 fL mean corpuscular volume (reference range, 81.0-99.0 fL); 14 mg/dL blood urea nitrogen (reference range, 8-27 mg/dL); 1.18 mg/dL creatinine (reference range, 0.60-1.60 mg/dL); 3 mmol/h erythrocyte sedimentation rate (reference range, 0-30 mmol/h); 88 IU/L alkaline phosphatase (reference range, 34-130 IU/L); and 11.3 mg/dL uric acid (reference range, 2.4-7.9 mg/dL). Hemoglobin electrophoresis studies showed a 49% hemoglobin A1 (reference range, 95%-98%); 3.0% hemoglobin A2 (reference range, 2%-3%); 3.1% hemoglobin F (reference range, < 0.6%); and 44.9% hemoglobin Syracuse (reference range, absent). It was negative for JAK2 V617F mutation. An X-ray of the bilateral feet showed irregularity/erosion involving the medial border of the great toe metatarsal head, joint effusions, and sclerotic margins (Figure 1). A prominent plantar calcaneal spur was present (Figure 2). Synovial fluid analysis detected the presence of negatively birefringent needle-shaped urate crystals.
Per the Clinical Gout Diagnosis tool, which has a sensitivity of 97%, this patient scored high given the findings of greater than one attack of acute arthritis, mono/oligoarthritic attacks, podagra, erythema, probable tophi, and hyperuricemia. This raised the likelihood of his presentation being an acute flare of tophaceous gout.3 He was treated with colchicine and prednisone for acute exacerbation. Once the exacerbation subsided, the colchicine was discontinued, and allopurinol was added. The uric acid goal was < 6 mg/dL and was consistently maintained. Over the subsequent months, he reported mild joint pain if he stopped taking allopurinol but did not report a recurrence in disease exacerbation.
Discussion
Hemoglobin Syracuse was first identified in the early 1970s after the discovery of similar familial hemoglobinopathies unique for their high oxygen affinity hemoglobin.1 High oxygen affinity hemoglobin functions by causing a leftward shift in the hemoglobin dissociation curve and therefore slower off-loading of oxygen into tissues.4 The hypoxic state at the tissue level created by the hemoglobin binding tightly to oxygen promotes the production of erythropoietin, increasing red blood cell and hemoglobin production.5 A study looking at uric acid levels in patients living at high altitudes (which can imitate the low-oxygen state seen in high affinity hemoglobinopathy) theorized that increased erythroblast turnover in the setting of polycythemia involves increased purine metabolism and consequently, uric acid as a breakdown product.6 Uric acid levels have also been used as a marker for hypoxia in studies regarding sleep apnea. Tissue hypoxia can increase adenosine triphosphate breakdown. One byproduct of this breakdown is hypoxanthine, which is further metabolized by xanthine oxidase, which, in turn, produces uric acid.7
The relationship between elevated uric acid and gout was first studied in the mid-nineteenth century after Alfred Barring Garrod identified urate deposits in the articular cartilage of patients with gout.1 These urate deposits garner a proinflammatory response with the activation of the complement cascade, resulting in the recruitment of neutrophils, macrophages, and lymphocytes. Recurrent gout flares eventually result in a chronic granulomatous inflammatory response to the deposited crystals resulting in the classic tophi.8 A study looking at patients with thalassemia showed that while elevated serum uric acid levels were common in these patients, only 6% developed gout. Significant risk factors were noted to be intact spleen and inefficient urinary excretion of urea due to chronic kidney disease.9
Current treatment of gout flares consistsof pain control in the acute phase and prevention in the long-term setting. The first-line treatment for acute gout attack is colchicine, prednisone, or nonsteroidal anti-inflammatory drugs. Clinicians can consider switching or combining these therapies if ineffective or in the event of severe exacerbation. Prophylactic therapy involves urate-lowering agents, such as allopurinol and febuxostat.10
Conclusions
This case illustrates how a rare disorder of high oxygen affinity hemoglobin, SH, can present itself with findings of elevated serum uric acid and tophaceous gout. Most patients with hyperuricemia never develop gout, but having a condition that increases their serum levels of uric acid can increase their chances.11 It is important for clinicians to consider this increased risk when a patient with hemoglobinopathy presents with joint pain.
Hemoglobinopathies are inherited disorders of hemoglobin that alter oxygen binding capacity by affecting the production of a specific subset of globin chains or their structure.1 A lesser-known subtype, Syracuse hemoglobinopathy (SH), was first identified in 4 generations of a family in the 1970s.2 As with other disorders of hemoglobin structure, there is an inherent risk of increased cell breakdown and turnover. This case discusses the presentation of gout in a patient with a history of SH.
Case presentation
A 44-year-old man with known SH, tobacco use disorder, and shoulder osteoarthritis presented with pain and palpable nodular masses on bilateral elbows, metacarpophalangeal joints, and feet progressively over 5 years. Of note, he was initially misdiagnosed with polycythemia vera after an incidental finding of elevated hematocrit more than 10 years prior. His mother, maternal aunt, and maternal grandmother have all been treated for polycythemia vera.
On examination, there were irregular palpable masses of varying sizes, erythema, and tenderness over the second metacarpophalangeal joint of the left hand, bilateral elbows, and bilateral metatarsophalangeal joints. Laboratory studies were remarkable for 19.8 g/dL hemoglobin (reference range, 12.0-16.0 g/dL); 63.4% hematocrit (reference range, 37.0%-47.0%); 219 × 103 µL platelets (reference range, 150-450 × 103 µL); 79.3 fL mean corpuscular volume (reference range, 81.0-99.0 fL); 14 mg/dL blood urea nitrogen (reference range, 8-27 mg/dL); 1.18 mg/dL creatinine (reference range, 0.60-1.60 mg/dL); 3 mmol/h erythrocyte sedimentation rate (reference range, 0-30 mmol/h); 88 IU/L alkaline phosphatase (reference range, 34-130 IU/L); and 11.3 mg/dL uric acid (reference range, 2.4-7.9 mg/dL). Hemoglobin electrophoresis studies showed a 49% hemoglobin A1 (reference range, 95%-98%); 3.0% hemoglobin A2 (reference range, 2%-3%); 3.1% hemoglobin F (reference range, < 0.6%); and 44.9% hemoglobin Syracuse (reference range, absent). It was negative for JAK2 V617F mutation. An X-ray of the bilateral feet showed irregularity/erosion involving the medial border of the great toe metatarsal head, joint effusions, and sclerotic margins (Figure 1). A prominent plantar calcaneal spur was present (Figure 2). Synovial fluid analysis detected the presence of negatively birefringent needle-shaped urate crystals.
Per the Clinical Gout Diagnosis tool, which has a sensitivity of 97%, this patient scored high given the findings of greater than one attack of acute arthritis, mono/oligoarthritic attacks, podagra, erythema, probable tophi, and hyperuricemia. This raised the likelihood of his presentation being an acute flare of tophaceous gout.3 He was treated with colchicine and prednisone for acute exacerbation. Once the exacerbation subsided, the colchicine was discontinued, and allopurinol was added. The uric acid goal was < 6 mg/dL and was consistently maintained. Over the subsequent months, he reported mild joint pain if he stopped taking allopurinol but did not report a recurrence in disease exacerbation.
Discussion
Hemoglobin Syracuse was first identified in the early 1970s after the discovery of similar familial hemoglobinopathies unique for their high oxygen affinity hemoglobin.1 High oxygen affinity hemoglobin functions by causing a leftward shift in the hemoglobin dissociation curve and therefore slower off-loading of oxygen into tissues.4 The hypoxic state at the tissue level created by the hemoglobin binding tightly to oxygen promotes the production of erythropoietin, increasing red blood cell and hemoglobin production.5 A study looking at uric acid levels in patients living at high altitudes (which can imitate the low-oxygen state seen in high affinity hemoglobinopathy) theorized that increased erythroblast turnover in the setting of polycythemia involves increased purine metabolism and consequently, uric acid as a breakdown product.6 Uric acid levels have also been used as a marker for hypoxia in studies regarding sleep apnea. Tissue hypoxia can increase adenosine triphosphate breakdown. One byproduct of this breakdown is hypoxanthine, which is further metabolized by xanthine oxidase, which, in turn, produces uric acid.7
The relationship between elevated uric acid and gout was first studied in the mid-nineteenth century after Alfred Barring Garrod identified urate deposits in the articular cartilage of patients with gout.1 These urate deposits garner a proinflammatory response with the activation of the complement cascade, resulting in the recruitment of neutrophils, macrophages, and lymphocytes. Recurrent gout flares eventually result in a chronic granulomatous inflammatory response to the deposited crystals resulting in the classic tophi.8 A study looking at patients with thalassemia showed that while elevated serum uric acid levels were common in these patients, only 6% developed gout. Significant risk factors were noted to be intact spleen and inefficient urinary excretion of urea due to chronic kidney disease.9
Current treatment of gout flares consistsof pain control in the acute phase and prevention in the long-term setting. The first-line treatment for acute gout attack is colchicine, prednisone, or nonsteroidal anti-inflammatory drugs. Clinicians can consider switching or combining these therapies if ineffective or in the event of severe exacerbation. Prophylactic therapy involves urate-lowering agents, such as allopurinol and febuxostat.10
Conclusions
This case illustrates how a rare disorder of high oxygen affinity hemoglobin, SH, can present itself with findings of elevated serum uric acid and tophaceous gout. Most patients with hyperuricemia never develop gout, but having a condition that increases their serum levels of uric acid can increase their chances.11 It is important for clinicians to consider this increased risk when a patient with hemoglobinopathy presents with joint pain.
1. Garrod AB. The Nature and Treatment of Gout and Rheumatic Gout. 2nd ed. Walton and Maberly; 1859.
2. Jensen M, Oski FA, Nathan DG, Bunn HF. Hemoglobin Syracuse (alpha2beta2-143(H21)His leads to Pro), a new high-affinity variant detected by special electrophoretic methods. Observations on the auto-oxidation of normal and variant hemoglobins. J Clin Invest. 1975;55(3):469-477. doi:10.1172/JCI107953
3. Vázquez-Mellado J, Hernández-Cuevas CB, Alvarez-Hernández E, et al. The diagnostic value of the proposal for clinical gout diagnosis (CGD). Clin Rheumatol. 2012;31(3):429-434. doi:10.1007/s10067-011-1873-4
4. Kaufman DP, Kandle PF, Murray IV, et al. Physiology, Oxyhemoglobin Dissociation Curve. [Updated 2023 Jul 31]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK499818/
5. Yudin J, Verhovsek M. How we diagnose and manage altered oxygen affinity hemoglobin variants. Am J Hematol. 2019;94(5):597-603. doi:10.1002/ajh.25425
6. Jefferson JA, Escudero E, Hurtado ME, et al. Hyperuricemia, hypertension, and proteinuria associated with high-altitude polycythemia. Am J Kidney Dis. 2002;39(6):1135-1142. doi:10.1053/ajkd.2002.33380
7. Hirotsu C, Tufik S, Guindalini C, Mazzotti DR, Bittencourt LR, Andersen ML. Association between uric acid levels and obstructive sleep apnea syndrome in a large epidemiological sample. PLoS One. 2013;8(6):e66891. Published 2013 Jun 24. doi:10.1371/journal.pone.0066891
8. Dalbeth N, Phipps-Green A, Frampton C, Neogi T, Taylor WJ, Merriman TR. Relationship between serum urate concentration and clinically evident incident gout: an individual participant data analysis. Ann Rheum Dis. 2018;77(7):1048-1052. doi:10.1136/annrheumdis-2017-212288
9. Ballou SP, Khan MA, Kushner I, Harris JW. Secondary gout in hemoglobinopathies: report of two cases and review of the literature. Am J Hematol. 1977;2(4):397-402. doi:10.1002/ajh.2830020410
10. Khanna D, Khanna PP, Fitzgerald JD, et al. 2012 American College of Rheumatology guidelines for management of gout. Part 2: therapy and antiinflammatory prophylaxis of acute gouty arthritis. Arthritis Care Res (Hoboken). 2012;64(10):1447-1461. doi:10.1002/acr.21773
11. Dalbeth N, Choi HK, Joosten LAB, et al. Gout. Nat Rev Dis Primers. 2019;5(1):69. Published 2019 Sep 26. doi:10.1038/s41572-019-0115-y
1. Garrod AB. The Nature and Treatment of Gout and Rheumatic Gout. 2nd ed. Walton and Maberly; 1859.
2. Jensen M, Oski FA, Nathan DG, Bunn HF. Hemoglobin Syracuse (alpha2beta2-143(H21)His leads to Pro), a new high-affinity variant detected by special electrophoretic methods. Observations on the auto-oxidation of normal and variant hemoglobins. J Clin Invest. 1975;55(3):469-477. doi:10.1172/JCI107953
3. Vázquez-Mellado J, Hernández-Cuevas CB, Alvarez-Hernández E, et al. The diagnostic value of the proposal for clinical gout diagnosis (CGD). Clin Rheumatol. 2012;31(3):429-434. doi:10.1007/s10067-011-1873-4
4. Kaufman DP, Kandle PF, Murray IV, et al. Physiology, Oxyhemoglobin Dissociation Curve. [Updated 2023 Jul 31]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK499818/
5. Yudin J, Verhovsek M. How we diagnose and manage altered oxygen affinity hemoglobin variants. Am J Hematol. 2019;94(5):597-603. doi:10.1002/ajh.25425
6. Jefferson JA, Escudero E, Hurtado ME, et al. Hyperuricemia, hypertension, and proteinuria associated with high-altitude polycythemia. Am J Kidney Dis. 2002;39(6):1135-1142. doi:10.1053/ajkd.2002.33380
7. Hirotsu C, Tufik S, Guindalini C, Mazzotti DR, Bittencourt LR, Andersen ML. Association between uric acid levels and obstructive sleep apnea syndrome in a large epidemiological sample. PLoS One. 2013;8(6):e66891. Published 2013 Jun 24. doi:10.1371/journal.pone.0066891
8. Dalbeth N, Phipps-Green A, Frampton C, Neogi T, Taylor WJ, Merriman TR. Relationship between serum urate concentration and clinically evident incident gout: an individual participant data analysis. Ann Rheum Dis. 2018;77(7):1048-1052. doi:10.1136/annrheumdis-2017-212288
9. Ballou SP, Khan MA, Kushner I, Harris JW. Secondary gout in hemoglobinopathies: report of two cases and review of the literature. Am J Hematol. 1977;2(4):397-402. doi:10.1002/ajh.2830020410
10. Khanna D, Khanna PP, Fitzgerald JD, et al. 2012 American College of Rheumatology guidelines for management of gout. Part 2: therapy and antiinflammatory prophylaxis of acute gouty arthritis. Arthritis Care Res (Hoboken). 2012;64(10):1447-1461. doi:10.1002/acr.21773
11. Dalbeth N, Choi HK, Joosten LAB, et al. Gout. Nat Rev Dis Primers. 2019;5(1):69. Published 2019 Sep 26. doi:10.1038/s41572-019-0115-y
Are Text Pages an Effective Nudge to Increase Attendance at Internal Medicine Morning Report Conferences? A Cluster Randomized Controlled Trial
Regularly scheduled educational conferences, such as case-based morning reports, have been a standard part of internal medicine residencies for decades.1-4 In addition to better patient care from the knowledge gained at educational conferences, attendance by interns and residents (collectively called house staff) may be associated with higher in-service examination scores.5 Unfortunately, competing priorities, including patient care and trainee supervision, may contribute to an action-intention gap among house staff that reduces attendance.6-8 Low attendance at morning reports represents wasted effort and lost educational opportunities; therefore, strategies to increase attendance are needed. Of several methods studied, more resource-intensive interventions (eg, providing food) were the most successful.6,9-12
Using the behavioral economics framework of nudge strategies, we hypothesized that a less intensive intervention of a daily reminder text page would encourage medical students, interns, and residents (collectively called learners) to attend the morning report conference.8,13 However, given the high cognitive load created by frequent task switching, a reminder text page could disrupt workflow and patient care without promoting the intended behavior change.14-17 Because of this uncertainty, our objective was to determine whether a preconference text page increased learner attendance at morning report conferences.
Methods
This study was a single-center, multiple-crossover cluster randomized controlled trial conducted at the Veteran Affairs Boston Healthcare System (VABHS) in Massachusetts. Study participants included house staff rotating on daytime inpatient rotations from 4 residency programs and students from 2 medical schools. The setting was the morning report, an in-person, interactive, case-based conference held Monday through Thursday, from 8:00
Learners assigned to rotate on the inpatient medicine, cardiology, medicine consultation, and patient safety rotations were eligible to attend these conferences and for inclusion in the study. Learners rotating in the medical intensive care unit, on night float, or on day float (an admitting shift for which residents are not on-site until late afternoon) were excluded. Additional details of the study population are available in the supplement (eAppendix). The study period was originally planned for September 30, 2019, to March 31, 2020, but data collection was stopped on March 12, 2020, due to the COVID-19 pandemic and suspension of in-person conferences. We chose the study period, which determined our sample size, to exclude the first 3 months of the academic year (July-September) because during that time learners acclimate to the inpatient workflow. We also chose not to include the last 3 months of the academic year to provide time for data analysis and preparation of the manuscript within the academic year.
Intervention and Outcome Assessment
Each intervention and control period was 3 weeks long; the first period was randomly determined by coin flip and alternated thereafter. Additional details of randomization are available in the supplement (Appendix 1). During intervention periods, all house staff received a page at 7:55
A daily facesheet (a roster of house staff names and photos) was used to identify learners for conference attendance. This facesheet was already used for other purposes at VABHS. At 8:00
During control periods, no text page reminder of upcoming conferences was sent, but the attendance of total learners at 8:00
Statistical Analysis
The primary outcome was the proportion of eligible learners present at 8:10
To estimate the primary outcome, we modeled the risk difference adjusted for covariates using a generalized estimating equation accounting for the clustering of attendance behavior within individuals and controlling for date and team. Secondary outcomes were estimated similarly. To evaluate the robustness of the primary outcome, we performed a sensitivity analysis using a multilevel generalized linear model with clustering by individual learner and team. Additional details on our statistical analysis plan, including accessing our raw data and analysis code, are available in Appendices 2 and 3. Categorical variables were compared using the χ2 or Fisher exact test. Continuous variables were compared using the t test or Wilcoxon rank-sum tests. All P values were 2-sided, and a significance level of ≤ .05 was considered statistically significant. Analysis was performed in Stata v16.1. Our study was deemed exempt by the VABHS Institutional Review Board, and this article was prepared following the CONSORT reporting guidelines. The trial protocol has been registered with the International Standard Randomized Controlled Trial Number registry
Results
Over the study period, 329 unique learners rotated on inpatient medical services at the VABHS and 211 were eligible to attend 85 morning report conferences and 22 Jeopardy conferences (Figure). Outcomes data were available for 100% of eligible participants. Forty-seven (55%) of the morning report conferences occurred during the intervention period (Table 1).
Morning report attendance observed at 8:10
On-time attendance was lower than at 8:10
To estimate the impact of rotating on teams with lighter clinical workloads on the association between receipt of a reminder page and conference attendance, we repeated our primary analysis with a test of interaction between team assignment and the intervention, which was not significant (P = .90). To estimate the impact of morning workload on the association between receipt of a reminder page and conference attendance, we performed a subgroup analysis limited to learners rotating on teams eligible to receive overnight admissions and included the number of overnight admissions as a covariate in our regression model. A test of interaction between the intervention and the number of overnight admissions on conference attendance was not significant (P = .73).
In a subgroup analysis limited to learners on teams eligible to receive overnight admissions and controlling for the number of overnight admissions (a proxy for morning workload), no significant interaction between the intervention and admissions was observed. We also assessed for interaction between learner type and receipt of a reminder page on conference attendance and found no evidence of such an effect.
Discussion
Among a diverse population of learners from multiple academic institutions rotating at a single, large, urban VA medical center, a nudge strategy of sending a reminder text page before morning report conferences was associated with a 4.0% absolute increase in attendance measured 10 minutes after the conference started compared with not sending a reminder page. Overall, only one-quarter of learners attended the morning report at the start at 8:00
We designed our analysis to overcome several limitations of prior studies on the effect of reminder text pages on conference attendance. First, to account for differences in conference attendance behavior of individual learners, we used a generalized estimating equation model that allowed clustering of outcomes by individual. Second, we controlled for the date to account for secular trends in conference attendance over the academic year. Finally, we controlled for the team to account for the possibility that the conference attendance behavior of one learner on a team influences the behavior of other learners on the same team.
We also evaluated the effect of a reminder page on attendance at a weekly Jeopardy conference. Interestingly, reminder pages seemed to increase on-time Jeopardy attendance, although this effect was no longer statistically significant at 8:10
We also assessed the interaction between sending a reminder page and learner type and its effect on conference attendance and found no evidence to support such an effect. Because medical students do not receive reminder pages, their conference attendance behavior can be thought of as indicative of clustering within teams. Though there was no evidence of a significant interaction, given the small number of students, our study may be underpowered to find a benefit for this group.
The results of this study differ from Smith and colleagues, who found that reminder pages had no overall effect on conference attendance for fellows; however, no sample size justification was provided in that study, making it difficult to evaluate the likelihood of a false-negative finding.7 Our study differs in several ways: the timing of the reminder page (5 minutes vs 30 minutes prior to the conference), the method by which attendance was recorded (by an independent observer vs learner sign-in), and the time that attendance was recorded (2 prespecified times vs continuously). As far as we know, our study is the first to evaluate the nudge effect of reminder text pages on internal medicine resident attendance at conferences, with attendance taken by an observer.
Limitations
This study has some limitations. First, it was conducted at a single VA medical center. An additional limitation was our decision to classify learners who arrived after 8:10
Unfortunately, due to the COVID-19 pandemic and the suspension of in-person conferences, our study ended earlier than anticipated. This resulted in an imbalance of morning report conferences that occurred during each period: 55% during the intervention period, and 45% during the control period. However, because we accounted for the clustering of conference attendance behavior within individuals in our model, this imbalance is unlikely to introduce bias in our estimation of the effect of the intervention.
Another limitation relates to the evolving landscape of educational conferences in the postpandemic era.18 Whether our results can be generalized to increase virtual conference attendance is unknown. Finally, it is not clear whether a 4% absolute increase in conference attendance is educationally meaningful or justifies the effort of sending a reminder page.
Conclusions
In this cluster randomized controlled trial conducted at a single VA medical center, reminder pages sent 5 minutes before the start of morning report conferences resulted in a 4% increase in conference attendance. Our results suggest that reminder pages are one strategy that may result in a small increase in conference attendance, but whether this small increase is educationally significant will vary across training programs applying this strategy.
Acknowledgments
The authors are indebted to Kenneth J. Mukamal and Katharine A. Robb, who provided invaluable guidance in data analysis. Todd Reese assisted in data organization and presentation of data, and Mark Tuttle designed the facesheet. None of these individuals received compensation for their assistance.
1. Daniels VJ, Goldstein CE. Changing morning report: an educational intervention to address curricular needs. J Biomed Educ. 2014;2014:1-5. doi:10.1155/2014/830701
2. Parrino TA, Villanueva AG. The principles and practice of morning report. JAMA. 1986;256(6):730-733. doi:10.1001/jama.1986.03380060056025
3. Wenger NS, Shpiner RB. An analysis of morning report: implications for internal medicine education. Ann Intern Med. 1993;119(5):395-399. doi:10.7326/0003-4819-119-5-199309010-00008
4. Ways M, Kroenke K, Umali J, Buchwald D. Morning report. A survey of resident attitudes. Arch Intern Med. 1995;155(13):1433-1437. doi:10.1001/archinte.155.13.1433
5. McDonald FS, Zeger SL, Kolars JC. Associations of conference attendance with internal medicine in-training examination scores. Mayo Clin Proc. 2008;83(4):449-453. doi:10.4065/83.4.449
6. FitzGerald JD, Wenger NS. Didactic teaching conferences for IM residents: who attends, and is attendance related to medical certifying examination scores? Acad Med. 2003;78(1):84-89. doi:10.1097/00001888-200301000-00015
7. Smith J, Zaffiri L, Clary J, Davis T, Bosslet GT. The effect of paging reminders on fellowship conference attendance: a multi-program randomized crossover study. J Grad Med Educ. 2016;8(3):372-377. doi:10.4300/JGME-D-15-00487.1
8. Sheeran P, Webb TL. The intention-behavior gap. Soc Personal Psychol Compass. 2016;10(9):503-518. doi:10.1111/spc3.12265
9. McDonald RJ, Luetmer PH, Kallmes DF. If you starve them, will they still come? Do complementary food provisions affect faculty meeting attendance in academic radiology? J Am Coll Radiol. 2011;8(11):809-810. doi:10.1016/j.jacr.2011.06.003
10. Segovis CM, Mueller PS, Rethlefsen ML, et al. If you feed them, they will come: a prospective study of the effects of complimentary food on attendance and physician attitudes at medical grand rounds at an academic medical center. BMC Med Educ. 2007;7:22. Published 2007 Jul 12. doi:10.1186/1472-6920-7-22
11. Mueller PS, Litin SC, Sowden ML, Habermann TM, LaRusso NF. Strategies for improving attendance at medical grand rounds at an academic medical center. Mayo Clin Proc. 2003;78(5):549-553. doi:10.4065/78.5.549
12. Tarabichi S, DeLeon M, Krumrei N, Hanna J, Maloney Patel N. Competition as a means for improving academic scores and attendance at education conference. J Surg Educ. 2018;75(6):1437-1440. doi:10.1016/j.jsurg.2018.04.020
13. Thaler RH, Sunstein CR. Nudge: Improving Decisions About Health, Wealth, and Happiness. Rev. and Expanded Ed. Penguin Books; 2009.
14. Weijers RJ, de Koning BB, Paas F. Nudging in education: from theory towards guidelines for successful implementation. Eur J Psychol Educ. 2021;36:883-902. Published 2020 Aug 24. doi:10.1007/s10212-020-00495-0
15. Wieland ML, Loertscher LL, Nelson DR, Szostek JH, Ficalora RD. A strategy to reduce interruptions at hospital morning report. J Grad Med Educ. 2010;2(1):83-84. doi:10.4300/JGME-D-09-00084.1
16. Witherspoon L, Nham E, Abdi H, et al. Is it time to rethink how we page physicians? Understanding paging patterns in a tertiary care hospital. BMC Health Serv Res. 2019;19(1):992. Published 2019 Dec 23. doi:10.1186/s12913-019-4844-0
17. Fargen KM, O’Connor T, Raymond S, Sporrer JM, Friedman WA. An observational study of hospital paging practices and workflow interruption among on-call junior neurological surgery residents. J Grad Med Educ. 2012;4(4):467-471. doi:10.4300/JGME-D-11-00306.1
18. Chick RC, Clifton GT, Peace KM, et al. Using technology to maintain the education of residents during the COVID-19 pandemic. J Surg Educ. 2020;77(4):729-732. doi:10.1016/j.jsurg.2020.03.018
Regularly scheduled educational conferences, such as case-based morning reports, have been a standard part of internal medicine residencies for decades.1-4 In addition to better patient care from the knowledge gained at educational conferences, attendance by interns and residents (collectively called house staff) may be associated with higher in-service examination scores.5 Unfortunately, competing priorities, including patient care and trainee supervision, may contribute to an action-intention gap among house staff that reduces attendance.6-8 Low attendance at morning reports represents wasted effort and lost educational opportunities; therefore, strategies to increase attendance are needed. Of several methods studied, more resource-intensive interventions (eg, providing food) were the most successful.6,9-12
Using the behavioral economics framework of nudge strategies, we hypothesized that a less intensive intervention of a daily reminder text page would encourage medical students, interns, and residents (collectively called learners) to attend the morning report conference.8,13 However, given the high cognitive load created by frequent task switching, a reminder text page could disrupt workflow and patient care without promoting the intended behavior change.14-17 Because of this uncertainty, our objective was to determine whether a preconference text page increased learner attendance at morning report conferences.
Methods
This study was a single-center, multiple-crossover cluster randomized controlled trial conducted at the Veteran Affairs Boston Healthcare System (VABHS) in Massachusetts. Study participants included house staff rotating on daytime inpatient rotations from 4 residency programs and students from 2 medical schools. The setting was the morning report, an in-person, interactive, case-based conference held Monday through Thursday, from 8:00
Learners assigned to rotate on the inpatient medicine, cardiology, medicine consultation, and patient safety rotations were eligible to attend these conferences and for inclusion in the study. Learners rotating in the medical intensive care unit, on night float, or on day float (an admitting shift for which residents are not on-site until late afternoon) were excluded. Additional details of the study population are available in the supplement (eAppendix). The study period was originally planned for September 30, 2019, to March 31, 2020, but data collection was stopped on March 12, 2020, due to the COVID-19 pandemic and suspension of in-person conferences. We chose the study period, which determined our sample size, to exclude the first 3 months of the academic year (July-September) because during that time learners acclimate to the inpatient workflow. We also chose not to include the last 3 months of the academic year to provide time for data analysis and preparation of the manuscript within the academic year.
Intervention and Outcome Assessment
Each intervention and control period was 3 weeks long; the first period was randomly determined by coin flip and alternated thereafter. Additional details of randomization are available in the supplement (Appendix 1). During intervention periods, all house staff received a page at 7:55
A daily facesheet (a roster of house staff names and photos) was used to identify learners for conference attendance. This facesheet was already used for other purposes at VABHS. At 8:00
During control periods, no text page reminder of upcoming conferences was sent, but the attendance of total learners at 8:00
Statistical Analysis
The primary outcome was the proportion of eligible learners present at 8:10
To estimate the primary outcome, we modeled the risk difference adjusted for covariates using a generalized estimating equation accounting for the clustering of attendance behavior within individuals and controlling for date and team. Secondary outcomes were estimated similarly. To evaluate the robustness of the primary outcome, we performed a sensitivity analysis using a multilevel generalized linear model with clustering by individual learner and team. Additional details on our statistical analysis plan, including accessing our raw data and analysis code, are available in Appendices 2 and 3. Categorical variables were compared using the χ2 or Fisher exact test. Continuous variables were compared using the t test or Wilcoxon rank-sum tests. All P values were 2-sided, and a significance level of ≤ .05 was considered statistically significant. Analysis was performed in Stata v16.1. Our study was deemed exempt by the VABHS Institutional Review Board, and this article was prepared following the CONSORT reporting guidelines. The trial protocol has been registered with the International Standard Randomized Controlled Trial Number registry
Results
Over the study period, 329 unique learners rotated on inpatient medical services at the VABHS and 211 were eligible to attend 85 morning report conferences and 22 Jeopardy conferences (Figure). Outcomes data were available for 100% of eligible participants. Forty-seven (55%) of the morning report conferences occurred during the intervention period (Table 1).
Morning report attendance observed at 8:10
On-time attendance was lower than at 8:10
To estimate the impact of rotating on teams with lighter clinical workloads on the association between receipt of a reminder page and conference attendance, we repeated our primary analysis with a test of interaction between team assignment and the intervention, which was not significant (P = .90). To estimate the impact of morning workload on the association between receipt of a reminder page and conference attendance, we performed a subgroup analysis limited to learners rotating on teams eligible to receive overnight admissions and included the number of overnight admissions as a covariate in our regression model. A test of interaction between the intervention and the number of overnight admissions on conference attendance was not significant (P = .73).
In a subgroup analysis limited to learners on teams eligible to receive overnight admissions and controlling for the number of overnight admissions (a proxy for morning workload), no significant interaction between the intervention and admissions was observed. We also assessed for interaction between learner type and receipt of a reminder page on conference attendance and found no evidence of such an effect.
Discussion
Among a diverse population of learners from multiple academic institutions rotating at a single, large, urban VA medical center, a nudge strategy of sending a reminder text page before morning report conferences was associated with a 4.0% absolute increase in attendance measured 10 minutes after the conference started compared with not sending a reminder page. Overall, only one-quarter of learners attended the morning report at the start at 8:00
We designed our analysis to overcome several limitations of prior studies on the effect of reminder text pages on conference attendance. First, to account for differences in conference attendance behavior of individual learners, we used a generalized estimating equation model that allowed clustering of outcomes by individual. Second, we controlled for the date to account for secular trends in conference attendance over the academic year. Finally, we controlled for the team to account for the possibility that the conference attendance behavior of one learner on a team influences the behavior of other learners on the same team.
We also evaluated the effect of a reminder page on attendance at a weekly Jeopardy conference. Interestingly, reminder pages seemed to increase on-time Jeopardy attendance, although this effect was no longer statistically significant at 8:10
We also assessed the interaction between sending a reminder page and learner type and its effect on conference attendance and found no evidence to support such an effect. Because medical students do not receive reminder pages, their conference attendance behavior can be thought of as indicative of clustering within teams. Though there was no evidence of a significant interaction, given the small number of students, our study may be underpowered to find a benefit for this group.
The results of this study differ from Smith and colleagues, who found that reminder pages had no overall effect on conference attendance for fellows; however, no sample size justification was provided in that study, making it difficult to evaluate the likelihood of a false-negative finding.7 Our study differs in several ways: the timing of the reminder page (5 minutes vs 30 minutes prior to the conference), the method by which attendance was recorded (by an independent observer vs learner sign-in), and the time that attendance was recorded (2 prespecified times vs continuously). As far as we know, our study is the first to evaluate the nudge effect of reminder text pages on internal medicine resident attendance at conferences, with attendance taken by an observer.
Limitations
This study has some limitations. First, it was conducted at a single VA medical center. An additional limitation was our decision to classify learners who arrived after 8:10
Unfortunately, due to the COVID-19 pandemic and the suspension of in-person conferences, our study ended earlier than anticipated. This resulted in an imbalance of morning report conferences that occurred during each period: 55% during the intervention period, and 45% during the control period. However, because we accounted for the clustering of conference attendance behavior within individuals in our model, this imbalance is unlikely to introduce bias in our estimation of the effect of the intervention.
Another limitation relates to the evolving landscape of educational conferences in the postpandemic era.18 Whether our results can be generalized to increase virtual conference attendance is unknown. Finally, it is not clear whether a 4% absolute increase in conference attendance is educationally meaningful or justifies the effort of sending a reminder page.
Conclusions
In this cluster randomized controlled trial conducted at a single VA medical center, reminder pages sent 5 minutes before the start of morning report conferences resulted in a 4% increase in conference attendance. Our results suggest that reminder pages are one strategy that may result in a small increase in conference attendance, but whether this small increase is educationally significant will vary across training programs applying this strategy.
Acknowledgments
The authors are indebted to Kenneth J. Mukamal and Katharine A. Robb, who provided invaluable guidance in data analysis. Todd Reese assisted in data organization and presentation of data, and Mark Tuttle designed the facesheet. None of these individuals received compensation for their assistance.
Regularly scheduled educational conferences, such as case-based morning reports, have been a standard part of internal medicine residencies for decades.1-4 In addition to better patient care from the knowledge gained at educational conferences, attendance by interns and residents (collectively called house staff) may be associated with higher in-service examination scores.5 Unfortunately, competing priorities, including patient care and trainee supervision, may contribute to an action-intention gap among house staff that reduces attendance.6-8 Low attendance at morning reports represents wasted effort and lost educational opportunities; therefore, strategies to increase attendance are needed. Of several methods studied, more resource-intensive interventions (eg, providing food) were the most successful.6,9-12
Using the behavioral economics framework of nudge strategies, we hypothesized that a less intensive intervention of a daily reminder text page would encourage medical students, interns, and residents (collectively called learners) to attend the morning report conference.8,13 However, given the high cognitive load created by frequent task switching, a reminder text page could disrupt workflow and patient care without promoting the intended behavior change.14-17 Because of this uncertainty, our objective was to determine whether a preconference text page increased learner attendance at morning report conferences.
Methods
This study was a single-center, multiple-crossover cluster randomized controlled trial conducted at the Veteran Affairs Boston Healthcare System (VABHS) in Massachusetts. Study participants included house staff rotating on daytime inpatient rotations from 4 residency programs and students from 2 medical schools. The setting was the morning report, an in-person, interactive, case-based conference held Monday through Thursday, from 8:00
Learners assigned to rotate on the inpatient medicine, cardiology, medicine consultation, and patient safety rotations were eligible to attend these conferences and for inclusion in the study. Learners rotating in the medical intensive care unit, on night float, or on day float (an admitting shift for which residents are not on-site until late afternoon) were excluded. Additional details of the study population are available in the supplement (eAppendix). The study period was originally planned for September 30, 2019, to March 31, 2020, but data collection was stopped on March 12, 2020, due to the COVID-19 pandemic and suspension of in-person conferences. We chose the study period, which determined our sample size, to exclude the first 3 months of the academic year (July-September) because during that time learners acclimate to the inpatient workflow. We also chose not to include the last 3 months of the academic year to provide time for data analysis and preparation of the manuscript within the academic year.
Intervention and Outcome Assessment
Each intervention and control period was 3 weeks long; the first period was randomly determined by coin flip and alternated thereafter. Additional details of randomization are available in the supplement (Appendix 1). During intervention periods, all house staff received a page at 7:55
A daily facesheet (a roster of house staff names and photos) was used to identify learners for conference attendance. This facesheet was already used for other purposes at VABHS. At 8:00
During control periods, no text page reminder of upcoming conferences was sent, but the attendance of total learners at 8:00
Statistical Analysis
The primary outcome was the proportion of eligible learners present at 8:10
To estimate the primary outcome, we modeled the risk difference adjusted for covariates using a generalized estimating equation accounting for the clustering of attendance behavior within individuals and controlling for date and team. Secondary outcomes were estimated similarly. To evaluate the robustness of the primary outcome, we performed a sensitivity analysis using a multilevel generalized linear model with clustering by individual learner and team. Additional details on our statistical analysis plan, including accessing our raw data and analysis code, are available in Appendices 2 and 3. Categorical variables were compared using the χ2 or Fisher exact test. Continuous variables were compared using the t test or Wilcoxon rank-sum tests. All P values were 2-sided, and a significance level of ≤ .05 was considered statistically significant. Analysis was performed in Stata v16.1. Our study was deemed exempt by the VABHS Institutional Review Board, and this article was prepared following the CONSORT reporting guidelines. The trial protocol has been registered with the International Standard Randomized Controlled Trial Number registry
Results
Over the study period, 329 unique learners rotated on inpatient medical services at the VABHS and 211 were eligible to attend 85 morning report conferences and 22 Jeopardy conferences (Figure). Outcomes data were available for 100% of eligible participants. Forty-seven (55%) of the morning report conferences occurred during the intervention period (Table 1).
Morning report attendance observed at 8:10
On-time attendance was lower than at 8:10
To estimate the impact of rotating on teams with lighter clinical workloads on the association between receipt of a reminder page and conference attendance, we repeated our primary analysis with a test of interaction between team assignment and the intervention, which was not significant (P = .90). To estimate the impact of morning workload on the association between receipt of a reminder page and conference attendance, we performed a subgroup analysis limited to learners rotating on teams eligible to receive overnight admissions and included the number of overnight admissions as a covariate in our regression model. A test of interaction between the intervention and the number of overnight admissions on conference attendance was not significant (P = .73).
In a subgroup analysis limited to learners on teams eligible to receive overnight admissions and controlling for the number of overnight admissions (a proxy for morning workload), no significant interaction between the intervention and admissions was observed. We also assessed for interaction between learner type and receipt of a reminder page on conference attendance and found no evidence of such an effect.
Discussion
Among a diverse population of learners from multiple academic institutions rotating at a single, large, urban VA medical center, a nudge strategy of sending a reminder text page before morning report conferences was associated with a 4.0% absolute increase in attendance measured 10 minutes after the conference started compared with not sending a reminder page. Overall, only one-quarter of learners attended the morning report at the start at 8:00
We designed our analysis to overcome several limitations of prior studies on the effect of reminder text pages on conference attendance. First, to account for differences in conference attendance behavior of individual learners, we used a generalized estimating equation model that allowed clustering of outcomes by individual. Second, we controlled for the date to account for secular trends in conference attendance over the academic year. Finally, we controlled for the team to account for the possibility that the conference attendance behavior of one learner on a team influences the behavior of other learners on the same team.
We also evaluated the effect of a reminder page on attendance at a weekly Jeopardy conference. Interestingly, reminder pages seemed to increase on-time Jeopardy attendance, although this effect was no longer statistically significant at 8:10
We also assessed the interaction between sending a reminder page and learner type and its effect on conference attendance and found no evidence to support such an effect. Because medical students do not receive reminder pages, their conference attendance behavior can be thought of as indicative of clustering within teams. Though there was no evidence of a significant interaction, given the small number of students, our study may be underpowered to find a benefit for this group.
The results of this study differ from Smith and colleagues, who found that reminder pages had no overall effect on conference attendance for fellows; however, no sample size justification was provided in that study, making it difficult to evaluate the likelihood of a false-negative finding.7 Our study differs in several ways: the timing of the reminder page (5 minutes vs 30 minutes prior to the conference), the method by which attendance was recorded (by an independent observer vs learner sign-in), and the time that attendance was recorded (2 prespecified times vs continuously). As far as we know, our study is the first to evaluate the nudge effect of reminder text pages on internal medicine resident attendance at conferences, with attendance taken by an observer.
Limitations
This study has some limitations. First, it was conducted at a single VA medical center. An additional limitation was our decision to classify learners who arrived after 8:10
Unfortunately, due to the COVID-19 pandemic and the suspension of in-person conferences, our study ended earlier than anticipated. This resulted in an imbalance of morning report conferences that occurred during each period: 55% during the intervention period, and 45% during the control period. However, because we accounted for the clustering of conference attendance behavior within individuals in our model, this imbalance is unlikely to introduce bias in our estimation of the effect of the intervention.
Another limitation relates to the evolving landscape of educational conferences in the postpandemic era.18 Whether our results can be generalized to increase virtual conference attendance is unknown. Finally, it is not clear whether a 4% absolute increase in conference attendance is educationally meaningful or justifies the effort of sending a reminder page.
Conclusions
In this cluster randomized controlled trial conducted at a single VA medical center, reminder pages sent 5 minutes before the start of morning report conferences resulted in a 4% increase in conference attendance. Our results suggest that reminder pages are one strategy that may result in a small increase in conference attendance, but whether this small increase is educationally significant will vary across training programs applying this strategy.
Acknowledgments
The authors are indebted to Kenneth J. Mukamal and Katharine A. Robb, who provided invaluable guidance in data analysis. Todd Reese assisted in data organization and presentation of data, and Mark Tuttle designed the facesheet. None of these individuals received compensation for their assistance.
1. Daniels VJ, Goldstein CE. Changing morning report: an educational intervention to address curricular needs. J Biomed Educ. 2014;2014:1-5. doi:10.1155/2014/830701
2. Parrino TA, Villanueva AG. The principles and practice of morning report. JAMA. 1986;256(6):730-733. doi:10.1001/jama.1986.03380060056025
3. Wenger NS, Shpiner RB. An analysis of morning report: implications for internal medicine education. Ann Intern Med. 1993;119(5):395-399. doi:10.7326/0003-4819-119-5-199309010-00008
4. Ways M, Kroenke K, Umali J, Buchwald D. Morning report. A survey of resident attitudes. Arch Intern Med. 1995;155(13):1433-1437. doi:10.1001/archinte.155.13.1433
5. McDonald FS, Zeger SL, Kolars JC. Associations of conference attendance with internal medicine in-training examination scores. Mayo Clin Proc. 2008;83(4):449-453. doi:10.4065/83.4.449
6. FitzGerald JD, Wenger NS. Didactic teaching conferences for IM residents: who attends, and is attendance related to medical certifying examination scores? Acad Med. 2003;78(1):84-89. doi:10.1097/00001888-200301000-00015
7. Smith J, Zaffiri L, Clary J, Davis T, Bosslet GT. The effect of paging reminders on fellowship conference attendance: a multi-program randomized crossover study. J Grad Med Educ. 2016;8(3):372-377. doi:10.4300/JGME-D-15-00487.1
8. Sheeran P, Webb TL. The intention-behavior gap. Soc Personal Psychol Compass. 2016;10(9):503-518. doi:10.1111/spc3.12265
9. McDonald RJ, Luetmer PH, Kallmes DF. If you starve them, will they still come? Do complementary food provisions affect faculty meeting attendance in academic radiology? J Am Coll Radiol. 2011;8(11):809-810. doi:10.1016/j.jacr.2011.06.003
10. Segovis CM, Mueller PS, Rethlefsen ML, et al. If you feed them, they will come: a prospective study of the effects of complimentary food on attendance and physician attitudes at medical grand rounds at an academic medical center. BMC Med Educ. 2007;7:22. Published 2007 Jul 12. doi:10.1186/1472-6920-7-22
11. Mueller PS, Litin SC, Sowden ML, Habermann TM, LaRusso NF. Strategies for improving attendance at medical grand rounds at an academic medical center. Mayo Clin Proc. 2003;78(5):549-553. doi:10.4065/78.5.549
12. Tarabichi S, DeLeon M, Krumrei N, Hanna J, Maloney Patel N. Competition as a means for improving academic scores and attendance at education conference. J Surg Educ. 2018;75(6):1437-1440. doi:10.1016/j.jsurg.2018.04.020
13. Thaler RH, Sunstein CR. Nudge: Improving Decisions About Health, Wealth, and Happiness. Rev. and Expanded Ed. Penguin Books; 2009.
14. Weijers RJ, de Koning BB, Paas F. Nudging in education: from theory towards guidelines for successful implementation. Eur J Psychol Educ. 2021;36:883-902. Published 2020 Aug 24. doi:10.1007/s10212-020-00495-0
15. Wieland ML, Loertscher LL, Nelson DR, Szostek JH, Ficalora RD. A strategy to reduce interruptions at hospital morning report. J Grad Med Educ. 2010;2(1):83-84. doi:10.4300/JGME-D-09-00084.1
16. Witherspoon L, Nham E, Abdi H, et al. Is it time to rethink how we page physicians? Understanding paging patterns in a tertiary care hospital. BMC Health Serv Res. 2019;19(1):992. Published 2019 Dec 23. doi:10.1186/s12913-019-4844-0
17. Fargen KM, O’Connor T, Raymond S, Sporrer JM, Friedman WA. An observational study of hospital paging practices and workflow interruption among on-call junior neurological surgery residents. J Grad Med Educ. 2012;4(4):467-471. doi:10.4300/JGME-D-11-00306.1
18. Chick RC, Clifton GT, Peace KM, et al. Using technology to maintain the education of residents during the COVID-19 pandemic. J Surg Educ. 2020;77(4):729-732. doi:10.1016/j.jsurg.2020.03.018
1. Daniels VJ, Goldstein CE. Changing morning report: an educational intervention to address curricular needs. J Biomed Educ. 2014;2014:1-5. doi:10.1155/2014/830701
2. Parrino TA, Villanueva AG. The principles and practice of morning report. JAMA. 1986;256(6):730-733. doi:10.1001/jama.1986.03380060056025
3. Wenger NS, Shpiner RB. An analysis of morning report: implications for internal medicine education. Ann Intern Med. 1993;119(5):395-399. doi:10.7326/0003-4819-119-5-199309010-00008
4. Ways M, Kroenke K, Umali J, Buchwald D. Morning report. A survey of resident attitudes. Arch Intern Med. 1995;155(13):1433-1437. doi:10.1001/archinte.155.13.1433
5. McDonald FS, Zeger SL, Kolars JC. Associations of conference attendance with internal medicine in-training examination scores. Mayo Clin Proc. 2008;83(4):449-453. doi:10.4065/83.4.449
6. FitzGerald JD, Wenger NS. Didactic teaching conferences for IM residents: who attends, and is attendance related to medical certifying examination scores? Acad Med. 2003;78(1):84-89. doi:10.1097/00001888-200301000-00015
7. Smith J, Zaffiri L, Clary J, Davis T, Bosslet GT. The effect of paging reminders on fellowship conference attendance: a multi-program randomized crossover study. J Grad Med Educ. 2016;8(3):372-377. doi:10.4300/JGME-D-15-00487.1
8. Sheeran P, Webb TL. The intention-behavior gap. Soc Personal Psychol Compass. 2016;10(9):503-518. doi:10.1111/spc3.12265
9. McDonald RJ, Luetmer PH, Kallmes DF. If you starve them, will they still come? Do complementary food provisions affect faculty meeting attendance in academic radiology? J Am Coll Radiol. 2011;8(11):809-810. doi:10.1016/j.jacr.2011.06.003
10. Segovis CM, Mueller PS, Rethlefsen ML, et al. If you feed them, they will come: a prospective study of the effects of complimentary food on attendance and physician attitudes at medical grand rounds at an academic medical center. BMC Med Educ. 2007;7:22. Published 2007 Jul 12. doi:10.1186/1472-6920-7-22
11. Mueller PS, Litin SC, Sowden ML, Habermann TM, LaRusso NF. Strategies for improving attendance at medical grand rounds at an academic medical center. Mayo Clin Proc. 2003;78(5):549-553. doi:10.4065/78.5.549
12. Tarabichi S, DeLeon M, Krumrei N, Hanna J, Maloney Patel N. Competition as a means for improving academic scores and attendance at education conference. J Surg Educ. 2018;75(6):1437-1440. doi:10.1016/j.jsurg.2018.04.020
13. Thaler RH, Sunstein CR. Nudge: Improving Decisions About Health, Wealth, and Happiness. Rev. and Expanded Ed. Penguin Books; 2009.
14. Weijers RJ, de Koning BB, Paas F. Nudging in education: from theory towards guidelines for successful implementation. Eur J Psychol Educ. 2021;36:883-902. Published 2020 Aug 24. doi:10.1007/s10212-020-00495-0
15. Wieland ML, Loertscher LL, Nelson DR, Szostek JH, Ficalora RD. A strategy to reduce interruptions at hospital morning report. J Grad Med Educ. 2010;2(1):83-84. doi:10.4300/JGME-D-09-00084.1
16. Witherspoon L, Nham E, Abdi H, et al. Is it time to rethink how we page physicians? Understanding paging patterns in a tertiary care hospital. BMC Health Serv Res. 2019;19(1):992. Published 2019 Dec 23. doi:10.1186/s12913-019-4844-0
17. Fargen KM, O’Connor T, Raymond S, Sporrer JM, Friedman WA. An observational study of hospital paging practices and workflow interruption among on-call junior neurological surgery residents. J Grad Med Educ. 2012;4(4):467-471. doi:10.4300/JGME-D-11-00306.1
18. Chick RC, Clifton GT, Peace KM, et al. Using technology to maintain the education of residents during the COVID-19 pandemic. J Surg Educ. 2020;77(4):729-732. doi:10.1016/j.jsurg.2020.03.018
Nephrology–Palliative Care Collaboration to Promote Outpatient Hemodialysis Goals of Care Conversations
Estimates of chronic kidney disease (CKD) among veterans range between 34% and 47% higher than in the general population.1 As patients progress to end-stage kidney disease and begin chronic dialysis, they often experience further functional and cognitive decline and a high symptom burden, leading to poor quality of life.2 Clinicians should initiate goals of care conversations (GOCCs) to support high-risk patients on dialysis to ensure that the interventions they receive align with their goals and preferences, since many patients on dialysis prefer measures focused on pain relief and discomfort.3,4 While proactive GOCCs are supported among nephrology associations, few such conversations take place.5,6 In one study, more than half of patients on dialysis stated they had not discussed end-of-life preferences in the past 12 months.4 As a result, patients may not consider the larger implications of receiving dialysis indefinitely as a life-sustaining treatment (LST).
In May 2018, the US Department of Veterans Affairs (VA) National Center for Ethics in Health Care rolled out the Life-Sustaining Treatment Decisions Initiative to proactively engage patients with serious illnesses, such as those with end-stage kidney disease, in GOCCs to clarify their preferences for LSTs.7 After comprehensive training, a preliminary audit at the Edward Hines, Jr. VA Hospital (EHJVAH) in Hines, Illinois, revealed that only 27% of patients on dialysis had LST preferences documented in a standardized LST note.
Nephrologists cite multiple barriers to proactively addressing goals of care with patients with advanced CKD, including clinician discomfort, perceived lack of time, infrastructure, and training.8,9 Similarly, the absence of a multidisciplinary advance care planning approach—specifically bringing together palliative care (PC) clinicians with nephrologists—has been highlighted but not as well studied.10,11
In this quality improvement (QI) project, we aimed to establish a workflow to enhance collaboration between nephrology and PC and to increase the percentage of VA patients on outpatient hemodialysis who engaged in GOCCs, as documented by completion of an LST progress note in the VA’s electronic health record (EHR). We developed a collaboration among PC, nephrology, and social work to improve the rates of documented GOCCs and LST patients on dialysis.
Implementation
EHJVAH is a 1A facility with > 80 patients who receive outpatient hemodialysis on campus. At the time of this collaboration in the fall of 2019, the collaborative dialysis team comprised 2 social workers and a nephrologist. The PC team included a coordinator, 2 nurse practitioners, and 3 physicians. A QI nurse was involved in the initial data gathering for this project.
The PC and nephrology medical directors developed a workflow process that reflected organizational and clinical steps in planning, initiating, and completing GOCCs with patients on outpatient dialysis (Table 1). The proposed process engaged an interdisciplinary PC and nephrology group and was revised to incorporate staff suggestions.
A prospective review of 85 EHJVAH hemodialysis unit patient records was conducted between September 1, 2019, and September 30, 2020 (Table 2). We reviewed LST completion rates for all patients receiving dialysis within this timeframe. During the intervention period, the PC team approached 40 patients without LST notes to engage in GOCCs.
Discussion
Over the 13-month collaboration, LST note completion rates increased from 27% to 81%, with 69 of 85 patients having a documented LST progress note in the EHR. PC approached nearly half of all patients on dialysis. Most patients agreed to be seen by the PC team, with 72% of those approached agreeing to a PC consultation. Previous research has suggested that having a trusted dialysis staff member included in GOCCs contributes to high acceptance rates.12
PC is a relatively uncommon partnership for nephrologists, and PC and hospice services are underutilized in patients on dialysis both nationally and within the VA.13-15 Our outcomes could be replicated, as PC is required at all VA sites.
Conclusions
The innovation of an interdisciplinary nephrology–PC collaboration was an important step in increasing high-quality GOCCs and eliciting patient preferences for LSTs among patients on dialysis. PC integration for patients on dialysis is associated with improved symptom management, fewer aggressive health care measures, and a higher likelihood of dying in one’s preferred setting.16 While this partnership focused on patients already receiving dialysis, successful PC interventions are felt most keenly upstream, before dialysis initiation.
Acknowledgments
The authors acknowledge the contributions of their colleague, Mary McCabe, DNP, Quality Systems Improvement, Edward Hines, Jr. Veterans Affairs Hospital. The authors also acknowledge the clinical dedication of the dialysis social workers, Sarah Adam, LCSW, and Sarah Kraner, LCSW, without which this collaboration would not have been possible.
1. Patel N, Golzy M, Nainani N, et al. Prevalence of various comorbidities among veterans with chronic kidney disease and its comparison with other datasets. Ren Fail. 2016;38(2):204-208. doi:10.3109/0886022X.2015.1117924
2. Weisbord SD, Carmody SS, Bruns FJ, et al. Symptom burden, quality of life, advance care planning and the potential value of palliative care in severely ill haemodialysis patients. Nephrol Dial Transplant. 2003;18(7):1345-1352. doi:10.1093/ndt/gfg105
3. Wachterman MW, Marcantonio ER, Davis RB, et al. Relationship between the prognostic expectations of seriously ill patients undergoing hemodialysis and their nephrologists. JAMA Intern Med. 2013;173(13):1206-1214. doi:10.1001/jamainternmed.2013.6036
4. Davison SN. End-of-life care preferences and needs: perceptions of patients with chronic kidney disease. Clin J Am Soc Nephrol. 2010;5(2):195-204. doi:10.2215/CJN.05960809
5. Williams AW, Dwyer AC, Eddy AA, et al; American Society of Nephrology Quality, and Patient Safety Task Force. Critical and honest conversations: the evidence behind the “Choosing Wisely” campaign recommendations by the American Society of Nephrology. Clin J Am Soc Nephrol. 2012;7(10):1664-1672. doi:10.2215/CJN.04970512
6. Renal Physicians Association. Shared Decision-Making in the Appropriate Initiation of and Withdrawal from Dialysis. 2nd ed. Renal Physicians Association; 2010.
7. US Department of Veterans Affairs, National Center for Ethics in Health Care. Goals of care conversations training for nurses, social workers, psychologists, and chaplains. Updated October 9, 2018. Accessed August 31, 2023. https://www.ethics.va.gov/goalsofcaretraining/team.asp
8. Goff SL, Unruh ML, Klingensmith J, et al. Advance care planning with patients on hemodialysis: an implementation study. BMC Palliat Care. 2019;18(1):64. Published 2019 Jul 26. doi:10.1186/s12904-019-0437-2
9. O’Hare AM, Szarka J, McFarland LV, et al. Provider perspectives on advance care planning for patients with kidney disease: whose job is it anyway? Clin J Am Soc Nephrol. 2016;11(5):855-866. doi:10.2215/CJN.11351015
10. Koncicki HM, Schell JO. Communication skills and decision making for elderly patients with advanced kidney disease: a guide for nephrologists. Am J Kidney Dis. 2016;67(4):688-695. doi:10.1053/j.ajkd.2015.09.032
11. Holley JL, Davison SN. Advance care planning for patients with advanced CKD: a need to move forward. Clin J Am Soc Nephrol. 2015;10(3):344-346. doi:10.2215/CJN.00290115
12. Davison SN. Facilitating advance care planning for patients with end-stage renal disease: the patient perspective. Clin J Am Soc Nephrol. 2006;1(5):1023-1028. doi:10.2215/CJN.01050306
13. Murray AM, Arko C, Chen SC, Gilbertson DT, Moss AH. Use of hospice in the United States dialysis population. Clin J Am Soc Nephrol. 2006;1(6):1248-1255. doi:10.2215/CJN.00970306
14. Williams ME, Sandeep J, Catic A. Aging and ESRD demographics: consequences for the practice of dialysis. Semin Dial. 2012;25(6):617-622. doi:10.1111/sdi.12029
15. US Dept of Veterans Affairs. FY 2020 annual report. Palliative and hospice care.
16. Chandna SM, Da Silva-Gane M, Marshall C, Warwicker P, Greenwood RN, Farrington K. Survival of elderly patients with stage 5 CKD: comparison of conservative management and renal replacement therapy. Nephrol Dial Transplant. 2011;26(5):1608-1614. doi:10.1093/ndt/gfq630
17. Fadem SZ, Fadem J. HD mortality predictor. Accessed August 31, 2023. http://touchcalc.com/calculators/sq
18. National Center for Ethics in Health Care. Setting health care goals: a guide for people with hearth problems. Updated June 2016. Accessed August 31, 2023. https://www.ethics.va.gov/docs/GoCC/lst_booklet_for_patients_setting_health_care_goals_final.pdf
Estimates of chronic kidney disease (CKD) among veterans range between 34% and 47% higher than in the general population.1 As patients progress to end-stage kidney disease and begin chronic dialysis, they often experience further functional and cognitive decline and a high symptom burden, leading to poor quality of life.2 Clinicians should initiate goals of care conversations (GOCCs) to support high-risk patients on dialysis to ensure that the interventions they receive align with their goals and preferences, since many patients on dialysis prefer measures focused on pain relief and discomfort.3,4 While proactive GOCCs are supported among nephrology associations, few such conversations take place.5,6 In one study, more than half of patients on dialysis stated they had not discussed end-of-life preferences in the past 12 months.4 As a result, patients may not consider the larger implications of receiving dialysis indefinitely as a life-sustaining treatment (LST).
In May 2018, the US Department of Veterans Affairs (VA) National Center for Ethics in Health Care rolled out the Life-Sustaining Treatment Decisions Initiative to proactively engage patients with serious illnesses, such as those with end-stage kidney disease, in GOCCs to clarify their preferences for LSTs.7 After comprehensive training, a preliminary audit at the Edward Hines, Jr. VA Hospital (EHJVAH) in Hines, Illinois, revealed that only 27% of patients on dialysis had LST preferences documented in a standardized LST note.
Nephrologists cite multiple barriers to proactively addressing goals of care with patients with advanced CKD, including clinician discomfort, perceived lack of time, infrastructure, and training.8,9 Similarly, the absence of a multidisciplinary advance care planning approach—specifically bringing together palliative care (PC) clinicians with nephrologists—has been highlighted but not as well studied.10,11
In this quality improvement (QI) project, we aimed to establish a workflow to enhance collaboration between nephrology and PC and to increase the percentage of VA patients on outpatient hemodialysis who engaged in GOCCs, as documented by completion of an LST progress note in the VA’s electronic health record (EHR). We developed a collaboration among PC, nephrology, and social work to improve the rates of documented GOCCs and LST patients on dialysis.
Implementation
EHJVAH is a 1A facility with > 80 patients who receive outpatient hemodialysis on campus. At the time of this collaboration in the fall of 2019, the collaborative dialysis team comprised 2 social workers and a nephrologist. The PC team included a coordinator, 2 nurse practitioners, and 3 physicians. A QI nurse was involved in the initial data gathering for this project.
The PC and nephrology medical directors developed a workflow process that reflected organizational and clinical steps in planning, initiating, and completing GOCCs with patients on outpatient dialysis (Table 1). The proposed process engaged an interdisciplinary PC and nephrology group and was revised to incorporate staff suggestions.
A prospective review of 85 EHJVAH hemodialysis unit patient records was conducted between September 1, 2019, and September 30, 2020 (Table 2). We reviewed LST completion rates for all patients receiving dialysis within this timeframe. During the intervention period, the PC team approached 40 patients without LST notes to engage in GOCCs.
Discussion
Over the 13-month collaboration, LST note completion rates increased from 27% to 81%, with 69 of 85 patients having a documented LST progress note in the EHR. PC approached nearly half of all patients on dialysis. Most patients agreed to be seen by the PC team, with 72% of those approached agreeing to a PC consultation. Previous research has suggested that having a trusted dialysis staff member included in GOCCs contributes to high acceptance rates.12
PC is a relatively uncommon partnership for nephrologists, and PC and hospice services are underutilized in patients on dialysis both nationally and within the VA.13-15 Our outcomes could be replicated, as PC is required at all VA sites.
Conclusions
The innovation of an interdisciplinary nephrology–PC collaboration was an important step in increasing high-quality GOCCs and eliciting patient preferences for LSTs among patients on dialysis. PC integration for patients on dialysis is associated with improved symptom management, fewer aggressive health care measures, and a higher likelihood of dying in one’s preferred setting.16 While this partnership focused on patients already receiving dialysis, successful PC interventions are felt most keenly upstream, before dialysis initiation.
Acknowledgments
The authors acknowledge the contributions of their colleague, Mary McCabe, DNP, Quality Systems Improvement, Edward Hines, Jr. Veterans Affairs Hospital. The authors also acknowledge the clinical dedication of the dialysis social workers, Sarah Adam, LCSW, and Sarah Kraner, LCSW, without which this collaboration would not have been possible.
Estimates of chronic kidney disease (CKD) among veterans range between 34% and 47% higher than in the general population.1 As patients progress to end-stage kidney disease and begin chronic dialysis, they often experience further functional and cognitive decline and a high symptom burden, leading to poor quality of life.2 Clinicians should initiate goals of care conversations (GOCCs) to support high-risk patients on dialysis to ensure that the interventions they receive align with their goals and preferences, since many patients on dialysis prefer measures focused on pain relief and discomfort.3,4 While proactive GOCCs are supported among nephrology associations, few such conversations take place.5,6 In one study, more than half of patients on dialysis stated they had not discussed end-of-life preferences in the past 12 months.4 As a result, patients may not consider the larger implications of receiving dialysis indefinitely as a life-sustaining treatment (LST).
In May 2018, the US Department of Veterans Affairs (VA) National Center for Ethics in Health Care rolled out the Life-Sustaining Treatment Decisions Initiative to proactively engage patients with serious illnesses, such as those with end-stage kidney disease, in GOCCs to clarify their preferences for LSTs.7 After comprehensive training, a preliminary audit at the Edward Hines, Jr. VA Hospital (EHJVAH) in Hines, Illinois, revealed that only 27% of patients on dialysis had LST preferences documented in a standardized LST note.
Nephrologists cite multiple barriers to proactively addressing goals of care with patients with advanced CKD, including clinician discomfort, perceived lack of time, infrastructure, and training.8,9 Similarly, the absence of a multidisciplinary advance care planning approach—specifically bringing together palliative care (PC) clinicians with nephrologists—has been highlighted but not as well studied.10,11
In this quality improvement (QI) project, we aimed to establish a workflow to enhance collaboration between nephrology and PC and to increase the percentage of VA patients on outpatient hemodialysis who engaged in GOCCs, as documented by completion of an LST progress note in the VA’s electronic health record (EHR). We developed a collaboration among PC, nephrology, and social work to improve the rates of documented GOCCs and LST patients on dialysis.
Implementation
EHJVAH is a 1A facility with > 80 patients who receive outpatient hemodialysis on campus. At the time of this collaboration in the fall of 2019, the collaborative dialysis team comprised 2 social workers and a nephrologist. The PC team included a coordinator, 2 nurse practitioners, and 3 physicians. A QI nurse was involved in the initial data gathering for this project.
The PC and nephrology medical directors developed a workflow process that reflected organizational and clinical steps in planning, initiating, and completing GOCCs with patients on outpatient dialysis (Table 1). The proposed process engaged an interdisciplinary PC and nephrology group and was revised to incorporate staff suggestions.
A prospective review of 85 EHJVAH hemodialysis unit patient records was conducted between September 1, 2019, and September 30, 2020 (Table 2). We reviewed LST completion rates for all patients receiving dialysis within this timeframe. During the intervention period, the PC team approached 40 patients without LST notes to engage in GOCCs.
Discussion
Over the 13-month collaboration, LST note completion rates increased from 27% to 81%, with 69 of 85 patients having a documented LST progress note in the EHR. PC approached nearly half of all patients on dialysis. Most patients agreed to be seen by the PC team, with 72% of those approached agreeing to a PC consultation. Previous research has suggested that having a trusted dialysis staff member included in GOCCs contributes to high acceptance rates.12
PC is a relatively uncommon partnership for nephrologists, and PC and hospice services are underutilized in patients on dialysis both nationally and within the VA.13-15 Our outcomes could be replicated, as PC is required at all VA sites.
Conclusions
The innovation of an interdisciplinary nephrology–PC collaboration was an important step in increasing high-quality GOCCs and eliciting patient preferences for LSTs among patients on dialysis. PC integration for patients on dialysis is associated with improved symptom management, fewer aggressive health care measures, and a higher likelihood of dying in one’s preferred setting.16 While this partnership focused on patients already receiving dialysis, successful PC interventions are felt most keenly upstream, before dialysis initiation.
Acknowledgments
The authors acknowledge the contributions of their colleague, Mary McCabe, DNP, Quality Systems Improvement, Edward Hines, Jr. Veterans Affairs Hospital. The authors also acknowledge the clinical dedication of the dialysis social workers, Sarah Adam, LCSW, and Sarah Kraner, LCSW, without which this collaboration would not have been possible.
1. Patel N, Golzy M, Nainani N, et al. Prevalence of various comorbidities among veterans with chronic kidney disease and its comparison with other datasets. Ren Fail. 2016;38(2):204-208. doi:10.3109/0886022X.2015.1117924
2. Weisbord SD, Carmody SS, Bruns FJ, et al. Symptom burden, quality of life, advance care planning and the potential value of palliative care in severely ill haemodialysis patients. Nephrol Dial Transplant. 2003;18(7):1345-1352. doi:10.1093/ndt/gfg105
3. Wachterman MW, Marcantonio ER, Davis RB, et al. Relationship between the prognostic expectations of seriously ill patients undergoing hemodialysis and their nephrologists. JAMA Intern Med. 2013;173(13):1206-1214. doi:10.1001/jamainternmed.2013.6036
4. Davison SN. End-of-life care preferences and needs: perceptions of patients with chronic kidney disease. Clin J Am Soc Nephrol. 2010;5(2):195-204. doi:10.2215/CJN.05960809
5. Williams AW, Dwyer AC, Eddy AA, et al; American Society of Nephrology Quality, and Patient Safety Task Force. Critical and honest conversations: the evidence behind the “Choosing Wisely” campaign recommendations by the American Society of Nephrology. Clin J Am Soc Nephrol. 2012;7(10):1664-1672. doi:10.2215/CJN.04970512
6. Renal Physicians Association. Shared Decision-Making in the Appropriate Initiation of and Withdrawal from Dialysis. 2nd ed. Renal Physicians Association; 2010.
7. US Department of Veterans Affairs, National Center for Ethics in Health Care. Goals of care conversations training for nurses, social workers, psychologists, and chaplains. Updated October 9, 2018. Accessed August 31, 2023. https://www.ethics.va.gov/goalsofcaretraining/team.asp
8. Goff SL, Unruh ML, Klingensmith J, et al. Advance care planning with patients on hemodialysis: an implementation study. BMC Palliat Care. 2019;18(1):64. Published 2019 Jul 26. doi:10.1186/s12904-019-0437-2
9. O’Hare AM, Szarka J, McFarland LV, et al. Provider perspectives on advance care planning for patients with kidney disease: whose job is it anyway? Clin J Am Soc Nephrol. 2016;11(5):855-866. doi:10.2215/CJN.11351015
10. Koncicki HM, Schell JO. Communication skills and decision making for elderly patients with advanced kidney disease: a guide for nephrologists. Am J Kidney Dis. 2016;67(4):688-695. doi:10.1053/j.ajkd.2015.09.032
11. Holley JL, Davison SN. Advance care planning for patients with advanced CKD: a need to move forward. Clin J Am Soc Nephrol. 2015;10(3):344-346. doi:10.2215/CJN.00290115
12. Davison SN. Facilitating advance care planning for patients with end-stage renal disease: the patient perspective. Clin J Am Soc Nephrol. 2006;1(5):1023-1028. doi:10.2215/CJN.01050306
13. Murray AM, Arko C, Chen SC, Gilbertson DT, Moss AH. Use of hospice in the United States dialysis population. Clin J Am Soc Nephrol. 2006;1(6):1248-1255. doi:10.2215/CJN.00970306
14. Williams ME, Sandeep J, Catic A. Aging and ESRD demographics: consequences for the practice of dialysis. Semin Dial. 2012;25(6):617-622. doi:10.1111/sdi.12029
15. US Dept of Veterans Affairs. FY 2020 annual report. Palliative and hospice care.
16. Chandna SM, Da Silva-Gane M, Marshall C, Warwicker P, Greenwood RN, Farrington K. Survival of elderly patients with stage 5 CKD: comparison of conservative management and renal replacement therapy. Nephrol Dial Transplant. 2011;26(5):1608-1614. doi:10.1093/ndt/gfq630
17. Fadem SZ, Fadem J. HD mortality predictor. Accessed August 31, 2023. http://touchcalc.com/calculators/sq
18. National Center for Ethics in Health Care. Setting health care goals: a guide for people with hearth problems. Updated June 2016. Accessed August 31, 2023. https://www.ethics.va.gov/docs/GoCC/lst_booklet_for_patients_setting_health_care_goals_final.pdf
1. Patel N, Golzy M, Nainani N, et al. Prevalence of various comorbidities among veterans with chronic kidney disease and its comparison with other datasets. Ren Fail. 2016;38(2):204-208. doi:10.3109/0886022X.2015.1117924
2. Weisbord SD, Carmody SS, Bruns FJ, et al. Symptom burden, quality of life, advance care planning and the potential value of palliative care in severely ill haemodialysis patients. Nephrol Dial Transplant. 2003;18(7):1345-1352. doi:10.1093/ndt/gfg105
3. Wachterman MW, Marcantonio ER, Davis RB, et al. Relationship between the prognostic expectations of seriously ill patients undergoing hemodialysis and their nephrologists. JAMA Intern Med. 2013;173(13):1206-1214. doi:10.1001/jamainternmed.2013.6036
4. Davison SN. End-of-life care preferences and needs: perceptions of patients with chronic kidney disease. Clin J Am Soc Nephrol. 2010;5(2):195-204. doi:10.2215/CJN.05960809
5. Williams AW, Dwyer AC, Eddy AA, et al; American Society of Nephrology Quality, and Patient Safety Task Force. Critical and honest conversations: the evidence behind the “Choosing Wisely” campaign recommendations by the American Society of Nephrology. Clin J Am Soc Nephrol. 2012;7(10):1664-1672. doi:10.2215/CJN.04970512
6. Renal Physicians Association. Shared Decision-Making in the Appropriate Initiation of and Withdrawal from Dialysis. 2nd ed. Renal Physicians Association; 2010.
7. US Department of Veterans Affairs, National Center for Ethics in Health Care. Goals of care conversations training for nurses, social workers, psychologists, and chaplains. Updated October 9, 2018. Accessed August 31, 2023. https://www.ethics.va.gov/goalsofcaretraining/team.asp
8. Goff SL, Unruh ML, Klingensmith J, et al. Advance care planning with patients on hemodialysis: an implementation study. BMC Palliat Care. 2019;18(1):64. Published 2019 Jul 26. doi:10.1186/s12904-019-0437-2
9. O’Hare AM, Szarka J, McFarland LV, et al. Provider perspectives on advance care planning for patients with kidney disease: whose job is it anyway? Clin J Am Soc Nephrol. 2016;11(5):855-866. doi:10.2215/CJN.11351015
10. Koncicki HM, Schell JO. Communication skills and decision making for elderly patients with advanced kidney disease: a guide for nephrologists. Am J Kidney Dis. 2016;67(4):688-695. doi:10.1053/j.ajkd.2015.09.032
11. Holley JL, Davison SN. Advance care planning for patients with advanced CKD: a need to move forward. Clin J Am Soc Nephrol. 2015;10(3):344-346. doi:10.2215/CJN.00290115
12. Davison SN. Facilitating advance care planning for patients with end-stage renal disease: the patient perspective. Clin J Am Soc Nephrol. 2006;1(5):1023-1028. doi:10.2215/CJN.01050306
13. Murray AM, Arko C, Chen SC, Gilbertson DT, Moss AH. Use of hospice in the United States dialysis population. Clin J Am Soc Nephrol. 2006;1(6):1248-1255. doi:10.2215/CJN.00970306
14. Williams ME, Sandeep J, Catic A. Aging and ESRD demographics: consequences for the practice of dialysis. Semin Dial. 2012;25(6):617-622. doi:10.1111/sdi.12029
15. US Dept of Veterans Affairs. FY 2020 annual report. Palliative and hospice care.
16. Chandna SM, Da Silva-Gane M, Marshall C, Warwicker P, Greenwood RN, Farrington K. Survival of elderly patients with stage 5 CKD: comparison of conservative management and renal replacement therapy. Nephrol Dial Transplant. 2011;26(5):1608-1614. doi:10.1093/ndt/gfq630
17. Fadem SZ, Fadem J. HD mortality predictor. Accessed August 31, 2023. http://touchcalc.com/calculators/sq
18. National Center for Ethics in Health Care. Setting health care goals: a guide for people with hearth problems. Updated June 2016. Accessed August 31, 2023. https://www.ethics.va.gov/docs/GoCC/lst_booklet_for_patients_setting_health_care_goals_final.pdf
Precision medicine takes individual approach to diabetes
HAMBURG, GERMANY –
“Diabetes recommendations often focus on what works well for the average person. However, because diabetes is an incredibly heterogeneous disease, few people are Mr. or Mrs. ‘average’ and one-size-fits-all approaches fail many people in need. Precision medicine seeks to address this major problem,” said Precision Medicine in Diabetes Initiative (PDMI) cochair Paul Franks, PhD, MPhil, head of the department of translational medicine at the Novo Nordisk Foundation in Denmark.
The report is the second from the joint American Diabetes Association/European Association for the Study of Diabetes PDMI, a consortium organized in 2018 with the aim of addressing “the untenable health and economic burdens of diabetes prevention and care.”
Based on findings from 15 systematic reviews and expert opinions, the new statement covers the key precision medicine pillars of prevention, diagnosis, treatment, and prognosis for each of four major recognized forms of diabetes: monogenic, gestational, type 1, and type 2. It addresses clinical translation of precision medicine research, including near-term actionable measures. Working groups were tasked with defining the key research questions that need to be addressed for precision diabetes medicine to be implemented into clinical practice by 2030.
Dr. Franks noted that “precision medicine seeks to improve diabetes prevention and care by combining data about a person’s health or disease state and response to medications. The aim is to tailor the advice given about diabetes prevention or treatment to the person in question, rather than having them make do with generic advice. Precision medicine very much focuses on treating the person and not the disease.”
A 90-minute symposium summarizing the report was presented at the annual meeting of the European Association for the Study of Diabetes. An executive summary was simultaneously published in the journal Nature Medicine. Four additional complementary papers, covering cardiometabolic disease precision medicine, diabetes heterogeneity, precision medicine of obesity, and precision cardiometabolic medicine in low- and middle-income countries, were published separately in The Lancet Diabetes & Endocrinology.
In a comment, Kamlesh Khunti, MD, professor of primary care diabetes and vascular medicine at the University of Leicester, England, called the new report “fantastic collaborative work.”
However, Dr. Khunti said, “I think at the moment we’re at the discovery stage of precision medicine. The clinical utility of that, we’ll have to see over the years.”
Dr. Khunti also pointed out: “A lot of the work done in precision medicine has been on specific diseases, like diabetes and cardiovascular disease. But, 30% of people don’t just have one disease, they have multiple long-term conditions. I think we need to start thinking about that now, rather than single conditions, because we want to look at drug targets that will hit multiple long-term conditions rather than one single condition.”
Currently, a dearth of data
Even just within diabetes, there is a dearth of quality data. In fact, Dr. Franks told this news organization, there has only been one precision medicine trial in diabetes, called TriMaster, comparing individual responses to three different second-line treatments for type 2 diabetes after metformin. “The problem with that trial is that the second-line medications it investigated aren’t widely prescribed now. The trial was designed back in 2014. It took a long time, then there was COVID, and by the time it was published too much time had elapsed and it was already out of date.”
Ideally, to make this effort current, Dr. Franks said, “is to get drug companies to implement these trials into their development pipelines. If you think about it, it’s far more efficient to implement precision medicine early in the drug development process than late, because when you do it late you end up having to do lots of comparisons of different possibilities. When you do it early you sort out those comparisons as part of the development process, so it really comes down to companies being willing to do that and regulators being willing to accept results from those trials. That’s another challenge, which is why we stress regulatory engagement as a key thing.”
In the future, he said, using the second-line type 2 diabetes drug as an example, when a person is diagnosed with type 2 diabetes they might automatically be given a companion diagnostic that’s more sophisticated and more precise than current ways of defining cardiovascular risk to better predict which individuals are more likely to experience a cardiovascular event.
This concept, referred to as “precision diagnostics,” is a “core driver of precision medicine,” Dr. Franks said. “If we can get a higher predictive accuracy on cardiovascular outcomes in people with diabetes, essentially treatment allocation is likely to be more precise too, because you’re not treating people you don’t need to treat and you’re not missing people you should have treated. I think that’s probably how it will work out.”
‘Studying diverse populations benefits everyone’
An important component emphasized in the report is the lack of “relevant, high-quality research in people of non-European ancestry, hindering the development and implementation of precision diabetes medicine in many of the most heavily burdened populations worldwide.”
That specific issue was addressed during the symposium by Shivani Misra, MBBS, PhD clinical senior lecturer in diabetes and endocrinology at Imperial College, London, and the lead author of the separate complementary paper on the topic.
Dr. Misra argued against the notion that precision medicine is only for wealthy countries, noting that diabetes and other noncommunicable diseases are becoming major health problems in low- and middle-income countries. “Resource-restricted settings may derive the greatest benefits from precision medicine,” she said. “Studying diverse populations benefits everyone.”
And worldwide, she noted, “the right drug for the right person will improve cost-effectiveness in the long-term.”
Dr. Franks is an employee of the Novo Nordisk Foundation, a “purely philanthropic enterprise-owning foundation” with a portfolio of 151 companies. He has received consultancy fees from Zoe Ltd., Eli Lilly, and Novo Nordisk, and research funding from multiple pharmaceutical companies. Dr. Khunti has acted as a consultant, speaker, or received grants for investigator-initiated studies from AstraZeneca, Novartis, Novo Nordisk, Sanofi-Aventis, Lilly and Merck Sharp & Dohme, Boehringer Ingelheim, Bayer, Berlin-Chemie/Menarini Group, Janssen, and Napp. Dr. Misra has received speaker fees from Sanofi and ABCD and an investigator-initiated research grant from Dexcom, and is a trustee for the Diabetes Research and Wellness Foundation.
A version of this article first appeared on Medscape.com.
HAMBURG, GERMANY –
“Diabetes recommendations often focus on what works well for the average person. However, because diabetes is an incredibly heterogeneous disease, few people are Mr. or Mrs. ‘average’ and one-size-fits-all approaches fail many people in need. Precision medicine seeks to address this major problem,” said Precision Medicine in Diabetes Initiative (PDMI) cochair Paul Franks, PhD, MPhil, head of the department of translational medicine at the Novo Nordisk Foundation in Denmark.
The report is the second from the joint American Diabetes Association/European Association for the Study of Diabetes PDMI, a consortium organized in 2018 with the aim of addressing “the untenable health and economic burdens of diabetes prevention and care.”
Based on findings from 15 systematic reviews and expert opinions, the new statement covers the key precision medicine pillars of prevention, diagnosis, treatment, and prognosis for each of four major recognized forms of diabetes: monogenic, gestational, type 1, and type 2. It addresses clinical translation of precision medicine research, including near-term actionable measures. Working groups were tasked with defining the key research questions that need to be addressed for precision diabetes medicine to be implemented into clinical practice by 2030.
Dr. Franks noted that “precision medicine seeks to improve diabetes prevention and care by combining data about a person’s health or disease state and response to medications. The aim is to tailor the advice given about diabetes prevention or treatment to the person in question, rather than having them make do with generic advice. Precision medicine very much focuses on treating the person and not the disease.”
A 90-minute symposium summarizing the report was presented at the annual meeting of the European Association for the Study of Diabetes. An executive summary was simultaneously published in the journal Nature Medicine. Four additional complementary papers, covering cardiometabolic disease precision medicine, diabetes heterogeneity, precision medicine of obesity, and precision cardiometabolic medicine in low- and middle-income countries, were published separately in The Lancet Diabetes & Endocrinology.
In a comment, Kamlesh Khunti, MD, professor of primary care diabetes and vascular medicine at the University of Leicester, England, called the new report “fantastic collaborative work.”
However, Dr. Khunti said, “I think at the moment we’re at the discovery stage of precision medicine. The clinical utility of that, we’ll have to see over the years.”
Dr. Khunti also pointed out: “A lot of the work done in precision medicine has been on specific diseases, like diabetes and cardiovascular disease. But, 30% of people don’t just have one disease, they have multiple long-term conditions. I think we need to start thinking about that now, rather than single conditions, because we want to look at drug targets that will hit multiple long-term conditions rather than one single condition.”
Currently, a dearth of data
Even just within diabetes, there is a dearth of quality data. In fact, Dr. Franks told this news organization, there has only been one precision medicine trial in diabetes, called TriMaster, comparing individual responses to three different second-line treatments for type 2 diabetes after metformin. “The problem with that trial is that the second-line medications it investigated aren’t widely prescribed now. The trial was designed back in 2014. It took a long time, then there was COVID, and by the time it was published too much time had elapsed and it was already out of date.”
Ideally, to make this effort current, Dr. Franks said, “is to get drug companies to implement these trials into their development pipelines. If you think about it, it’s far more efficient to implement precision medicine early in the drug development process than late, because when you do it late you end up having to do lots of comparisons of different possibilities. When you do it early you sort out those comparisons as part of the development process, so it really comes down to companies being willing to do that and regulators being willing to accept results from those trials. That’s another challenge, which is why we stress regulatory engagement as a key thing.”
In the future, he said, using the second-line type 2 diabetes drug as an example, when a person is diagnosed with type 2 diabetes they might automatically be given a companion diagnostic that’s more sophisticated and more precise than current ways of defining cardiovascular risk to better predict which individuals are more likely to experience a cardiovascular event.
This concept, referred to as “precision diagnostics,” is a “core driver of precision medicine,” Dr. Franks said. “If we can get a higher predictive accuracy on cardiovascular outcomes in people with diabetes, essentially treatment allocation is likely to be more precise too, because you’re not treating people you don’t need to treat and you’re not missing people you should have treated. I think that’s probably how it will work out.”
‘Studying diverse populations benefits everyone’
An important component emphasized in the report is the lack of “relevant, high-quality research in people of non-European ancestry, hindering the development and implementation of precision diabetes medicine in many of the most heavily burdened populations worldwide.”
That specific issue was addressed during the symposium by Shivani Misra, MBBS, PhD clinical senior lecturer in diabetes and endocrinology at Imperial College, London, and the lead author of the separate complementary paper on the topic.
Dr. Misra argued against the notion that precision medicine is only for wealthy countries, noting that diabetes and other noncommunicable diseases are becoming major health problems in low- and middle-income countries. “Resource-restricted settings may derive the greatest benefits from precision medicine,” she said. “Studying diverse populations benefits everyone.”
And worldwide, she noted, “the right drug for the right person will improve cost-effectiveness in the long-term.”
Dr. Franks is an employee of the Novo Nordisk Foundation, a “purely philanthropic enterprise-owning foundation” with a portfolio of 151 companies. He has received consultancy fees from Zoe Ltd., Eli Lilly, and Novo Nordisk, and research funding from multiple pharmaceutical companies. Dr. Khunti has acted as a consultant, speaker, or received grants for investigator-initiated studies from AstraZeneca, Novartis, Novo Nordisk, Sanofi-Aventis, Lilly and Merck Sharp & Dohme, Boehringer Ingelheim, Bayer, Berlin-Chemie/Menarini Group, Janssen, and Napp. Dr. Misra has received speaker fees from Sanofi and ABCD and an investigator-initiated research grant from Dexcom, and is a trustee for the Diabetes Research and Wellness Foundation.
A version of this article first appeared on Medscape.com.
HAMBURG, GERMANY –
“Diabetes recommendations often focus on what works well for the average person. However, because diabetes is an incredibly heterogeneous disease, few people are Mr. or Mrs. ‘average’ and one-size-fits-all approaches fail many people in need. Precision medicine seeks to address this major problem,” said Precision Medicine in Diabetes Initiative (PDMI) cochair Paul Franks, PhD, MPhil, head of the department of translational medicine at the Novo Nordisk Foundation in Denmark.
The report is the second from the joint American Diabetes Association/European Association for the Study of Diabetes PDMI, a consortium organized in 2018 with the aim of addressing “the untenable health and economic burdens of diabetes prevention and care.”
Based on findings from 15 systematic reviews and expert opinions, the new statement covers the key precision medicine pillars of prevention, diagnosis, treatment, and prognosis for each of four major recognized forms of diabetes: monogenic, gestational, type 1, and type 2. It addresses clinical translation of precision medicine research, including near-term actionable measures. Working groups were tasked with defining the key research questions that need to be addressed for precision diabetes medicine to be implemented into clinical practice by 2030.
Dr. Franks noted that “precision medicine seeks to improve diabetes prevention and care by combining data about a person’s health or disease state and response to medications. The aim is to tailor the advice given about diabetes prevention or treatment to the person in question, rather than having them make do with generic advice. Precision medicine very much focuses on treating the person and not the disease.”
A 90-minute symposium summarizing the report was presented at the annual meeting of the European Association for the Study of Diabetes. An executive summary was simultaneously published in the journal Nature Medicine. Four additional complementary papers, covering cardiometabolic disease precision medicine, diabetes heterogeneity, precision medicine of obesity, and precision cardiometabolic medicine in low- and middle-income countries, were published separately in The Lancet Diabetes & Endocrinology.
In a comment, Kamlesh Khunti, MD, professor of primary care diabetes and vascular medicine at the University of Leicester, England, called the new report “fantastic collaborative work.”
However, Dr. Khunti said, “I think at the moment we’re at the discovery stage of precision medicine. The clinical utility of that, we’ll have to see over the years.”
Dr. Khunti also pointed out: “A lot of the work done in precision medicine has been on specific diseases, like diabetes and cardiovascular disease. But, 30% of people don’t just have one disease, they have multiple long-term conditions. I think we need to start thinking about that now, rather than single conditions, because we want to look at drug targets that will hit multiple long-term conditions rather than one single condition.”
Currently, a dearth of data
Even just within diabetes, there is a dearth of quality data. In fact, Dr. Franks told this news organization, there has only been one precision medicine trial in diabetes, called TriMaster, comparing individual responses to three different second-line treatments for type 2 diabetes after metformin. “The problem with that trial is that the second-line medications it investigated aren’t widely prescribed now. The trial was designed back in 2014. It took a long time, then there was COVID, and by the time it was published too much time had elapsed and it was already out of date.”
Ideally, to make this effort current, Dr. Franks said, “is to get drug companies to implement these trials into their development pipelines. If you think about it, it’s far more efficient to implement precision medicine early in the drug development process than late, because when you do it late you end up having to do lots of comparisons of different possibilities. When you do it early you sort out those comparisons as part of the development process, so it really comes down to companies being willing to do that and regulators being willing to accept results from those trials. That’s another challenge, which is why we stress regulatory engagement as a key thing.”
In the future, he said, using the second-line type 2 diabetes drug as an example, when a person is diagnosed with type 2 diabetes they might automatically be given a companion diagnostic that’s more sophisticated and more precise than current ways of defining cardiovascular risk to better predict which individuals are more likely to experience a cardiovascular event.
This concept, referred to as “precision diagnostics,” is a “core driver of precision medicine,” Dr. Franks said. “If we can get a higher predictive accuracy on cardiovascular outcomes in people with diabetes, essentially treatment allocation is likely to be more precise too, because you’re not treating people you don’t need to treat and you’re not missing people you should have treated. I think that’s probably how it will work out.”
‘Studying diverse populations benefits everyone’
An important component emphasized in the report is the lack of “relevant, high-quality research in people of non-European ancestry, hindering the development and implementation of precision diabetes medicine in many of the most heavily burdened populations worldwide.”
That specific issue was addressed during the symposium by Shivani Misra, MBBS, PhD clinical senior lecturer in diabetes and endocrinology at Imperial College, London, and the lead author of the separate complementary paper on the topic.
Dr. Misra argued against the notion that precision medicine is only for wealthy countries, noting that diabetes and other noncommunicable diseases are becoming major health problems in low- and middle-income countries. “Resource-restricted settings may derive the greatest benefits from precision medicine,” she said. “Studying diverse populations benefits everyone.”
And worldwide, she noted, “the right drug for the right person will improve cost-effectiveness in the long-term.”
Dr. Franks is an employee of the Novo Nordisk Foundation, a “purely philanthropic enterprise-owning foundation” with a portfolio of 151 companies. He has received consultancy fees from Zoe Ltd., Eli Lilly, and Novo Nordisk, and research funding from multiple pharmaceutical companies. Dr. Khunti has acted as a consultant, speaker, or received grants for investigator-initiated studies from AstraZeneca, Novartis, Novo Nordisk, Sanofi-Aventis, Lilly and Merck Sharp & Dohme, Boehringer Ingelheim, Bayer, Berlin-Chemie/Menarini Group, Janssen, and Napp. Dr. Misra has received speaker fees from Sanofi and ABCD and an investigator-initiated research grant from Dexcom, and is a trustee for the Diabetes Research and Wellness Foundation.
A version of this article first appeared on Medscape.com.
FROM EASD 2023
What is the future for multicancer early-detection tests?
Suzette Delaloge, MD, MSc, oncologist, breast cancer specialist, and director of the individualized cancer prevention program (Interception) at the Gustave Roussy Institute in Villejuif, France, looks into these “liquid biopsies” and shares her reservations about their potential marketing, especially to the organized care plans.
Question: What are the general principles underpinning these MCED tests?
Suzette Delaloge, MD, MSc: Despite their specificities, the general idea is to detect certain cancer markers in various body fluids (blood, urine, saliva, etc.), for example, molecules released by cancer cells (cytokines, inflammatory proteins, leptin, etc.) or distinctive features of the DNA in tumor cells. In blood, these molecules can be found in plasma or in serum. In urine, it’s more about detecting kidney, bladder, and urinary tract cancers.
Q: What sort of time frame are we looking at for these MCED tests to be used in routine practice?
Dr. Delaloge: They first appeared around 10 years ago. Development of these tests has intensified in recent years. There are numerous research laboratories, both public and private, that are developing different early-detection tests for cancer.
Some of these development processes are about to come to an end and are expected to be in regular, concrete use within 5-10 years. For the most advanced developments, the main biologic material researched and analyzed is DNA from cancer cells. We all have fragments of DNA from dead cells in our plasma (apoptosis), but cancer cells release more of these than others, and most importantly, their DNA has distinctive characteristics. The idea is to develop tests capable of detecting these characteristics.
Liquid biopsies based on genomic biomarkers could make MCED a reality, especially for cancers for which there is no standard screening process. But at this stage of the research, there are limitations, including low sensitivity for detecting stage I cancers in validation studies and an increased risk for overdiagnosis.
Q: What specific set of characteristics are the most advanced approaches based on?
Dr. Delaloge: They’re based on the analysis of DNA methylation, a biological process by which CH3 methyl groups are added to the DNA molecule and that determines gene expression. This phenomenon differs depending on whether the cell is cancerous. Among the tests currently under development making use of this specific characteristic is the Galleri test, which is the most advanced of them all.
A previous British National Health Service study, SYMPLIFY, which was published in 2023 by researchers at the University of Oxford, was conducted in symptomatic patients attending a health center. It offers promising results in a diagnostic situation. It has nothing at all to do with screening here. A large, randomized English study, NHS-Galleri, is underway, this time involving the general population, with the aim of assessing the potential benefit of the same test as screening in 140,000 people between ages 50 and 77 years.
In the SYMPLIFY study, which was carried out in symptomatic patients attending a health center, the Galleri MCED test had a positive predictive value of 75.5%, a negative predictive value of 97.6%, a sensitivity of 66.3%, and a specificity of 98.4%. Sensitivity increased with age and cancer stage from 24.2% at stage I to 95.3% at stage IV. For cases for which a cancer signal was detected in patients with cancer, the prediction of the original site of the cancer by the MCED test was accurate in 85.2% of cases. This large-scale prospective evaluation of an MCED diagnostic test confirms its feasibility in a symptomatic population but is not yet sufficiently accurate to “confirm or rule out the presence of cancer.” According to the authors, “in cases in which the MCED test detects a cancer signal in this context, the probability of a diagnosis of cancer being made is considerably higher and may identify cancers at sites other than those suspected during the initial referral phase, thus reducing delays in diagnosis.” A negative test means a lower likelihood of cancer but not so low that proper investigation can be ruled out. Further tests will be needed to optimize use of a negative predictive value.
Q: Does MCED testing concern all types of cancer?
Dr. Delaloge: The Galleri test is based on full profiling of DNA methylation. This allows for early diagnosis of cancer even before it can be seen on imaging tests. The issue with these tests is that they aren’t that good at early diagnosis of the most common types of cancer (breast, colorectal, cervical, etc.) for which we already have more efficient means such as the fecal immunochemical test for colorectal cancer, mammography, HPV testing, and so on.
These blood tests would thus not be aimed at replacing routine screening but rather at screening asymptomatic individuals or those with nonspecific signs for cancers for which we have few or no screening measures and which are on the rise, such as deep tumors and cancer diagnosed at a late stage, namely pancreas, bile duct, ovarian, esophageal, lung, stomach, etc.
The results from the studies published are promising, but others are underway to confirm the benefit of these MCEDs. The challenge is to identify cancer at an early stage, at a stage where it will be easier to cure the patient and control its growth using treatments that are less onerous for the patient and that have fewer aftereffects but not at the expense of a massive increase in overdiagnosis, as seen with prostate-specific antigen levels in prostate cancer a few years ago!
Q: What would be the focus of these MCED tests?
Dr. Delaloge: We must be alert to the risk for the market development of MCED tests. For now, they are mostly, especially the Galleri test, developed in the general population to screen for types of cancer that could not be detected in any other way but also because it’s the most financially beneficial situation. The designers want to position themselves in the general population, regardless of whether this means they’ll have to test hundreds of people to find one for whom the test is beneficial. What’s more, developing tests in isolation, without considering their place in ad hoc treatment pathways, is not realistic. It’s likely that some of these tests will be marketed within the next 10 years, but the health care systems destined to receive them are not remotely ready to do so.
Q: An even more recent publication, from late July 2023, is even more exciting in relation to early detection of lung cancer using circulating DNA sequencing. What are your thoughts on it?
Dr. Delaloge: Initially overtaken by other technologies in favor of MCED approaches, DNA sequencing as a technique to detect somatic mutations seems to have reentered the competition with this new-generation research. The authors published some very interesting results, especially for stage I lung cancer with a very high sensitivity of 75%. [Editor’s note: A machine-learning model using genome-wide mutational profiles combined with other features and followed by CT imaging detected more than 90% of patients with lung cancer, including those with stage I and II disease.]
This research illustrates the difficulty of providing high performance while covering a broad range of cancers. Here, the good results mainly concern lung cancer. Researchers and health care authorities must be alert to ensuring that MCED tests prove themselves in terms of sensitivity and specificity in responding to a medical need and in their impact on specific mortality. This craze for MCED tests must not hinder the development of “single-cancer” technologies that may be much better for detecting specific cancers. This recent publication is interesting in this respect, because this sequencing test seems to be particularly good at detecting lung cancer.
Q: Another approach used in MCED tests is based on analyzing the size of DNA fragments in the blood. Can you explain how this works?
Dr. Delaloge: When cancer is not present, the size of DNA fragments in cells is much more homogeneous. Here also, the benefit of MCED based on this technique rests on the very early detection of cancers that are less common than those for which we already have good screening methods available.
Other approaches, still at the experimental stage, detect certain proteins, certain inflammatory molecules, RNA, etc. But for many researchers, the future will involve pairing tests on the basis of circulating DNA in the blood with the detection of specific molecules indicating the presence of cancer to obtain early screening tests that are even more effective or that possibly even allow us to identify an appropriate treatment at an early stage.
The development of a simple test based on a blood draw that allows us to screen early for all cancers and that would replace all current screening measures is, therefore, not imminent, although it could potentially be on the horizon in years to come. Alongside this, an important issue is the benefit of cancer screening in the general population vs. in a targeted population with a specific risk. The latter option is in development but requires an individualized screening pathway based on blood testing and current screening methods: imaging, etc. It also depends on an individual’s cancer risk profile such as age, personal and family medical history, genetic predisposition, and so on.
According to recent modeling, these multicancer tests could theoretically prevent a minimum of 2,000 deaths from cancer per 100,000 people between ages 50 and 79 years screened per year (17% fewer deaths from cancer per year).
This article was translated from the Medscape French Edition. A version appeared on Medscape.com.
Suzette Delaloge, MD, MSc, oncologist, breast cancer specialist, and director of the individualized cancer prevention program (Interception) at the Gustave Roussy Institute in Villejuif, France, looks into these “liquid biopsies” and shares her reservations about their potential marketing, especially to the organized care plans.
Question: What are the general principles underpinning these MCED tests?
Suzette Delaloge, MD, MSc: Despite their specificities, the general idea is to detect certain cancer markers in various body fluids (blood, urine, saliva, etc.), for example, molecules released by cancer cells (cytokines, inflammatory proteins, leptin, etc.) or distinctive features of the DNA in tumor cells. In blood, these molecules can be found in plasma or in serum. In urine, it’s more about detecting kidney, bladder, and urinary tract cancers.
Q: What sort of time frame are we looking at for these MCED tests to be used in routine practice?
Dr. Delaloge: They first appeared around 10 years ago. Development of these tests has intensified in recent years. There are numerous research laboratories, both public and private, that are developing different early-detection tests for cancer.
Some of these development processes are about to come to an end and are expected to be in regular, concrete use within 5-10 years. For the most advanced developments, the main biologic material researched and analyzed is DNA from cancer cells. We all have fragments of DNA from dead cells in our plasma (apoptosis), but cancer cells release more of these than others, and most importantly, their DNA has distinctive characteristics. The idea is to develop tests capable of detecting these characteristics.
Liquid biopsies based on genomic biomarkers could make MCED a reality, especially for cancers for which there is no standard screening process. But at this stage of the research, there are limitations, including low sensitivity for detecting stage I cancers in validation studies and an increased risk for overdiagnosis.
Q: What specific set of characteristics are the most advanced approaches based on?
Dr. Delaloge: They’re based on the analysis of DNA methylation, a biological process by which CH3 methyl groups are added to the DNA molecule and that determines gene expression. This phenomenon differs depending on whether the cell is cancerous. Among the tests currently under development making use of this specific characteristic is the Galleri test, which is the most advanced of them all.
A previous British National Health Service study, SYMPLIFY, which was published in 2023 by researchers at the University of Oxford, was conducted in symptomatic patients attending a health center. It offers promising results in a diagnostic situation. It has nothing at all to do with screening here. A large, randomized English study, NHS-Galleri, is underway, this time involving the general population, with the aim of assessing the potential benefit of the same test as screening in 140,000 people between ages 50 and 77 years.
In the SYMPLIFY study, which was carried out in symptomatic patients attending a health center, the Galleri MCED test had a positive predictive value of 75.5%, a negative predictive value of 97.6%, a sensitivity of 66.3%, and a specificity of 98.4%. Sensitivity increased with age and cancer stage from 24.2% at stage I to 95.3% at stage IV. For cases for which a cancer signal was detected in patients with cancer, the prediction of the original site of the cancer by the MCED test was accurate in 85.2% of cases. This large-scale prospective evaluation of an MCED diagnostic test confirms its feasibility in a symptomatic population but is not yet sufficiently accurate to “confirm or rule out the presence of cancer.” According to the authors, “in cases in which the MCED test detects a cancer signal in this context, the probability of a diagnosis of cancer being made is considerably higher and may identify cancers at sites other than those suspected during the initial referral phase, thus reducing delays in diagnosis.” A negative test means a lower likelihood of cancer but not so low that proper investigation can be ruled out. Further tests will be needed to optimize use of a negative predictive value.
Q: Does MCED testing concern all types of cancer?
Dr. Delaloge: The Galleri test is based on full profiling of DNA methylation. This allows for early diagnosis of cancer even before it can be seen on imaging tests. The issue with these tests is that they aren’t that good at early diagnosis of the most common types of cancer (breast, colorectal, cervical, etc.) for which we already have more efficient means such as the fecal immunochemical test for colorectal cancer, mammography, HPV testing, and so on.
These blood tests would thus not be aimed at replacing routine screening but rather at screening asymptomatic individuals or those with nonspecific signs for cancers for which we have few or no screening measures and which are on the rise, such as deep tumors and cancer diagnosed at a late stage, namely pancreas, bile duct, ovarian, esophageal, lung, stomach, etc.
The results from the studies published are promising, but others are underway to confirm the benefit of these MCEDs. The challenge is to identify cancer at an early stage, at a stage where it will be easier to cure the patient and control its growth using treatments that are less onerous for the patient and that have fewer aftereffects but not at the expense of a massive increase in overdiagnosis, as seen with prostate-specific antigen levels in prostate cancer a few years ago!
Q: What would be the focus of these MCED tests?
Dr. Delaloge: We must be alert to the risk for the market development of MCED tests. For now, they are mostly, especially the Galleri test, developed in the general population to screen for types of cancer that could not be detected in any other way but also because it’s the most financially beneficial situation. The designers want to position themselves in the general population, regardless of whether this means they’ll have to test hundreds of people to find one for whom the test is beneficial. What’s more, developing tests in isolation, without considering their place in ad hoc treatment pathways, is not realistic. It’s likely that some of these tests will be marketed within the next 10 years, but the health care systems destined to receive them are not remotely ready to do so.
Q: An even more recent publication, from late July 2023, is even more exciting in relation to early detection of lung cancer using circulating DNA sequencing. What are your thoughts on it?
Dr. Delaloge: Initially overtaken by other technologies in favor of MCED approaches, DNA sequencing as a technique to detect somatic mutations seems to have reentered the competition with this new-generation research. The authors published some very interesting results, especially for stage I lung cancer with a very high sensitivity of 75%. [Editor’s note: A machine-learning model using genome-wide mutational profiles combined with other features and followed by CT imaging detected more than 90% of patients with lung cancer, including those with stage I and II disease.]
This research illustrates the difficulty of providing high performance while covering a broad range of cancers. Here, the good results mainly concern lung cancer. Researchers and health care authorities must be alert to ensuring that MCED tests prove themselves in terms of sensitivity and specificity in responding to a medical need and in their impact on specific mortality. This craze for MCED tests must not hinder the development of “single-cancer” technologies that may be much better for detecting specific cancers. This recent publication is interesting in this respect, because this sequencing test seems to be particularly good at detecting lung cancer.
Q: Another approach used in MCED tests is based on analyzing the size of DNA fragments in the blood. Can you explain how this works?
Dr. Delaloge: When cancer is not present, the size of DNA fragments in cells is much more homogeneous. Here also, the benefit of MCED based on this technique rests on the very early detection of cancers that are less common than those for which we already have good screening methods available.
Other approaches, still at the experimental stage, detect certain proteins, certain inflammatory molecules, RNA, etc. But for many researchers, the future will involve pairing tests on the basis of circulating DNA in the blood with the detection of specific molecules indicating the presence of cancer to obtain early screening tests that are even more effective or that possibly even allow us to identify an appropriate treatment at an early stage.
The development of a simple test based on a blood draw that allows us to screen early for all cancers and that would replace all current screening measures is, therefore, not imminent, although it could potentially be on the horizon in years to come. Alongside this, an important issue is the benefit of cancer screening in the general population vs. in a targeted population with a specific risk. The latter option is in development but requires an individualized screening pathway based on blood testing and current screening methods: imaging, etc. It also depends on an individual’s cancer risk profile such as age, personal and family medical history, genetic predisposition, and so on.
According to recent modeling, these multicancer tests could theoretically prevent a minimum of 2,000 deaths from cancer per 100,000 people between ages 50 and 79 years screened per year (17% fewer deaths from cancer per year).
This article was translated from the Medscape French Edition. A version appeared on Medscape.com.
Suzette Delaloge, MD, MSc, oncologist, breast cancer specialist, and director of the individualized cancer prevention program (Interception) at the Gustave Roussy Institute in Villejuif, France, looks into these “liquid biopsies” and shares her reservations about their potential marketing, especially to the organized care plans.
Question: What are the general principles underpinning these MCED tests?
Suzette Delaloge, MD, MSc: Despite their specificities, the general idea is to detect certain cancer markers in various body fluids (blood, urine, saliva, etc.), for example, molecules released by cancer cells (cytokines, inflammatory proteins, leptin, etc.) or distinctive features of the DNA in tumor cells. In blood, these molecules can be found in plasma or in serum. In urine, it’s more about detecting kidney, bladder, and urinary tract cancers.
Q: What sort of time frame are we looking at for these MCED tests to be used in routine practice?
Dr. Delaloge: They first appeared around 10 years ago. Development of these tests has intensified in recent years. There are numerous research laboratories, both public and private, that are developing different early-detection tests for cancer.
Some of these development processes are about to come to an end and are expected to be in regular, concrete use within 5-10 years. For the most advanced developments, the main biologic material researched and analyzed is DNA from cancer cells. We all have fragments of DNA from dead cells in our plasma (apoptosis), but cancer cells release more of these than others, and most importantly, their DNA has distinctive characteristics. The idea is to develop tests capable of detecting these characteristics.
Liquid biopsies based on genomic biomarkers could make MCED a reality, especially for cancers for which there is no standard screening process. But at this stage of the research, there are limitations, including low sensitivity for detecting stage I cancers in validation studies and an increased risk for overdiagnosis.
Q: What specific set of characteristics are the most advanced approaches based on?
Dr. Delaloge: They’re based on the analysis of DNA methylation, a biological process by which CH3 methyl groups are added to the DNA molecule and that determines gene expression. This phenomenon differs depending on whether the cell is cancerous. Among the tests currently under development making use of this specific characteristic is the Galleri test, which is the most advanced of them all.
A previous British National Health Service study, SYMPLIFY, which was published in 2023 by researchers at the University of Oxford, was conducted in symptomatic patients attending a health center. It offers promising results in a diagnostic situation. It has nothing at all to do with screening here. A large, randomized English study, NHS-Galleri, is underway, this time involving the general population, with the aim of assessing the potential benefit of the same test as screening in 140,000 people between ages 50 and 77 years.
In the SYMPLIFY study, which was carried out in symptomatic patients attending a health center, the Galleri MCED test had a positive predictive value of 75.5%, a negative predictive value of 97.6%, a sensitivity of 66.3%, and a specificity of 98.4%. Sensitivity increased with age and cancer stage from 24.2% at stage I to 95.3% at stage IV. For cases for which a cancer signal was detected in patients with cancer, the prediction of the original site of the cancer by the MCED test was accurate in 85.2% of cases. This large-scale prospective evaluation of an MCED diagnostic test confirms its feasibility in a symptomatic population but is not yet sufficiently accurate to “confirm or rule out the presence of cancer.” According to the authors, “in cases in which the MCED test detects a cancer signal in this context, the probability of a diagnosis of cancer being made is considerably higher and may identify cancers at sites other than those suspected during the initial referral phase, thus reducing delays in diagnosis.” A negative test means a lower likelihood of cancer but not so low that proper investigation can be ruled out. Further tests will be needed to optimize use of a negative predictive value.
Q: Does MCED testing concern all types of cancer?
Dr. Delaloge: The Galleri test is based on full profiling of DNA methylation. This allows for early diagnosis of cancer even before it can be seen on imaging tests. The issue with these tests is that they aren’t that good at early diagnosis of the most common types of cancer (breast, colorectal, cervical, etc.) for which we already have more efficient means such as the fecal immunochemical test for colorectal cancer, mammography, HPV testing, and so on.
These blood tests would thus not be aimed at replacing routine screening but rather at screening asymptomatic individuals or those with nonspecific signs for cancers for which we have few or no screening measures and which are on the rise, such as deep tumors and cancer diagnosed at a late stage, namely pancreas, bile duct, ovarian, esophageal, lung, stomach, etc.
The results from the studies published are promising, but others are underway to confirm the benefit of these MCEDs. The challenge is to identify cancer at an early stage, at a stage where it will be easier to cure the patient and control its growth using treatments that are less onerous for the patient and that have fewer aftereffects but not at the expense of a massive increase in overdiagnosis, as seen with prostate-specific antigen levels in prostate cancer a few years ago!
Q: What would be the focus of these MCED tests?
Dr. Delaloge: We must be alert to the risk for the market development of MCED tests. For now, they are mostly, especially the Galleri test, developed in the general population to screen for types of cancer that could not be detected in any other way but also because it’s the most financially beneficial situation. The designers want to position themselves in the general population, regardless of whether this means they’ll have to test hundreds of people to find one for whom the test is beneficial. What’s more, developing tests in isolation, without considering their place in ad hoc treatment pathways, is not realistic. It’s likely that some of these tests will be marketed within the next 10 years, but the health care systems destined to receive them are not remotely ready to do so.
Q: An even more recent publication, from late July 2023, is even more exciting in relation to early detection of lung cancer using circulating DNA sequencing. What are your thoughts on it?
Dr. Delaloge: Initially overtaken by other technologies in favor of MCED approaches, DNA sequencing as a technique to detect somatic mutations seems to have reentered the competition with this new-generation research. The authors published some very interesting results, especially for stage I lung cancer with a very high sensitivity of 75%. [Editor’s note: A machine-learning model using genome-wide mutational profiles combined with other features and followed by CT imaging detected more than 90% of patients with lung cancer, including those with stage I and II disease.]
This research illustrates the difficulty of providing high performance while covering a broad range of cancers. Here, the good results mainly concern lung cancer. Researchers and health care authorities must be alert to ensuring that MCED tests prove themselves in terms of sensitivity and specificity in responding to a medical need and in their impact on specific mortality. This craze for MCED tests must not hinder the development of “single-cancer” technologies that may be much better for detecting specific cancers. This recent publication is interesting in this respect, because this sequencing test seems to be particularly good at detecting lung cancer.
Q: Another approach used in MCED tests is based on analyzing the size of DNA fragments in the blood. Can you explain how this works?
Dr. Delaloge: When cancer is not present, the size of DNA fragments in cells is much more homogeneous. Here also, the benefit of MCED based on this technique rests on the very early detection of cancers that are less common than those for which we already have good screening methods available.
Other approaches, still at the experimental stage, detect certain proteins, certain inflammatory molecules, RNA, etc. But for many researchers, the future will involve pairing tests on the basis of circulating DNA in the blood with the detection of specific molecules indicating the presence of cancer to obtain early screening tests that are even more effective or that possibly even allow us to identify an appropriate treatment at an early stage.
The development of a simple test based on a blood draw that allows us to screen early for all cancers and that would replace all current screening measures is, therefore, not imminent, although it could potentially be on the horizon in years to come. Alongside this, an important issue is the benefit of cancer screening in the general population vs. in a targeted population with a specific risk. The latter option is in development but requires an individualized screening pathway based on blood testing and current screening methods: imaging, etc. It also depends on an individual’s cancer risk profile such as age, personal and family medical history, genetic predisposition, and so on.
According to recent modeling, these multicancer tests could theoretically prevent a minimum of 2,000 deaths from cancer per 100,000 people between ages 50 and 79 years screened per year (17% fewer deaths from cancer per year).
This article was translated from the Medscape French Edition. A version appeared on Medscape.com.
Spironolactone safe, effective option for women with hidradenitis suppurativa
CARLSBAD, CALIF. –
Those are the key findings from a single-center retrospective study that Jennifer L. Hsiao, MD, and colleagues presented during a poster session at the annual symposium of the California Society of Dermatology & Dermatologic Surgery.
In an interview after the meeting, Dr. Hsiao, a dermatologist who directs the hidradenitis suppurativa clinic at the University of Southern California, Los Angeles, said that hormones are thought to play a role in HS pathogenesis given the typical HS symptom onset around puberty and fluctuations in disease activity with menses (typically premenstrual flares) and pregnancy. “Spironolactone, an anti-androgenic agent, is used to treat HS in women; however, there is a paucity of data on the efficacy of spironolactone for HS and whether certain patient characteristics may influence treatment response,” she told this news organization. “This study is unique in that we contribute to existing literature regarding spironolactone efficacy in HS and we also investigate whether the presence of menstrual HS flares or polycystic ovarian syndrome influences the likelihood of response to spironolactone.”
For the analysis, Dr. Hsiao and colleagues retrospectively reviewed the medical records of 53 adult women with HS who were prescribed spironolactone and who received care at USC’s HS clinic between January 2015 and December 2021. They collected data on demographics, comorbidities, HS medications, treatment response at 3 and 6 months, as well as adverse events. They also evaluated physician-assessed response to treatment when available.
The mean age of patients was 31 years, 37% were White, 30.4% were Black, 21.7% were Hispanic, 6.5% were Asian, and the remainder were biracial. The mean age at HS diagnosis was 25.1 years and the three most common comorbidities were acne (50.9%), obesity (45.3%), and anemia (37.7%). As for menstrual history, 56.6% had perimenstrual HS flares and 37.7% had irregular menstrual cycles. The top three classes of concomitant medications were antibiotics (58.5%), oral contraceptives (50.9%), and other birth control methods (18.9%).
The mean spironolactone dose was 104 mg/day; 84.1% of the women experienced improvement of HS 3 months after starting the drug, while 81.8% had improvement of their HS 6 months after starting the drug. The researchers also found that 56.6% of women had documented perimenstrual HS flares and 7.5% had PCOS.
“Spironolactone is often thought of as a helpful medication to consider if a patient reports having HS flares around menses or features of PCOS,” Dr. Hsiao said. However, she added, “our study found that there was no statistically significant difference in the response to spironolactone based on the presence of premenstrual flares or concomitant PCOS.” She said that spironolactone may be used as an adjunct therapeutic option in patients with more severe disease in addition to other medical and surgical therapies for HS. “Combining different treatment options that target different pathophysiologic factors is usually required to achieve adequate disease control in HS,” she said.
Dr. Hsiao acknowledged certain limitations of the study, including its single-center design and small sample size. “A confounding variable is that some patients were on other medications in addition to spironolactone, which may have influenced treatment outcomes,” she noted. “Larger prospective studies are needed to identify optimal dosing for spironolactone therapy in HS as well as predictors of treatment response.”
Adam Friedman, MD, professor and chair of dermatology at George Washington University, Washington, who was asked to comment on the study, said that with only one FDA-approved systemic medication for the management of HS (adalimumab), “we off-label bandits must be creative to curtail the incredibly painful impact this chronic, destructive inflammatory disease can have on our patients.”
“The evidence supporting our approaches, whether it be antibiotics, immunomodulators, or in this case, antihormonal therapies, is limited, so more data is always welcome,” said Dr. Friedman, who was not involved with the study. “One very interesting point raised by the authors, one I share with my trainees frequently from my own experience, is that regardless of menstrual cycle abnormalities, spironolactone can be impactful. This is important to remember, in that overt signs of hormonal influences is not a requisite for the use or effectiveness of antihormonal therapy.”
Dr. Hsiao disclosed that she is a member of board of directors for the Hidradenitis Suppurativa Foundation. She has also served as a consultant for AbbVie, Aclaris, Boehringer Ingelheim, Novartis, UCB, as a speaker for AbbVie, and as an investigator for Amgen, Boehringer Ingelheim, and Incyte. Dr. Friedman reported having no relevant financial disclosures.
CARLSBAD, CALIF. –
Those are the key findings from a single-center retrospective study that Jennifer L. Hsiao, MD, and colleagues presented during a poster session at the annual symposium of the California Society of Dermatology & Dermatologic Surgery.
In an interview after the meeting, Dr. Hsiao, a dermatologist who directs the hidradenitis suppurativa clinic at the University of Southern California, Los Angeles, said that hormones are thought to play a role in HS pathogenesis given the typical HS symptom onset around puberty and fluctuations in disease activity with menses (typically premenstrual flares) and pregnancy. “Spironolactone, an anti-androgenic agent, is used to treat HS in women; however, there is a paucity of data on the efficacy of spironolactone for HS and whether certain patient characteristics may influence treatment response,” she told this news organization. “This study is unique in that we contribute to existing literature regarding spironolactone efficacy in HS and we also investigate whether the presence of menstrual HS flares or polycystic ovarian syndrome influences the likelihood of response to spironolactone.”
For the analysis, Dr. Hsiao and colleagues retrospectively reviewed the medical records of 53 adult women with HS who were prescribed spironolactone and who received care at USC’s HS clinic between January 2015 and December 2021. They collected data on demographics, comorbidities, HS medications, treatment response at 3 and 6 months, as well as adverse events. They also evaluated physician-assessed response to treatment when available.
The mean age of patients was 31 years, 37% were White, 30.4% were Black, 21.7% were Hispanic, 6.5% were Asian, and the remainder were biracial. The mean age at HS diagnosis was 25.1 years and the three most common comorbidities were acne (50.9%), obesity (45.3%), and anemia (37.7%). As for menstrual history, 56.6% had perimenstrual HS flares and 37.7% had irregular menstrual cycles. The top three classes of concomitant medications were antibiotics (58.5%), oral contraceptives (50.9%), and other birth control methods (18.9%).
The mean spironolactone dose was 104 mg/day; 84.1% of the women experienced improvement of HS 3 months after starting the drug, while 81.8% had improvement of their HS 6 months after starting the drug. The researchers also found that 56.6% of women had documented perimenstrual HS flares and 7.5% had PCOS.
“Spironolactone is often thought of as a helpful medication to consider if a patient reports having HS flares around menses or features of PCOS,” Dr. Hsiao said. However, she added, “our study found that there was no statistically significant difference in the response to spironolactone based on the presence of premenstrual flares or concomitant PCOS.” She said that spironolactone may be used as an adjunct therapeutic option in patients with more severe disease in addition to other medical and surgical therapies for HS. “Combining different treatment options that target different pathophysiologic factors is usually required to achieve adequate disease control in HS,” she said.
Dr. Hsiao acknowledged certain limitations of the study, including its single-center design and small sample size. “A confounding variable is that some patients were on other medications in addition to spironolactone, which may have influenced treatment outcomes,” she noted. “Larger prospective studies are needed to identify optimal dosing for spironolactone therapy in HS as well as predictors of treatment response.”
Adam Friedman, MD, professor and chair of dermatology at George Washington University, Washington, who was asked to comment on the study, said that with only one FDA-approved systemic medication for the management of HS (adalimumab), “we off-label bandits must be creative to curtail the incredibly painful impact this chronic, destructive inflammatory disease can have on our patients.”
“The evidence supporting our approaches, whether it be antibiotics, immunomodulators, or in this case, antihormonal therapies, is limited, so more data is always welcome,” said Dr. Friedman, who was not involved with the study. “One very interesting point raised by the authors, one I share with my trainees frequently from my own experience, is that regardless of menstrual cycle abnormalities, spironolactone can be impactful. This is important to remember, in that overt signs of hormonal influences is not a requisite for the use or effectiveness of antihormonal therapy.”
Dr. Hsiao disclosed that she is a member of board of directors for the Hidradenitis Suppurativa Foundation. She has also served as a consultant for AbbVie, Aclaris, Boehringer Ingelheim, Novartis, UCB, as a speaker for AbbVie, and as an investigator for Amgen, Boehringer Ingelheim, and Incyte. Dr. Friedman reported having no relevant financial disclosures.
CARLSBAD, CALIF. –
Those are the key findings from a single-center retrospective study that Jennifer L. Hsiao, MD, and colleagues presented during a poster session at the annual symposium of the California Society of Dermatology & Dermatologic Surgery.
In an interview after the meeting, Dr. Hsiao, a dermatologist who directs the hidradenitis suppurativa clinic at the University of Southern California, Los Angeles, said that hormones are thought to play a role in HS pathogenesis given the typical HS symptom onset around puberty and fluctuations in disease activity with menses (typically premenstrual flares) and pregnancy. “Spironolactone, an anti-androgenic agent, is used to treat HS in women; however, there is a paucity of data on the efficacy of spironolactone for HS and whether certain patient characteristics may influence treatment response,” she told this news organization. “This study is unique in that we contribute to existing literature regarding spironolactone efficacy in HS and we also investigate whether the presence of menstrual HS flares or polycystic ovarian syndrome influences the likelihood of response to spironolactone.”
For the analysis, Dr. Hsiao and colleagues retrospectively reviewed the medical records of 53 adult women with HS who were prescribed spironolactone and who received care at USC’s HS clinic between January 2015 and December 2021. They collected data on demographics, comorbidities, HS medications, treatment response at 3 and 6 months, as well as adverse events. They also evaluated physician-assessed response to treatment when available.
The mean age of patients was 31 years, 37% were White, 30.4% were Black, 21.7% were Hispanic, 6.5% were Asian, and the remainder were biracial. The mean age at HS diagnosis was 25.1 years and the three most common comorbidities were acne (50.9%), obesity (45.3%), and anemia (37.7%). As for menstrual history, 56.6% had perimenstrual HS flares and 37.7% had irregular menstrual cycles. The top three classes of concomitant medications were antibiotics (58.5%), oral contraceptives (50.9%), and other birth control methods (18.9%).
The mean spironolactone dose was 104 mg/day; 84.1% of the women experienced improvement of HS 3 months after starting the drug, while 81.8% had improvement of their HS 6 months after starting the drug. The researchers also found that 56.6% of women had documented perimenstrual HS flares and 7.5% had PCOS.
“Spironolactone is often thought of as a helpful medication to consider if a patient reports having HS flares around menses or features of PCOS,” Dr. Hsiao said. However, she added, “our study found that there was no statistically significant difference in the response to spironolactone based on the presence of premenstrual flares or concomitant PCOS.” She said that spironolactone may be used as an adjunct therapeutic option in patients with more severe disease in addition to other medical and surgical therapies for HS. “Combining different treatment options that target different pathophysiologic factors is usually required to achieve adequate disease control in HS,” she said.
Dr. Hsiao acknowledged certain limitations of the study, including its single-center design and small sample size. “A confounding variable is that some patients were on other medications in addition to spironolactone, which may have influenced treatment outcomes,” she noted. “Larger prospective studies are needed to identify optimal dosing for spironolactone therapy in HS as well as predictors of treatment response.”
Adam Friedman, MD, professor and chair of dermatology at George Washington University, Washington, who was asked to comment on the study, said that with only one FDA-approved systemic medication for the management of HS (adalimumab), “we off-label bandits must be creative to curtail the incredibly painful impact this chronic, destructive inflammatory disease can have on our patients.”
“The evidence supporting our approaches, whether it be antibiotics, immunomodulators, or in this case, antihormonal therapies, is limited, so more data is always welcome,” said Dr. Friedman, who was not involved with the study. “One very interesting point raised by the authors, one I share with my trainees frequently from my own experience, is that regardless of menstrual cycle abnormalities, spironolactone can be impactful. This is important to remember, in that overt signs of hormonal influences is not a requisite for the use or effectiveness of antihormonal therapy.”
Dr. Hsiao disclosed that she is a member of board of directors for the Hidradenitis Suppurativa Foundation. She has also served as a consultant for AbbVie, Aclaris, Boehringer Ingelheim, Novartis, UCB, as a speaker for AbbVie, and as an investigator for Amgen, Boehringer Ingelheim, and Incyte. Dr. Friedman reported having no relevant financial disclosures.
AT CALDERM 2023
Federal Health Care Data Trends 2023
In this issue:
- Limb Loss and Prostheses
- Neurology
- Cardiology
- Mental Health
- Diabetes
- Rheumatoid Arthritis
- Respiratory illnesses
- Women's Health
- HPV and Related Cancers
In this issue:
- Limb Loss and Prostheses
- Neurology
- Cardiology
- Mental Health
- Diabetes
- Rheumatoid Arthritis
- Respiratory illnesses
- Women's Health
- HPV and Related Cancers
In this issue:
- Limb Loss and Prostheses
- Neurology
- Cardiology
- Mental Health
- Diabetes
- Rheumatoid Arthritis
- Respiratory illnesses
- Women's Health
- HPV and Related Cancers
Video-Based Coaching for Dermatology Resident Surgical Education
To the Editor:
Video-based coaching (VBC) involves a surgeon recording a surgery and then reviewing the video with a surgical coach; it is a form of education that is gaining popularity among surgical specialties.1 Video-based education is underutilized in dermatology residency training.2 We conducted a pilot study at our dermatology residency program to evaluate the efficacy and feasibility of VBC.
The University of Texas at Austin Dell Medical School institutional review board approved this study. All 4 first-year dermatology residents were recruited to participate in this study. Participants filled out a prestudy survey assessing their surgical experience, confidence in performing surgery, and attitudes on VBC. Participants used a head-mounted point-of-view camera to record themselves performing a wide local excision on the trunk or extremities of a live human patient. Participants then reviewed the recording on their own and scored themselves using the Objective Structured Assessment of Technical Skills (OSATS) scoring table (scored from 1 to 5, with 5 being the highest possible score for each element), which is a validated tool for assessing surgical skills (eTable 1).3 Given that there were no assistants participating in the surgery, this element of the OSATS scoring table was excluded, making a maximum possible score of 30 and a minimum possible score of 6. After scoring themselves, participants then had a 1-on-1 coaching session with a fellowship-trained dermatologic surgeon (M.F. or T.H.) via online teleconferencing.
During the coaching session, participants and coaches reviewed the video. The surgical coaches also scored the residents using the OSATS, then residents and coaches discussed how the resident could improve using the OSATS scores as a guide. The residents then completed a poststudy survey assessing their surgical experience, confidence in performing surgery, and attitudes on VBC. Descriptive statistics were reported.
On average, residents spent 31.3 minutes reviewing their own surgeries and scoring themselves. The average time for a coaching session, which included time spent scoring, was 13.8 minutes. Residents scored themselves lower than the surgical coaches did by an average of 5.25 points (eTable 2). Residents gave themselves an average total score of 10.5, while their respective surgical coaches gave the residents an average score of 15.75. There was a trend of residents with greater surgical experience having higher OSATS scores (Figure). After the coaching session, 3 of 4 residents reported that they felt more confident in their surgical skills. All residents felt more confident in assessing their surgical skills and felt that VBC was an effective teaching measure. All residents agreed that VBC should be continued as part of their residency training.
Video-based coaching has the potential to provide several benefits for dermatology trainees. Because receiving feedback intraoperatively often can be distracting and incomplete, video review can instead allow the surgeon to focus on performing the surgery and then later focus on learning while reviewing the video.1,4 Feedback also can be more comprehensive and delivered without concern for time constraints or disturbing clinic flow as well as without the additional concern of the patient overhearing comments and feedback.3 Although independent video review in the absence of coaching can lead to improvement in surgical skills, the addition of VBC provides even greater potential educational benefit.4 During the COVID-19 pandemic, VBC allowed coaches to provide feedback without additional exposures. We utilized dermatologic surgery faculty as coaches, but this format of training also would apply to general dermatology faculty.
Another goal of VBC is to enhance a trainee’s ability to perform self-directed learning, which requires accurate self-assessment.4 Accurately assessing one’s own strengths empowers a trainee to act with appropriate confidence, while understanding one’s own weaknesses allows a trainee to effectively balance confidence and caution in daily practice.5 Interestingly, in our study all residents scored themselves lower than surgical coaches, but with 1 coaching session, the residents subsequently reported greater surgical confidence.
Time constraints can be a potential barrier to surgical coaching.4 Our study demonstrates that VBC requires minimal time investment. Increasing the speed of video playback allowed for efficient evaluation of resident surgeries without compromising the coach’s ability to provide comprehensive feedback. Our feedback sessions were performed virtually, which allowed for ease of scheduling between trainees and coaches.
Our pilot study demonstrated that VBC is relatively easy to implement in a dermatology residency training setting, leveraging relatively low-cost technologies and allowing for a means of learning that residents felt was effective. Video-based coaching requires minimal time investment from both trainees and coaches and has the potential to enhance surgical confidence. Our current study is limited by its small sample size. Future studies should include follow-up recordings and assess the efficacy of VBC in enhancing surgical skills.
- Greenberg CC, Dombrowski J, Dimick JB. Video-based surgical coaching: an emerging approach to performance improvement. JAMA Surg. 2016;151:282-283.
- Dai J, Bordeaux JS, Miller CJ, et al. Assessing surgical training and deliberate practice methods in dermatology residency: a survey of dermatology program directors. Dermatol Surg. 2016;42:977-984.
- Chitgopeker P, Sidey K, Aronson A, et al. Surgical skills video-based assessment tool for dermatology residents: a prospective pilot study. J Am Acad Dermatol. 2020;83:614-616.
- Bull NB, Silverman CD, Bonrath EM. Targeted surgical coaching can improve operative self-assessment ability: a single-blinded nonrandomized trial. Surgery. 2020;167:308-313.
- Eva KW, Regehr G. Self-assessment in the health professions: a reformulation and research agenda. Acad Med. 2005;80(10 suppl):S46-S54.
To the Editor:
Video-based coaching (VBC) involves a surgeon recording a surgery and then reviewing the video with a surgical coach; it is a form of education that is gaining popularity among surgical specialties.1 Video-based education is underutilized in dermatology residency training.2 We conducted a pilot study at our dermatology residency program to evaluate the efficacy and feasibility of VBC.
The University of Texas at Austin Dell Medical School institutional review board approved this study. All 4 first-year dermatology residents were recruited to participate in this study. Participants filled out a prestudy survey assessing their surgical experience, confidence in performing surgery, and attitudes on VBC. Participants used a head-mounted point-of-view camera to record themselves performing a wide local excision on the trunk or extremities of a live human patient. Participants then reviewed the recording on their own and scored themselves using the Objective Structured Assessment of Technical Skills (OSATS) scoring table (scored from 1 to 5, with 5 being the highest possible score for each element), which is a validated tool for assessing surgical skills (eTable 1).3 Given that there were no assistants participating in the surgery, this element of the OSATS scoring table was excluded, making a maximum possible score of 30 and a minimum possible score of 6. After scoring themselves, participants then had a 1-on-1 coaching session with a fellowship-trained dermatologic surgeon (M.F. or T.H.) via online teleconferencing.
During the coaching session, participants and coaches reviewed the video. The surgical coaches also scored the residents using the OSATS, then residents and coaches discussed how the resident could improve using the OSATS scores as a guide. The residents then completed a poststudy survey assessing their surgical experience, confidence in performing surgery, and attitudes on VBC. Descriptive statistics were reported.
On average, residents spent 31.3 minutes reviewing their own surgeries and scoring themselves. The average time for a coaching session, which included time spent scoring, was 13.8 minutes. Residents scored themselves lower than the surgical coaches did by an average of 5.25 points (eTable 2). Residents gave themselves an average total score of 10.5, while their respective surgical coaches gave the residents an average score of 15.75. There was a trend of residents with greater surgical experience having higher OSATS scores (Figure). After the coaching session, 3 of 4 residents reported that they felt more confident in their surgical skills. All residents felt more confident in assessing their surgical skills and felt that VBC was an effective teaching measure. All residents agreed that VBC should be continued as part of their residency training.
Video-based coaching has the potential to provide several benefits for dermatology trainees. Because receiving feedback intraoperatively often can be distracting and incomplete, video review can instead allow the surgeon to focus on performing the surgery and then later focus on learning while reviewing the video.1,4 Feedback also can be more comprehensive and delivered without concern for time constraints or disturbing clinic flow as well as without the additional concern of the patient overhearing comments and feedback.3 Although independent video review in the absence of coaching can lead to improvement in surgical skills, the addition of VBC provides even greater potential educational benefit.4 During the COVID-19 pandemic, VBC allowed coaches to provide feedback without additional exposures. We utilized dermatologic surgery faculty as coaches, but this format of training also would apply to general dermatology faculty.
Another goal of VBC is to enhance a trainee’s ability to perform self-directed learning, which requires accurate self-assessment.4 Accurately assessing one’s own strengths empowers a trainee to act with appropriate confidence, while understanding one’s own weaknesses allows a trainee to effectively balance confidence and caution in daily practice.5 Interestingly, in our study all residents scored themselves lower than surgical coaches, but with 1 coaching session, the residents subsequently reported greater surgical confidence.
Time constraints can be a potential barrier to surgical coaching.4 Our study demonstrates that VBC requires minimal time investment. Increasing the speed of video playback allowed for efficient evaluation of resident surgeries without compromising the coach’s ability to provide comprehensive feedback. Our feedback sessions were performed virtually, which allowed for ease of scheduling between trainees and coaches.
Our pilot study demonstrated that VBC is relatively easy to implement in a dermatology residency training setting, leveraging relatively low-cost technologies and allowing for a means of learning that residents felt was effective. Video-based coaching requires minimal time investment from both trainees and coaches and has the potential to enhance surgical confidence. Our current study is limited by its small sample size. Future studies should include follow-up recordings and assess the efficacy of VBC in enhancing surgical skills.
To the Editor:
Video-based coaching (VBC) involves a surgeon recording a surgery and then reviewing the video with a surgical coach; it is a form of education that is gaining popularity among surgical specialties.1 Video-based education is underutilized in dermatology residency training.2 We conducted a pilot study at our dermatology residency program to evaluate the efficacy and feasibility of VBC.
The University of Texas at Austin Dell Medical School institutional review board approved this study. All 4 first-year dermatology residents were recruited to participate in this study. Participants filled out a prestudy survey assessing their surgical experience, confidence in performing surgery, and attitudes on VBC. Participants used a head-mounted point-of-view camera to record themselves performing a wide local excision on the trunk or extremities of a live human patient. Participants then reviewed the recording on their own and scored themselves using the Objective Structured Assessment of Technical Skills (OSATS) scoring table (scored from 1 to 5, with 5 being the highest possible score for each element), which is a validated tool for assessing surgical skills (eTable 1).3 Given that there were no assistants participating in the surgery, this element of the OSATS scoring table was excluded, making a maximum possible score of 30 and a minimum possible score of 6. After scoring themselves, participants then had a 1-on-1 coaching session with a fellowship-trained dermatologic surgeon (M.F. or T.H.) via online teleconferencing.
During the coaching session, participants and coaches reviewed the video. The surgical coaches also scored the residents using the OSATS, then residents and coaches discussed how the resident could improve using the OSATS scores as a guide. The residents then completed a poststudy survey assessing their surgical experience, confidence in performing surgery, and attitudes on VBC. Descriptive statistics were reported.
On average, residents spent 31.3 minutes reviewing their own surgeries and scoring themselves. The average time for a coaching session, which included time spent scoring, was 13.8 minutes. Residents scored themselves lower than the surgical coaches did by an average of 5.25 points (eTable 2). Residents gave themselves an average total score of 10.5, while their respective surgical coaches gave the residents an average score of 15.75. There was a trend of residents with greater surgical experience having higher OSATS scores (Figure). After the coaching session, 3 of 4 residents reported that they felt more confident in their surgical skills. All residents felt more confident in assessing their surgical skills and felt that VBC was an effective teaching measure. All residents agreed that VBC should be continued as part of their residency training.
Video-based coaching has the potential to provide several benefits for dermatology trainees. Because receiving feedback intraoperatively often can be distracting and incomplete, video review can instead allow the surgeon to focus on performing the surgery and then later focus on learning while reviewing the video.1,4 Feedback also can be more comprehensive and delivered without concern for time constraints or disturbing clinic flow as well as without the additional concern of the patient overhearing comments and feedback.3 Although independent video review in the absence of coaching can lead to improvement in surgical skills, the addition of VBC provides even greater potential educational benefit.4 During the COVID-19 pandemic, VBC allowed coaches to provide feedback without additional exposures. We utilized dermatologic surgery faculty as coaches, but this format of training also would apply to general dermatology faculty.
Another goal of VBC is to enhance a trainee’s ability to perform self-directed learning, which requires accurate self-assessment.4 Accurately assessing one’s own strengths empowers a trainee to act with appropriate confidence, while understanding one’s own weaknesses allows a trainee to effectively balance confidence and caution in daily practice.5 Interestingly, in our study all residents scored themselves lower than surgical coaches, but with 1 coaching session, the residents subsequently reported greater surgical confidence.
Time constraints can be a potential barrier to surgical coaching.4 Our study demonstrates that VBC requires minimal time investment. Increasing the speed of video playback allowed for efficient evaluation of resident surgeries without compromising the coach’s ability to provide comprehensive feedback. Our feedback sessions were performed virtually, which allowed for ease of scheduling between trainees and coaches.
Our pilot study demonstrated that VBC is relatively easy to implement in a dermatology residency training setting, leveraging relatively low-cost technologies and allowing for a means of learning that residents felt was effective. Video-based coaching requires minimal time investment from both trainees and coaches and has the potential to enhance surgical confidence. Our current study is limited by its small sample size. Future studies should include follow-up recordings and assess the efficacy of VBC in enhancing surgical skills.
- Greenberg CC, Dombrowski J, Dimick JB. Video-based surgical coaching: an emerging approach to performance improvement. JAMA Surg. 2016;151:282-283.
- Dai J, Bordeaux JS, Miller CJ, et al. Assessing surgical training and deliberate practice methods in dermatology residency: a survey of dermatology program directors. Dermatol Surg. 2016;42:977-984.
- Chitgopeker P, Sidey K, Aronson A, et al. Surgical skills video-based assessment tool for dermatology residents: a prospective pilot study. J Am Acad Dermatol. 2020;83:614-616.
- Bull NB, Silverman CD, Bonrath EM. Targeted surgical coaching can improve operative self-assessment ability: a single-blinded nonrandomized trial. Surgery. 2020;167:308-313.
- Eva KW, Regehr G. Self-assessment in the health professions: a reformulation and research agenda. Acad Med. 2005;80(10 suppl):S46-S54.
- Greenberg CC, Dombrowski J, Dimick JB. Video-based surgical coaching: an emerging approach to performance improvement. JAMA Surg. 2016;151:282-283.
- Dai J, Bordeaux JS, Miller CJ, et al. Assessing surgical training and deliberate practice methods in dermatology residency: a survey of dermatology program directors. Dermatol Surg. 2016;42:977-984.
- Chitgopeker P, Sidey K, Aronson A, et al. Surgical skills video-based assessment tool for dermatology residents: a prospective pilot study. J Am Acad Dermatol. 2020;83:614-616.
- Bull NB, Silverman CD, Bonrath EM. Targeted surgical coaching can improve operative self-assessment ability: a single-blinded nonrandomized trial. Surgery. 2020;167:308-313.
- Eva KW, Regehr G. Self-assessment in the health professions: a reformulation and research agenda. Acad Med. 2005;80(10 suppl):S46-S54.
PRACTICE POINTS
- Video-based coaching (VBC) for surgical procedures is an up-and-coming form of medical education that allows a “coach” to provide thoughtful and in-depth feedback while reviewing a recording with the surgeon in a private setting. This format has potential utility in teaching dermatology resident surgeons being coached by a dermatology faculty member.
- We performed a pilot study demonstrating that VBC can be performed easily with a minimal time investment for both the surgeon and the coach. Dermatology residents not only felt that VBC was an effective teaching method but also should become a formal part of their education.
Should children know the severity of their disease? AAP weighs in with report
When children have a serious illness, some families choose not to disclose the severity to them, reasoning that knowing the extent of the illness may take away their hope. Deciding whether to tell children or adolescents about the seriousness of their disease is a complex judgment and can pose legal, ethical, and moral challenges for parents and care providers.
Default should be inclusion
The American Academy of Pediatrics (AAP) recommends in a new clinical report that the default should be to include children in conversations about their illness in a developmentally appropriate way, to the extent parents are comfortable.
The report, written by Sara Taub, MD and Robert Macauley, MD, MDiv, both in the department of pediatrics at Oregon Health & Science University in Portland, on behalf of the AAP Committee on Bioethics, was published online and appears in the October issue of Pediatrics.
“Rather than taking away hope, as some may fear, this approach of openness may create a space for children to ask their questions, share their concerns, and set goals that are appropriate to the circumstances,” the authors wrote in a press release.
The report offers strategies based on ethical, historical, legal, and cultural considerations when discussing what to share with a child or adolescent.
Some of the AAP’s other recommendations include the following:
- If the parents request nondisclosure, the first response should be seeking to understand why they prefer that stance. The care team members should also explain their position to parents.
- If there is no consensus on disclosure, establishing what each party believes is the minimum information that should be shared is important.
- Additional resources to navigate disagreement may be helpful, such as hospital ethics committees, mediators and patient advocates.
- Conversations with the family should be documented in the medical record.
Children may know more than you think
Dr. Taub said that even very young children may know more about their disease than adults believe.
“Without disclosure,” she said, “as children hear the conversations around them, they glean partial information and may weave together stories that are more frightening than reality.”
Sometimes families and the care team disagree on disclosure and for that scenario, the report offers guidance in finding middle ground.
For instance, when pediatricians feel ethically obligated to share information when parents oppose sharing, “pediatricians can reframe the discussion from whether information should be shared with the patient to what information will be communicated, how, and by whom,” the authors said in a press release.
Should you tell 15-year-old paraplegia is likely?
The authors give a case example of a 15-year-old whose spinal tumor likely will lead to paraplegia within weeks. Very few treatment options are available.
The parents ask the care team to avoid any discussions with the child about prognosis, reasoning that the news will be crushing and it’s better to deal with it if or when it happens.
The care team, however, feels compelled to find out about specific activities important to the child that may no longer be feasible with paraplegia.
The parents cite the child’s love of soccer and desire to see the Statue of Liberty. With that information and keeping the parents’ wishes in mind, the team reframes the conversation with the child in terms of goals, acknowledging that mobility may be more difficult in the future.
That conversation leads the child and the family to discuss moving up the trip to New York they had planned.
Guidance where there has been little
Timothy Joos, MD, MPH, a pediatrician who practices at a community health center in Seattle, who was not part of the recommendation team, said he was glad to see the AAP issue advice on a complex topic for which there is little practical guidance.
The authors’ case examples were “heart-tugging,” he said, and will help pediatricians work through their own scenarios.
Dr. Joos agreed with the overall premise that the default should be sharing the information.
“One of the foundations of medicine is truthfulness and openness and if we depart from that, we really have to have a good reason,” Dr. Joos said.
He said that since lying to patients should be nonnegotiable for any physician, it may help to talk with the parents first before answering an inquisitive patient’s questions and then have all parties gather for a discussion.
The authors note that AAP’s clinical reports are written by medical experts and reflect the latest evidence. The reports go through several rounds of peer review before they can be approved by the AAP board of directors.
The authors and Dr. Joos report no relevant financial relationships.
When children have a serious illness, some families choose not to disclose the severity to them, reasoning that knowing the extent of the illness may take away their hope. Deciding whether to tell children or adolescents about the seriousness of their disease is a complex judgment and can pose legal, ethical, and moral challenges for parents and care providers.
Default should be inclusion
The American Academy of Pediatrics (AAP) recommends in a new clinical report that the default should be to include children in conversations about their illness in a developmentally appropriate way, to the extent parents are comfortable.
The report, written by Sara Taub, MD and Robert Macauley, MD, MDiv, both in the department of pediatrics at Oregon Health & Science University in Portland, on behalf of the AAP Committee on Bioethics, was published online and appears in the October issue of Pediatrics.
“Rather than taking away hope, as some may fear, this approach of openness may create a space for children to ask their questions, share their concerns, and set goals that are appropriate to the circumstances,” the authors wrote in a press release.
The report offers strategies based on ethical, historical, legal, and cultural considerations when discussing what to share with a child or adolescent.
Some of the AAP’s other recommendations include the following:
- If the parents request nondisclosure, the first response should be seeking to understand why they prefer that stance. The care team members should also explain their position to parents.
- If there is no consensus on disclosure, establishing what each party believes is the minimum information that should be shared is important.
- Additional resources to navigate disagreement may be helpful, such as hospital ethics committees, mediators and patient advocates.
- Conversations with the family should be documented in the medical record.
Children may know more than you think
Dr. Taub said that even very young children may know more about their disease than adults believe.
“Without disclosure,” she said, “as children hear the conversations around them, they glean partial information and may weave together stories that are more frightening than reality.”
Sometimes families and the care team disagree on disclosure and for that scenario, the report offers guidance in finding middle ground.
For instance, when pediatricians feel ethically obligated to share information when parents oppose sharing, “pediatricians can reframe the discussion from whether information should be shared with the patient to what information will be communicated, how, and by whom,” the authors said in a press release.
Should you tell 15-year-old paraplegia is likely?
The authors give a case example of a 15-year-old whose spinal tumor likely will lead to paraplegia within weeks. Very few treatment options are available.
The parents ask the care team to avoid any discussions with the child about prognosis, reasoning that the news will be crushing and it’s better to deal with it if or when it happens.
The care team, however, feels compelled to find out about specific activities important to the child that may no longer be feasible with paraplegia.
The parents cite the child’s love of soccer and desire to see the Statue of Liberty. With that information and keeping the parents’ wishes in mind, the team reframes the conversation with the child in terms of goals, acknowledging that mobility may be more difficult in the future.
That conversation leads the child and the family to discuss moving up the trip to New York they had planned.
Guidance where there has been little
Timothy Joos, MD, MPH, a pediatrician who practices at a community health center in Seattle, who was not part of the recommendation team, said he was glad to see the AAP issue advice on a complex topic for which there is little practical guidance.
The authors’ case examples were “heart-tugging,” he said, and will help pediatricians work through their own scenarios.
Dr. Joos agreed with the overall premise that the default should be sharing the information.
“One of the foundations of medicine is truthfulness and openness and if we depart from that, we really have to have a good reason,” Dr. Joos said.
He said that since lying to patients should be nonnegotiable for any physician, it may help to talk with the parents first before answering an inquisitive patient’s questions and then have all parties gather for a discussion.
The authors note that AAP’s clinical reports are written by medical experts and reflect the latest evidence. The reports go through several rounds of peer review before they can be approved by the AAP board of directors.
The authors and Dr. Joos report no relevant financial relationships.
When children have a serious illness, some families choose not to disclose the severity to them, reasoning that knowing the extent of the illness may take away their hope. Deciding whether to tell children or adolescents about the seriousness of their disease is a complex judgment and can pose legal, ethical, and moral challenges for parents and care providers.
Default should be inclusion
The American Academy of Pediatrics (AAP) recommends in a new clinical report that the default should be to include children in conversations about their illness in a developmentally appropriate way, to the extent parents are comfortable.
The report, written by Sara Taub, MD and Robert Macauley, MD, MDiv, both in the department of pediatrics at Oregon Health & Science University in Portland, on behalf of the AAP Committee on Bioethics, was published online and appears in the October issue of Pediatrics.
“Rather than taking away hope, as some may fear, this approach of openness may create a space for children to ask their questions, share their concerns, and set goals that are appropriate to the circumstances,” the authors wrote in a press release.
The report offers strategies based on ethical, historical, legal, and cultural considerations when discussing what to share with a child or adolescent.
Some of the AAP’s other recommendations include the following:
- If the parents request nondisclosure, the first response should be seeking to understand why they prefer that stance. The care team members should also explain their position to parents.
- If there is no consensus on disclosure, establishing what each party believes is the minimum information that should be shared is important.
- Additional resources to navigate disagreement may be helpful, such as hospital ethics committees, mediators and patient advocates.
- Conversations with the family should be documented in the medical record.
Children may know more than you think
Dr. Taub said that even very young children may know more about their disease than adults believe.
“Without disclosure,” she said, “as children hear the conversations around them, they glean partial information and may weave together stories that are more frightening than reality.”
Sometimes families and the care team disagree on disclosure and for that scenario, the report offers guidance in finding middle ground.
For instance, when pediatricians feel ethically obligated to share information when parents oppose sharing, “pediatricians can reframe the discussion from whether information should be shared with the patient to what information will be communicated, how, and by whom,” the authors said in a press release.
Should you tell 15-year-old paraplegia is likely?
The authors give a case example of a 15-year-old whose spinal tumor likely will lead to paraplegia within weeks. Very few treatment options are available.
The parents ask the care team to avoid any discussions with the child about prognosis, reasoning that the news will be crushing and it’s better to deal with it if or when it happens.
The care team, however, feels compelled to find out about specific activities important to the child that may no longer be feasible with paraplegia.
The parents cite the child’s love of soccer and desire to see the Statue of Liberty. With that information and keeping the parents’ wishes in mind, the team reframes the conversation with the child in terms of goals, acknowledging that mobility may be more difficult in the future.
That conversation leads the child and the family to discuss moving up the trip to New York they had planned.
Guidance where there has been little
Timothy Joos, MD, MPH, a pediatrician who practices at a community health center in Seattle, who was not part of the recommendation team, said he was glad to see the AAP issue advice on a complex topic for which there is little practical guidance.
The authors’ case examples were “heart-tugging,” he said, and will help pediatricians work through their own scenarios.
Dr. Joos agreed with the overall premise that the default should be sharing the information.
“One of the foundations of medicine is truthfulness and openness and if we depart from that, we really have to have a good reason,” Dr. Joos said.
He said that since lying to patients should be nonnegotiable for any physician, it may help to talk with the parents first before answering an inquisitive patient’s questions and then have all parties gather for a discussion.
The authors note that AAP’s clinical reports are written by medical experts and reflect the latest evidence. The reports go through several rounds of peer review before they can be approved by the AAP board of directors.
The authors and Dr. Joos report no relevant financial relationships.
From Pediatrics
Cost concerns lead to cancer treatment delays, nonadherence
TOPLINE:
METHODOLOGY:
- Navigating the complexities of insurance coverage is difficult for cancer patients, and the clinical impact of managing these intricacies remains unclear.
- To understand the issue, investigators surveyed 510 insured cancer patients in the United States about how often they estimate out-of-pocket costs for medications, doctors’ visits, and lab tests and scans, as well as how often they ask their insurance company to help them understand their coverage and how often they appeal coverage decisions.
- The team then correlated the answers with how often patients reported postponing or skipping doctors’ appointments and lab tests and how often they delayed filling prescriptions or skipped doses.
- Breast, colorectal, lung, and prostate cancer were the most common diagnoses among respondents.
TAKEAWAY:
- Overall, 55% of participants said they “never” or “rarely” engaged in any insurance-related cost tasks. The most frequently performed administrative tasks included finding out the cost before filling a prescription (28%) or before undergoing lab tests or scans (20%), as well as estimating the cost before agreeing to a treatment (20%), asking an insurance company for help understanding coverage (18%), or appealing a denial (17%).
- After adjusting for age, race/ethnicity, education, and monthly out-of-pocket costs, participants who engaged in any cost task were 18% more likely to experience treatment delays or forgo care.
- Every additional cost task or increase in frequency of a cost task was associated with 32% higher frequency of treatment delay or nonadherence.
- Age, race, and monthly out-of-pocket costs were more strongly associated with treatment delays/nonadherence than cost-task burden. Younger patients and Black patients were more likely than others to experience cost-related delays/nonadherence.
IN PRACTICE:
- “Reductions to administrative burden on patients, whether through patient-level education interventions, the adaptation of hospital-based navigation programs, or policy-focused changes to insurance systems, will be crucial” for helping patients with cancer to overcome administrative burdens and improve access to care, the authors said.
SOURCE:
- The study, led by Meredith Doherty, PhD, of the University of Pennsylvania, Philadelphia, was published in Cancer Epidemiology, Biomarkers and Prevention.
LIMITATIONS:
The survey was voluntary, which raises the possibility of self-selection bias. Recall bias may also have occurred, particularly among patients farther out from diagnosis and treatment. The investigators did not include uninsured patients and did not stratify patients by insurance type, and they did not measure or account for health care literacy.
DISCLOSURES:
The study was funded by the American Cancer Society. The investigators have disclosed no relevant financial relationships.
A version of this article appeared on Medscape.com.
TOPLINE:
METHODOLOGY:
- Navigating the complexities of insurance coverage is difficult for cancer patients, and the clinical impact of managing these intricacies remains unclear.
- To understand the issue, investigators surveyed 510 insured cancer patients in the United States about how often they estimate out-of-pocket costs for medications, doctors’ visits, and lab tests and scans, as well as how often they ask their insurance company to help them understand their coverage and how often they appeal coverage decisions.
- The team then correlated the answers with how often patients reported postponing or skipping doctors’ appointments and lab tests and how often they delayed filling prescriptions or skipped doses.
- Breast, colorectal, lung, and prostate cancer were the most common diagnoses among respondents.
TAKEAWAY:
- Overall, 55% of participants said they “never” or “rarely” engaged in any insurance-related cost tasks. The most frequently performed administrative tasks included finding out the cost before filling a prescription (28%) or before undergoing lab tests or scans (20%), as well as estimating the cost before agreeing to a treatment (20%), asking an insurance company for help understanding coverage (18%), or appealing a denial (17%).
- After adjusting for age, race/ethnicity, education, and monthly out-of-pocket costs, participants who engaged in any cost task were 18% more likely to experience treatment delays or forgo care.
- Every additional cost task or increase in frequency of a cost task was associated with 32% higher frequency of treatment delay or nonadherence.
- Age, race, and monthly out-of-pocket costs were more strongly associated with treatment delays/nonadherence than cost-task burden. Younger patients and Black patients were more likely than others to experience cost-related delays/nonadherence.
IN PRACTICE:
- “Reductions to administrative burden on patients, whether through patient-level education interventions, the adaptation of hospital-based navigation programs, or policy-focused changes to insurance systems, will be crucial” for helping patients with cancer to overcome administrative burdens and improve access to care, the authors said.
SOURCE:
- The study, led by Meredith Doherty, PhD, of the University of Pennsylvania, Philadelphia, was published in Cancer Epidemiology, Biomarkers and Prevention.
LIMITATIONS:
The survey was voluntary, which raises the possibility of self-selection bias. Recall bias may also have occurred, particularly among patients farther out from diagnosis and treatment. The investigators did not include uninsured patients and did not stratify patients by insurance type, and they did not measure or account for health care literacy.
DISCLOSURES:
The study was funded by the American Cancer Society. The investigators have disclosed no relevant financial relationships.
A version of this article appeared on Medscape.com.
TOPLINE:
METHODOLOGY:
- Navigating the complexities of insurance coverage is difficult for cancer patients, and the clinical impact of managing these intricacies remains unclear.
- To understand the issue, investigators surveyed 510 insured cancer patients in the United States about how often they estimate out-of-pocket costs for medications, doctors’ visits, and lab tests and scans, as well as how often they ask their insurance company to help them understand their coverage and how often they appeal coverage decisions.
- The team then correlated the answers with how often patients reported postponing or skipping doctors’ appointments and lab tests and how often they delayed filling prescriptions or skipped doses.
- Breast, colorectal, lung, and prostate cancer were the most common diagnoses among respondents.
TAKEAWAY:
- Overall, 55% of participants said they “never” or “rarely” engaged in any insurance-related cost tasks. The most frequently performed administrative tasks included finding out the cost before filling a prescription (28%) or before undergoing lab tests or scans (20%), as well as estimating the cost before agreeing to a treatment (20%), asking an insurance company for help understanding coverage (18%), or appealing a denial (17%).
- After adjusting for age, race/ethnicity, education, and monthly out-of-pocket costs, participants who engaged in any cost task were 18% more likely to experience treatment delays or forgo care.
- Every additional cost task or increase in frequency of a cost task was associated with 32% higher frequency of treatment delay or nonadherence.
- Age, race, and monthly out-of-pocket costs were more strongly associated with treatment delays/nonadherence than cost-task burden. Younger patients and Black patients were more likely than others to experience cost-related delays/nonadherence.
IN PRACTICE:
- “Reductions to administrative burden on patients, whether through patient-level education interventions, the adaptation of hospital-based navigation programs, or policy-focused changes to insurance systems, will be crucial” for helping patients with cancer to overcome administrative burdens and improve access to care, the authors said.
SOURCE:
- The study, led by Meredith Doherty, PhD, of the University of Pennsylvania, Philadelphia, was published in Cancer Epidemiology, Biomarkers and Prevention.
LIMITATIONS:
The survey was voluntary, which raises the possibility of self-selection bias. Recall bias may also have occurred, particularly among patients farther out from diagnosis and treatment. The investigators did not include uninsured patients and did not stratify patients by insurance type, and they did not measure or account for health care literacy.
DISCLOSURES:
The study was funded by the American Cancer Society. The investigators have disclosed no relevant financial relationships.
A version of this article appeared on Medscape.com.
FROM CANCER EPIDEMIOLOGY, BIOMARKERS AND PREVENTION