Senin, 30 April 2018

Allergies and Asthma May Be Linked to Mental Health

Allergies and Asthma May Be Linked to Mental Health


NEW YORK (Reuters Health) – People who suffer from asthma and allergic rhinitis have an increased risk for developing a psychiatric disorder, and assessing their emotional condition and monitoring their mental health might be worthwhile, say researchers from Taiwan.

Asthma, allergic rhinitis and atopic dermatitis – nicknamed the three “A’s” – are among some of the most common allergic diseases. “As a clinician, I observed that some patients with the three ‘A’s appeared to suffer emotionally. Therefore, I wanted to clarify whether these allergic diseases are associated with psychiatric disorders,” Dr. Nian-Sheng Tzeng from Tri-Service General Hospital said in a statement.

Using the Taiwan National Health Insurance (NHI) Program database, the researchers identified more than 186,000 adults, including 46,647 who suffered from allergic diseases, and 139,941 matched controls who did not.

Over 15 years, 10.8% people with allergic diseases developed a psychiatric disorder compared with 6.7% controls, translating into a significant 1.66-fold increase in risk for people with allergic disease (P<0.001) the researchers report in Frontiers in Psychiatry, online April 23.

Adults with allergic diseases had significantly elevated risks for developing an affective disorder (adjusted HR, 1.4), including depression (aHR 1.4) and bipolar disorder (aHR 1.1), and an anxiety disorder (aHR, 2.4), a psychotic disorder (aHR, 1.2) and dementia (aHR, 1.2).

The researchers divided participants with allergic diseases into six groups: asthma alone, allergic rhinitis alone, atopic dermatitis alone, asthma plus allergic rhinitis, asthma plus atopic dermatitis, allergic rhinitis plus atopic dermatitis and a combination of all these three allergic diseases.

Atopic dermatitis was associated with a lower overall risk of psychiatric disorders, but asthma and allergic rhinitis was associated an overall increased risk, they report.

Asthma was associated with a heightened risk of individual psychiatric disorders including anxiety and depression, dementia and bipolar disorder. Allergic rhinitis was associated with a lower risk of dementia but an increased risk of other psychiatric disorders. Having more allergic diseases was associated with an increased risk of psychiatric disorders, the authors note.

Dr. Tzeng and colleagues also found that use of oral prednisolone was associated with a lower risk of developing psychiatric disorders in asthma patients.

Also, the use of the beta-agonist aminophylline and leucotriene receptor antagonists was associated with a lower risk of psychiatric disorders, with or without prednisolone use.

The researchers note that some other studies have suggested a link between allergy-related inflammatory or immunological factors and psychiatric disorders. The psychological stress of a psychiatric disorder might also contribute to physical symptoms. Further study is needed to clarify the mechanisms underlying the association between allergic diseases and psychiatric disorders, they say.

Corresponding author Dr. Wu-Chien Chien of National Defense Medical Center in Taipei did not respond to a request for comment by press time.

The study had no commercial funding and the authors declare no conflicts of interest.

SOURCE: https://bit.ly/2HuU6Se

Front Psychiatry 2018.



Source link

Celecoxib May Help Curb Opioid Use After Head and Neck Cancer Surgery

Celecoxib May Help Curb Opioid Use After Head and Neck Cancer Surgery


NEW YORK (Reuters Health) – Celecoxib is associated with lower perioperative opioid requirements after head and neck surgery with free tissue reconstruction, researchers say.

Dr. Richard Cannon of the University of Utah School of Medicine in Salt Lake City matched 51 patients who received celecoxib postoperatively with 51 who did not. The mean age was 61.6 in the celecoxib cohort and 66.1 for controls. Half of both groups were women.

Celecoxib, 200 mg, was given twice daily through a feeding tube for at least five days starting on postoperative day one. Oral opioids – hydrocodone, oxycodone, morphine, and hydromorphone – were offered on a schedule and as needed, with doses converted into morphine milligram equivalents (MMEs). IV opioids were used for severe pain.

As reported online April 18 in JAMA Otolaryngology-Head and Neck Surgery and at the American Head & Neck Society annual meeting in National Harbor, Maryland, treatment with celecoxib was associated with decreased use of oral opioids (mean difference in daily MMES, 9.9 mg), IV opioids (mean difference, 3.9 mg), and total opioids (mean difference, 14mg).

Among patients who underwent the most common ablative procedure – composite oral resection – the effect was more significant. In this subset, the mean MMEs per day with vs without celecoxib, respectively, were 26.0 mg vs. 51.1 mg for oral drugs, 0.9 mg vs. 4.4 mg for IV administration, and 26.9 mg vs. 55.5 mg overall.

There was no significant difference in complication rates between the two groups.

“Rofecoxib, another COX-2 inhibitor, was taken off the market in 2004 owing to concerns about increased cardiovascular risk,” Dr. Cannon noted in an email to Reuters Health. “However, this concern has not been shown with celecoxib after long-term multi-institutional randomized clinical trials on numerous patients . . . demonstrated no difference in incidence of cardiovascular adverse events.”

“We saw no clinical difference in cardiovascular events in the cohort of patients that received celecoxib versus those patients that did not received celecoxib,” he added.

“Our data has limitations but represents a pilot study to evaluate potential mechanisms to decrease opioid use in patients who undergo head and neck surgery,” he said.

“Future studies should include prospective placebo-controlled trials including patient pain scores and patient-centered outcome measurements. Trials like this will be essential in providing further insight into the qualitative pain levels while minimizing potential observer bias,” he concluded.

Dr. Christopher G. Gharibo, associate professor of Anesthesiology, Perioperative Care, and Pain Medicine and Orthopedic Surgery at NYU Langone Health in New York City, agrees that “celecoxib can improve the quality of the pain relief while reducing the reliance on opioids and decreasing discharge doses.”

However, “celecoxib and other NSAIDs may be associated with exacerbation of end-organ diseases (including) cardiovascular, renal and gastrointestinal,” he told Reuters Health by email.

While NSAIDs other than celecoxib might be similarly effective in reducing opioid requirements, he said, “They’re associated with platelet inhibition and increasing the bleeding risk.”

SOURCE: http://bit.ly/2r94R5M

JAMA Otolaryngol Head Neck Surg 2018.



Source link

After Outcry, New CDC Director Asks for and Gets Salary Cut

After Outcry, New CDC Director Asks for and Gets Salary Cut


After an outcry among some Senate Democrats, the salary of the new director of the Centers for Disease Control and Prevention (CDC), Robert Redfield, MD, will be reduced by the US Department of Health and Human Services (HHS), according to media reports.

Redfield, a prominent HIV/AIDS researcher who has led the CDC since March, is paid $375,000. In comparison, his predecessor, former CDC Director Brenda Fitzgerald, MD — who resigned in January after about 6 months on the job after concerns arose regarding conflicts of interest relating to some of her personal investments — earned $197,300. Redfield’s boss, HHS Secretary Alex Azar, makes $199,700.

Redfield’s salary was established through a program to recruit high-level scientists for government jobs, but the amount came under harsh scrutiny over the weekend. HHS has not yet reported what his new salary will be.

Sen. Patty Murray (D-WA) wrote in a letter to Azar on April 26: “It is difficult to understand why someone with limited public health experience, particularly in a leadership role, is being disproportionately compensated for his work as compared to other accomplished scientists and public health leaders in comparable roles within the federal government.”

The New York Times reported that an HHS spokeswoman, who declined to be named, wrote in an emailed response to questions from the New York Times, “Dr Redfield has expressed to Secretary Azar that he does not wish to have his compensation become a distraction for the important work of the CDC. Therefore, consistent with Dr Redfield’s request to the Secretary, Dr Redfield’s compensation will be adjusted accordingly.”

According to his HHS biography, Redfield was founding director of the Department of Retroviral Research within the US Military HIV Research Program. He retired after 20 years of service in the US Army Medical Corps. He cofounded the University of Maryland’s Institute of Human Virology and served as the chief of infectious diseases and vice chair of medicine at the University of Maryland School of Medicine, Baltimore.

For more news, join us on Facebook and Twitter



Source link

Applying Silicon Valley Smarts to Age-Old Diseases

Applying Silicon Valley Smarts to Age-Old Diseases


YAOUNDÉ, Cameroon — On the second floor of an infectious-disease research facility in this African capital, Dr. Joseph Kamgno, the country’s leading expert on parasitic roundworms, stood at his desk staring down at the black hard-shelled case that had just arrived from a bioengineering lab at the University of California-Berkeley.

The case contained what appeared to be three ordinary iPhones. But the California researchers believed these phones could do something extraordinary — help quell river blindness, the second-leading cause of preventable blindness in the world.

There is already an effective treatment, a medication that can kill the baby worms that cause the blindness. And when nearly everyone in a community takes the drug every year for a decade or so, it can eliminate the disease from the area.

But treating communities widely for river blindness is a risky proposition: The treatment can cause coma or death in a small segment of the population that harbors a different parasite — another worm known as Loa loa. That’s why large swaths of Sub-Saharan Africa have been denied treatment for nearly two decades — because the cure for river blindness for certain people can prove far worse than the disease.

And that’s where Silicon Valley technology comes in. The Berkeley researchers figured out that they could quickly determine who has the Loa loa worm using a smartphone, customized to work like a microscope. They could then skip the medication for those people and give it to everyone else. Kamgno, who received the latest version of the phones in 2016, dubbed the mobile microscopes “revolutionary.”

The gadgets, called LoaScopes, are part of a broader effort to harness technology and innovation in the U.S., including California’s Silicon Valley, to fight age-old diseases in the developing world.

Over the years, major California universities — UC-Berkeley, UC-Davis, UCLA — have built cellphone microscopes geared to look at other bloodborne diseases in Africa and Asia, such as malaria and tuberculosis. UC-San Francisco researchers are using satellite images on Google Earth Engine to construct real-time maps of breeding conditions for malaria that can help predict infection rates in rural villages.

Drones are being used to deliver medical supplies to remote villages in Rwanda, and digital “ledgers” built with blockchain software could be used to track vaccinations in newborns, said Zvika Krieger, technology and policy expert at the World Economic Forum Center for the Fourth Industrial Revolution.

To accomplish their missions, nongovernmental and civil society organizations “are flocking to Silicon Valley,” he said.

Mobile Microscopes and Wiggly Worms

The LoaScope was created in UC-Berkeley’s Fletcher Lab, named after Daniel Fletcher, a wild-haired scientist who discovered 10 years ago the potential of cellphones as microscopes. Basically, the camera on the phone is positioned over a magnifying lens to capture a sample on a slide. Software can then analyze whatever is on the slide and transmit it to the cloud.

Standard light microscopes aren’t really mobile, and require electricity and a trained lab tech to operate. The mobile microscope is cheap, compact and can be used by anyone familiar with mobile phones, which are increasingly common around the world, even in remote villages.

Parasite expert Dr. Joseph Kamgno examines a new version of a cellphone-based microscope in his research facility in Yaoundé, Cameroon. (Brian Rinker for KHN)

The discovery spun off into a private business called CellScope, while Fletcher’s academic lab continued to research smartphones as microscopes for the university.

Several years ago, Fletcher and his team had never heard of river blindness and knew very little about neglected tropical diseases in general. The team eventually became part of a mobile phone revolution in the developing world, in which public health researchers were ratcheting up efforts to use these pocket computers to address health problems.

The Bill and Melinda Gates Foundation have bankrolled the LoaScope project since its inception in 2011, spending more than $5 million to date.

River blindness, or onchocerciasis, is a nasty disease that has burdened Africa for as long as anyone can remember. The disease is spread by black flies, which drop off and pick up worms as they suck people’s blood. The symptoms — terrible itching, rotting skin and, after decades of infection, blindness — are caused by early stage worm larvae that flood the body after adult worms mate.

The river blindness medication, ivermectin, kills these baby worms effectively. But when a person harboring tens of thousands of Loa loa worms in each drop of blood takes ivermectin, all the baby worms die off in a sort of mass extinction, causing potentially lethal brain swelling.

Upsides and Downsides

The small lab in Berkeley got involved with this complicated worm conundrum through a parasitic disease expert at the National Institutes of Health.

Dr. Thomas Nutman was tasked with finding a technology that could help solve the Loa loa problem. At first, he considered a project at UCLA in which a cellphone picture could be taken in the field, uploaded to the cloud and then analyzed by someone sitting at a computer in California.



Students, researchers and health workers learn to use the LoaScope, a cellphone microscope that can detect dangerous levels of a parasite called Loa loa. (Brian Rinker for KHN)

It sounded good in theory, but because thousands of people had to be tested before treatment, Nutman needed answers on the spot. Recalling work by Fletcher and his team, Nutman hopped on a plane to the Bay Area to meet them.

Fletcher and scientist Mike D’Ambrosio knew they had the technology to see the worms — but figuring out how to see and count them in just a couple of minutes “seemed daunting.”

“That’s where we had the idea to use the motion of the worm as a way to see it,” D’Ambrosio said. Early stage Loa loa larvae thrash around in the blood more vigorously than other worms. So D’Ambrosio and his colleagues created an algorithm to identify Loa loa based on its motion.

The LoaScope is an iPhone that attaches to a plastic box made by a 3-D printer. A blood sample on a plastic tube is inserted into the black box, which contains optics and hardware. Press a button on the screen of the iPhone and it takes a video of the blood sample and runs the algorithm.

But relying on bioengineers in the tech-savvy San Francisco Bay Area to create a solution comes with downsides familiar to anyone who works there: shutdowns and updates.

Months before the latest device was scheduled to ship out, the company the scientists used to sync all their data gathered from the LoaScope to the cloud shut down, forcing a rewrite of the related software code. Then the hardware company that made an essential microcontroller board quit production.

“That is the cost we pay for trying to build something out of consumer-based electronics and using cloud software that is always changing,” said D’Ambrosio, who became the lead research scientist for the LoaScope project.

On the other hand, he added, “the benefit is enormous. We’re able to build these integrated devices that do amazing things” at low cost.



Researchers test the latest version of the LoaScope in a village in Cameroon. (Brian Rinker for KHN)

Another problem the scientists had was figuring out who would pay for the devices.

“The business side of it is very unclear,” Fletcher said. “Part of the problem is that there isn’t a market for neglected tropical diseases.”

The Gates Foundation doesn’t typically pay to implement projects on a global scale. However, the foundation is negotiating a deal for a company to manufacture 10,000 LoaScopes, Nutman said.

Back in Cameroon, Kamgno’s research findings, published in the New England Journal of Medicine in November, showed that the LoaScope allowed wide treatment with ivermectin, and produced no adverse reactions in formerly “off-limits” communities. Kamgno’s research team is now training local health workers to use the LoaScope, and other countries soon may follow.

“We were surprised and happy to see that after only two days of training, the local people were able to do the treatment in their own community,” said Kamgno. “Almost all the young people have cellphones, and they can understand the LoaScope so quickly.”

This story was produced by Kaiser Health News, which publishes California Healthline, a service of the California Health Care Foundation.



Source link

What's Hot: Your Guide to APA 2018 Annual Meeting

What's Hot: Your Guide to APA 2018 Annual Meeting


Psychiatrists from around the world will gather in New York City from May 5 to 9 for the American Psychiatric Association (APA) 2018 annual meeting.

With more than 15,000 attendees expected, his year’s theme — Building Well-Being Through Innovation — addresses two key issues that psychiatrists face today: physician burnout, which affects 2 in 5 psychiatrists, and the role of technology and innovation in mental health care.

“This theme is woven throughout the program,” said APA President Anita Everett, MD, during a premeeting press briefing highlighting key research and speakers.

An entire track will focus on physician burnout and well-being. Sessions will explore strategies to promote physician wellness and interventions that can help psychiatrists stay ahead of changes and meet the needs of patients while maintaining professional satisfaction and personal balance, said Everett.

On Sunday, Darrell Kirch, MD, psychiatrist and president and CEO of the Association of American Medical Colleges, will discuss how psychiatrists and the broader medical community can build a resilient workforce for the future.

Several Sunday sessions will explore how technology is changing the field of psychiatry. Prof Susan Greenfield, founder and CEO, Neuro-Bio Ltd, will give a presentation entitled, How the Digital World is Changing the Way We Think and Feel, and Thomas R. Insel, MD, founder and president of Mindstrong Health, will answer the question, Will Technology Transform Mental Healthcare?

Innovation Zone Encore

The Mental Health Innovation Zone is back again this year by popular demand. “This is always very popular and a lively spot in the exhibit hall, and that will again be prominent this year,” said Everett. This year, the Innovation Zone will highlight a wide range of topics, including wearable technology for mental health, artificial intelligence, virtual reality, and apps used in recovery, she noted.

Learning Labs returns again this year. Sessions will emphasize hands-on learning and team training. And the “ever-popular” MindGames, in which teams of residents go head to head with each other in a Jeopardy-style competition on patient care, medical knowledge, and psychiatric history, is back and is “sure to be a fun and informative event,” said APA CEO and Medical Director Saul Levin, MD.

During Sunday’s opening session, retired US Army Lt. Gen Mark Hertling, former commanding general of US Army Europe, will give a talk on how physicians can apply leadership principles developed by the military to medical practice.

On Monday, Elinore McCance-Katz, MD, PhD, assistant secretary for mental health and substance use at the Substance Abuse and Mental Health Services Administration, will give the William C. Menninger Memorial Lecture. She will discuss mental health strategy at different levels of government. McCance-Katz is a long-time member of the APA and an expert on opioids.

Once again, the APA has partnered with the National Institute of Mental Health (NIMH) for a series of sessions that highlight the latest science on diagnosis and treatment, with special focus on personalized medicine and genomics. NIMH Director Joshua Gordon, MD, PhD, will deliver a plenary talk on computational psychiatry.

NIDA Takes Center Stage

Several sessions feature National Institute on Drug Abuse (NIDA) director Nora Volkow, MD, who will address new research and how it can affect the ongoing opioid crisis.

A number of sessions will focus on the “hot topic” of ketamine as a treatment for depression, Tristan Gorrindo, MD, APA director of education, told the briefing. Ketamine is an “exciting new treatment, but it comes with significant challenges, particularly related to appropriate patient selection. It’s really a hot topic right now for both patients and as psychiatrists,” he said.

Gorrindo noted that many APA members have “reached out to us quite often about ketamine, trying to figure out what is the right patient to refer for ketamine treatment. Is it a last-line treatment or a frontline treatment?”

With a record number of submissions this year, attendees have more than 500 sessions to choose from. Research tracks cover many areas of psychiatry, including those dedicated to the subspecialties of addiction psychiatry, childhood and adolescent psychiatry, consult liaison psychiatry, forensic psychiatry, and geriatric psychiatry.

There will be discussions on collaborative care, including new ways that psychiatrists can participate with primary care providers in healthcare delivery. Everett encouraged attendees to take advantage of the free collaborative care training the APA will be offering multiple times during the meeting. This year, the APA has added a new advanced course for psychiatrists who are ready to implement collaborative care in their communities, she said.

New Research Highlights

The APA has chosen four studies to highlight at a research press briefing on Sunday: a study on the African American clergy’s attitude toward professional mental health services; a study on the increasing prevalence of opiates in Maryland suicides; a study on how the Pokemon Go app improved measures of mental health and well-being in game players; and a study on how military sexual trauma interacts with major depressive disorder, post-traumatic stress disorder, and other medical conditions.

On Monday, the APA’s third national poll on mental health will be released. It will show “significant changes” in Americans’ anxiety from 2017 to 2018, Levin said. The survey also provides new insights into Americans’ views on current topics in public health, including gun violence and the opioid epidemic.

Linda Worley, MD, APA scientific program chair, provided a rundown of some of her favorite scientific sessions:

  • Common Challenges in Assessing and Treating Body Dysmorphic Disorder

  • Eating Disorders in Adolescents: Diagnosis, Treatment & Research Update

  • In the Classroom and on the Field: Improving Mental Health Care for Collegiate Student Athletes

  • Lithium: The Old New Wonder Drug

  • Telepsychiatry and Mental Health Technologies

  • To Treat or Not to Treat Perinatal Mood and Anxiety Disorders: Both Options Carry Risks

  • Beyond the Interview: Applying Smartphone Apps, Sensors and Web Technology to the Process of Clinical Assessment in Psychiatry

  • Issues and Controversies Around Marijuana Use: What’s the Buzz?

  • It’s Not All in Your Mind: Diagnosis and Treatment of Sexual Dysfunction

  • Why Are Women Physicians at Higher Risk for Burnout? Empowering the Next Generation to Do it Better (Than We Have)!

  • Cutting Edge Innovations to Provide Care

  • Thriving Despite the Stress: Living a Smooth Sailing Life!

For more Medscape Psychiatry news, join us on Facebook and Twitter.



Source link

Ubrogepant Safe, Effective for Migraine in Second Phase 3 Trial

Ubrogepant Safe, Effective for Migraine in Second Phase 3 Trial


On the heels of favorable results from the phase 3 ACHIEVE-I trial, which were presented last week at the American Academy of Neurology (AAN) 2018 Annual Meeting, topline results from the phase 3 ACHIEVE-2 trial also show that the novel oral calcitonin gene-related peptide (CGRP) receptor antagonist ubrogepant (Allergan) is safe and effective for treating acute migraine, the company announced.

In the earlier ACHIEVE-I, which included more than 1300 patients, significantly more participants receiving 50 or 100 mg of the study drug achieved pain freedom and absence of their most bothersome symptom (MBS) 2 hours after treatment than those who received matching placebo.

In ACHIEVE-2, which also included around 1300 patients in the modified intent-to-treat (mITT) analysis, significantly more of those randomly assigned to the drug at 25- or 50-mg doses achieved pain freedom at the 2-hour point vs those receiving placebo (the co-primary endpoint), while more of those receiving the 50-mg dose also achieved absence of MBS, Allergan reported in a press release and investor’s call.

Investigators also found that the 50-mg group had significantly more members who achieved pain relief, absence of photophobia, and absence of phonophobia at 2 hours and sustained pain relief and sustained pain freedom from 2 to 24 hours after treatment compared with the placebo group.

The most commonly reported adverse events were nausea and dizziness, each of which occurred in less than 2.5% of the participants. Assessment of hepatic safety revealed four cases of aminotransferase elevations greater than three times and less than five times the upper limit of normal — but none were found by the liver safety adjudication board to be treatment related.

“Given the prevalence of migraine and significant disability that many patients face, ubrogepant may provide a new option for those having tolerability issues with current migraine-specific treatments,” co-investigator Stephen Silberstein, MD, director of the Headache Center at Thomas Jefferson University, Philadelphia, Pennsylvania, said in the release.

Co-investigator David Dodick, MD, professor of neurology and director of the headache program at the Mayo Clinic, Scottsdale, Arizona, added during the investor’s call that the novel drug “absolutely” has a place in the acute treatment of migraine.

“It doesn’t constrict blood vessels, so it may be used in patients who have absolute or relative cardiovascular contraindications to the use of triptans. And importantly, patients are going to be able to use these treatments early in the course of an attack, when pain is mild, because they’re not fearful of side effects,” said Dodick.

The company announced that it anticipates filing a new drug application to the US Food and Drug Administration in 2019.

Co-Primary Endpoints

ACHIEVE-2 enrolled 1686 adult patients aged 18 to 75 years with a history of migraine. In the study’s mITT population, 435 patients were randomly assigned to receive ubrogepant 25 mg, 464 to the drug at 50 mg, and 456 to placebo. All treatments were to be used in response to a single migraine attack judged to be moderate to severe in intensity.

As mentioned, significantly more members of the 25- and 50-mg groups achieved pain freedom 2 hours after initial treatment dose, the co-primary endpoint 1, than did placebo group members (P = .03 and .01, respectively).

While more patients in each ubrogepant group also achieved absence of MBS, co-primary endpoint 2, the difference was significant only for those receiving the higher dose of the study drug (P = .07 and .01, respectively). More details for these two primary efficacy endpoints are shown in the table below.

Table. Primary Endpoints for 25 and 50 mg of Ubrogepant vs Placebo

Outcome Ubrogepant 25 mg (%) Ubrogepant 50 mg (%) Placebo (%)
Pain freedom 20.7a 21.8a 14.3
Absence of MBS 34.1 38.9a 27.4
aAchieved statistical significance vs placebo.

 

Other outcomes that were met by a significantly greater percentage in the 50-mg group included the following:

  • Pain relief at 2 hours (P = .01);

  • Absence of photophobia at 2 hours (P = .02);

  • Absence of phonophobia at 2 hours (P = .04);

  • Sustained pain relief from 2 to 24 hours (P = .01); and

  • Sustained pain freedom from 2 to 24 hours (P = .01).

“The consistency in response between both ACHIEVE I and ACHIEVE 2 provides further evidence that ubrogepant…offers a promising opportunity for the acute treatment of migraine,” David Nicholson, chief research and development officer at Allergan, said in the release.

The study was funded by Allergan.

Follow Deborah Brauser on Twitter: @MedscapeDeb . For more Medscape Neurology news, join us on Facebook and Twitter .



Source link

Number of NPs/PAs in Specialty Care Rises 22% Over a Decade

Number of NPs/PAs in Specialty Care Rises 22% Over a Decade


The number of nurse practitioners (NPs) and physician assistants (PAs) hired in specialty practices rose 22% from 2008 to 2016, according to a research letter published online today in JAMA Internal Medicine.

The numbers of advanced practice providers (APPs) grew even more in primary care (24%), report Grant R. Martsolf, PhD, MPH, from the School of Nursing at University of Pittsburgh in Pennsylvania,, and colleagues. However, they focused the study on specialty practices because growing use in primary care is well documented.

Overall, about 28% of all specialty practices employed APPs, including 49% of multispecialty practices and 21% of surgical practices. Employment of NPs in specialty practices grew at a faster rate than did employment of PAs (33% vs 20%).

In 5 of the top 10 specialties included in the report, APPs were employed in at least 25% of the practices. Dermatology had the largest growth.

Table. Top Specialties in Which at Least 25% of Practices Employ NPs/PAs

Specialty Practices That Employ APPs (2016) (%) Change From 2008 (%)
Cardiology 31.0 2.4
Obstetrics/gynecology 29.3 –0.7
Orthopedic surgery 29.1 3.9
Dermatology 36.3 32.5
Gastroenterology 28.7 14.2

 

Geographically, the states with the highest use of APPs in specialties were clustered in the Mountain regions and West North Central, including states such as Montana, North Dakota, South Dakota, Minnesota, and Iowa.

Among the reasons for overall growth in APP hiring, the authors point to the emergence of value-based care models, incentives for team-based care, and pressure to reduce costs.

Specialist practices may also be building new roles for APPs, they write.

Martsolf and colleagues used the 2008 and 2016 SK&A outpatient provider files to determine the prevalence of advance practice providers in specialties. The SK&A is a proprietary data set that includes information on 90% of physician practices in the United States.

The authors acknowledge limitations of the study: For example, they did not study specific duties of the APPs, and the data include only outpatient providers.

The authors have disclosed no relevant financial relationships.

JAMA Intern Med. Published online April 30, 2018. Abstract

For more news, join us on Facebook and Twitter



Source link

Depression and Bipolar Screening Essential for New Moms

Depression and Bipolar Screening Essential for New Moms


AUSTIN — Perinatal and postpartum depression affect one in seven women in the United States, but healthcare resources and access to care can be inconsistent or nonexistent for many.

“Maternal mental health problems are one of the most common complications of pregnancy, and we as OBs have a real opportunity to affect their care in a positive way by addressing and treating them, said Tiffany Moore Simas, MD, from the University of Massachusetts Medical School in Worcester.

Perinatal mental health disorders affect not only mothers, but also their families, she told Medscape Medical News. For mothers, untreated mental health conditions can contribute to poor adherence to medical care, smoking and substance use, pre-eclampsia, and suicide. For children, risks are elevated for low birth weight, preterm delivery, cognitive delay, behavioral problems, and infanticide.

Maternal suicide exceeds hemorrhage and hypertensive disorders as a cause of maternal mortality.

“Maternal suicide exceeds hemorrhage and hypertensive disorders as a cause of maternal mortality,” Moore Simas said here at the American College of Obstetricians and Gynecologists (ACOG) 2018 Annual Meeting.

Still, it is estimated that just one-quarter of women with perinatal mental health complications receive treatment, she reported.

Women need to be screened for perinatal mood and anxiety disorders at least twice: once during pregnancy and again after delivery, according to the US Preventive Services Task Force. The ACOG recommends screening for depression and anxiety at least once during the perinatal period.

The major validated screening tools for depression take no more than 10 minutes, and often less, to complete.

These include the Edinburgh Postnatal Depression Scale, a free depression and anxiety screen available in more than 40 languages; the Postpartum Depression Screening Scale; the Patient Health Questionnaire 9, which screens for depression in the general population; the Beck Depression Inventory and the Beck Depression Inventory II; the Center for Epidemiologic Studies Depression Scale; and the Zung Self-Rating Depression Scale.

All but the Zung scale are available in Spanish.

Integrating depression care into obstetric practices can be transformative for the women we serve.

The perinatal period is ideal for depression screening because providers have regular contact with women, Moore Simas explained. Obstetrician–gynecologists can decrease the stigma of mental health conditions and educate women so that they feel comfortable seeking care.

In addition, barriers to care at provider and practice levels — such as inadequate resources, lack of guidance and training for providers, and obstacles that prevent the performance of nonroutine screening within systems — must be removed, she said.

“Integrating depression care into obstetric practices can be transformative for the women we serve,” she explained.

The Maternal Mental Health: Depression and Anxiety patient safety bundle — developed by the ACOG Council on Patient Safety in Women’s Health Care, of which Moore Simas is a member — is designed to increase the ability of obstetrician–gynecologists to care for women with postpartum mood or other psychiatric disorders.

MCPAP for Moms — adapted from the Massachusetts Child Psychiatry Access Project (MCPAP) — enhances the ability of pediatricians and primary care providers to treat youth with mental health concerns. Programs in 32 states have now been modelled after MCPAP, and Moore Simas said she hopes to see a similar expansion of MCPAP for Moms.

“MCPAP for Moms is spreading, and it’s being viewed as a national model,” she pointed out. It offers obstetrician–gynecologists resources on consultation, care coordination, and education, and includes training on how and when to screen, what to do with positive screens, and the need to rule out bipolar disorder before prescribing medications.

Of the mothers who experience mood or other psychiatric disorders, it is estimated that 23% have bipolar disorder and 7% have some other diagnosis.

Screening for Bipolar Disorder

More than 70% of women with bipolar disorder experience postpartum psychosis, a psychiatric emergency that affects up to two in 1000 women overall and carries a 4% risk for infanticide.

When depression screening results are positive and antidepressants are indicated, providers can conduct a quick bipolar disorder screen.

The idea of adding a bipolar screening question when women screen positive for perinatal or postpartum depression was a revelation to Shamita Bansore, MD, from Good Samaritan Hospital in Downers Grove, Illinois, who attended the presentation.

In the past, Bansore has prescribed selective serotonin reuptake inhibitors immediately after learning that a patient needed support for depression or anxiety, but, as Moore Simas explained, patients with bipolar disorder can develop psychosis when taking these drugs.

The addition of a bipolar question to screens is “quick and easy,” although many obstetrician–gynecologists probably don’t do it, Bansore told Medscape Medical News. “I’m going to apply that right away.”

This presentation was “inspiring and hopeful,” said Ella Speichinger, MD, from the University of Missouri in Columbia, who described a recent patient who had been prescribed antidepressants and went on to develop psychosis at 3 months postpartum.

“She was prescribed an antidepressant because she was anxious, but she never had a screen for bipolar,” Speichinger told Medscape Medical News. “I wonder what her course would have been like had she had access to this kind of care.”

Providers have to advocate for funding for programs similar to MCPAP for Moms, said Moore Simas, who noted that funds were recently allocated to the Bringing Postpartum Depression Out of the Shadows Act, which was signed into law in 2016.

“Thinking politically, I need to be involved in my legislature to get something like funding for MCPAP programs pushed through,” Speichinger told Medscape Medical News. “But on a more granular level, when I go to work tomorrow, I should feel like I can pick up the phone and call somebody for advice because doing nothing is basically worse than doing something.”

Moore Simas reports serving on advisory boards, being a research consultant, and receiving speaker honoraria from Sage Therapeutics. Bansore and Speichinger have disclosed no relevant financial relationships.

American College of Obstetricians and Gynecologists (ACOG) 2018 Annual Meeting. Presented April 28, 2018.

Follow Medscape OBGYN on Twitter @MedscapeObGyn and Tara Haelle @TaraHaelle



Source link

Death of Alfie Evans Leaves End-of-Life Questions Unresolved

Death of Alfie Evans Leaves End-of-Life Questions Unresolved


LONDON — The death this weekend of Alfie Evans, the 23-month-old terminally ill British youngster, closes a chapter on a tragic case that exposed in the full glare of media attention the friction that can arise in end-of-life cases when families and healthcare professionals are at loggerheads over what is best for a child.

The failure of Alfie’s parents to resist medical opinion, overturn court judgements, and have the final say in their son’s care led to a backlash from the family’s supporters, who mounted an online campaign and demonstrated against administrators and medical staff at Alder Hey Children’s Hospital in Liverpool, England, where Alfie had been treated.

This led to heightened security and a police presence at the hospital amid complaints from hospital authorities that staff had been subjected to “highly abusive and threatening language and behaviour.”

In the Best Interests of the Child

However, experts in medical law say the decision of the courts to back health professionals in this case should not come as a surprise. “The only test is what is in the best interests of the child,” said Charles Foster, a practising barrister [a lawyer specialising in appearing in court] specialising in medical law and a fellow of Green Templeton College at the University of Oxford. “The second thing to understand is that the child is a distinct legal and ethical entity from its parents, and of course you don’t normally take other people’s interests into account in deciding on the best interests of a completely distinct person.”

The case of Liverpool-born Alfie Evans centred on his parents’ belief that they were entitled to the final word on his treatment, irrespective of the professional assessments, which said there was nothing the medical profession could do for their son.

After experiencing seizures at 7 months of age and being admitted to Alder Hey Children’s Hospital, Alfie was diagnosed with a rapidly progressive and destructive brain disease that led to him being in a coma for most of his short life.

“No Chance of Recovery”

“Alfie had a severe neurodegenerative disorder,” Professor Dominic Wilkinson, consultant neonatologist at the John Radcliffe Hospital, Oxford, told Medscape News UK. “It was analogous to a form of dementia but in a very young infant. He had progressively over time lost his neurological functions to the point where…he became dependent on respiratory support.”

Professor Wilkinson said there would have been “no chance of improvement or recovery, just as would be the case, very sadly, for an elderly person with dementia.”

The case drew worldwide media attention after a series of legal challenges by Alfie’s parents, to prevent hospital authorities withdrawing ventilation from their son and offering palliative care instead, were rejected by the courts.

Subsequent attempts to allow Alfie to be taken to the Bambino Gesu Hospital in Rome, Italy, were also rejected.

Alfie’s Timeline

Alfie Evans lived a tragically short life, but it contained an astonishingly large number of events:

May 9, 2016: Alfie Evans is born to parents Tom Evans and Kate James, now aged 21 and 20, respectively.

December 14, 2016: He is admitted to Alder Hey Accident and Emergency Department with a history of coughing, high temperature, and a reported episode of rhythmic jerking of all four limbs and his jaw.

December 19, 2016: An assessment by a consultant in paediatric neurology found Alfie had a slow breathing rate, apnoeas, and his most significant identifiable neurological response was to pain. He was transferred to the Paediatric Intensive Care Unit (PICU).

June 15, 2017: A review by Professor Judith Cross, honorary consultant in paediatric neurology, concluded that Alfie had a progressive, ultimately fatal neurodegenerative condition, most likely a mitochondrial disorder, and that his brain was beyond recovery.

December 11, 2017: Disagreements between healthcare professionals and parents emerge after Alfie’s parents say the hospital had applied to the High Court to withdraw their son’s ventilation.

February 20, 2018: Mr Justice Hayden ruled in favour of the hospital authorities, saying he accepted medical evidence that showed further treatment would be unsuccessful.

March 6, 2018: After Alfie’s parents mounted a legal challenge to the ruling, the Court of Appeal upheld the ruling by Mr Justice Hayden.

March 20, 2018: Supreme Court justices refused to give the couple permission to mount another appeal.

March 28, 2018: Judges at the European Court of Human Rights rejected a bid from Alfie’s parents for them to examine issues relating to Alfie’s future and dismissed claims of any human rights violation.

April 11, 2018: Mr Justice Hayden endorsed an end-of-life care plan for Alfie drawn up by specialists.

April 16, 2018: Claims by Alfie’s parents that their son was being wrongly “detained” at Alder Hey were overruled by the Court of Appeal.

April 18, 2018: Tom Evans meets Pope Francis in Rome and asks the leader of the Catholic church to help save his son’s life.

April 23, 2018: Pope Francis intervened, tweeting an appeal “that the suffering of his parents may be heard and that their desire to seek new forms of treatment may be granted.” But the European Court of Human Rights refused an application made by Alfie’s parents to take their child to Rome. At around 9 pm, Tom Evans reports that life support had been withdrawn from Alfie by doctors.

April 25, 2018: The Court of Appeal rejected an appeal by Alfie’s parents against a High Court ruling that the child could be taken home, but not abroad.

April 26, 2018: Alfie’s father told the media that he would meet doctors to “start asking to go home.”

April 28, 2018: Alfie’s parents announced on social media that their son died at 2:30 am.

Clinicians and the Courtroom

The legal framework for cases such as Alfie’s rests with the Supreme Court, the highest court in the United Kingdom.

Sara Forvague, reader in law at Lancaster University, told Medscape News UK via email: “Such disagreements highlight questions about the role of the State, in the form of the courts, in family life, with respect for private and family life enshrined in UK law via the Human Rights Act 1998. This Act incorporated the European Convention on Human Rights into UK law.”

The case has raised questions about whether a new regulatory framework could prevent the adversarial legal disputes that have characterised this and similar cases. Not according to Charles Foster, who said: “I think the test works well.”

He continued: “I think it would be really dangerous if parents who, understandably, are terribly close to the case and are emotionally involved with it had a right to say that a child who it had been found was suffering, or whose continued existence was futile, should, because of their own prejudices or concerns, or simple love, go on to have treatment which is found to be burdensome.”

He said that in the case of Alfie Evans’ proposed trip to Italy, the court took into consideration that movement of the patient would involve an increased risk of infection, shaking during a journey could provoke further seizures, and there would be difficulties maintaining his anticonvulsant regime.

The views of the parents are not irrelevant, according to Sara Forvague, who said that nevertheless the child’s welfare is the primary consideration. “This does not mean that the views and wishes of parents are irrelevant, but that the court’s focus is on what is best for the child — and not what is best for the parents.

“This is important because while most parents will have the best interests of their child at the centre of their thinking, parents can sometimes make decisions which are not, or do not seem to be, in their child’s best interests. And this is the point at which a court may intervene.”

The Charlie Gard Case

The case of Alfie Evans echoes the similar recent case of Charlie Gard, a baby from London born with a rare genetic disorder, mitochondrial DNA depletion syndrome, which causes progressive brain damage and muscle failure.

That case also attracted media attention because the baby’s parents disagreed with medical professionals at London’s Great Ormond Street Hospital about whether experimental treatment offered by a neurologist in the United States would be beneficial.

After an extensive legal battle, the High Court decided that Charlie should be taken off a ventilator and moved to a hospice, where he died shortly afterwards. At the time, The Washington Post wrote that the case had become “the embodiment of a passionate debate over his right to live or die, his parents’ right to choose for their child and whether his doctors had an obligation to intervene in his care.”

Public Feeling and the Role of the Media

A notable feature of the Alfie Evans case was a vociferous campaign waged by some members of the public in support of the child’s parents and directed, with varying degrees of animosity, against Alder Hey hospital staff.

This led to some staff feeling intimidated and concerned about reporting for work.

In an open letter on April 25 — two days after ventilation was withdrawn from Alfie — the chairman of Alder Hey Children’s NHS Foundation Trust, Sir David Henshaw, and the chief executive, Louise Shepherd, said they had been at the centre of a “social media storm” and that staff had experienced “unprecedented personal abuse.”

The letter said staff had been “shocked” by the reaction from some organisations and individuals that required police intervention to ensure the safety of staff, patients, and visitors to the hospital.

“Our nursing, medical and support staff come into work each day at Alder Hey determined to do the best for our patients and those who care for them,” the letter continued, but said the “many untrue statements about our work and the motivations of our staff” had been “hard to bear.”

Wilkinson, who is also director of medical ethics at the Oxford Uehiro Centre for Practical Ethics at the University of Oxford, said this is likely to have been compounded by members of Alfie’s medical team having misgivings about his treatment. “There’s a high incidence of what’s sometimes called ‘moral distress’ in intensive care units where health professionals find it incredibly challenging when they’re in a situation where they are forced to do things that they feel goes against their deeply held moral values.

“In this case, and in others like it, that is to provide treatment and to perform interventions on a child that they feel are not helping the child and may potentially be harming the child because they might be causing the child discomfort.”

Professor Wilkinson says this would have been compounded by the “public attention and threats, verbal abuse [and] harassment that this case has seen.”

He adds: “One of the things that I sometimes point out is that the easiest thing to do for the professionals in this situation is simply to do what the parent asks.

“I think it’s a measure of just how strongly the professionals felt that that would be the wrong thing to do that they were prepared to take the painful step of going to court.”



Source link

England's NHS Begins Review Into Cutting-Edge Health Tech

England's NHS Begins Review Into Cutting-Edge Health Tech


England’s National Health Service (NHS) has begun an independent expert review of future technologies to help transform healthcare through genomics, artificial intelligence (AI), and improvements in connecting patients to their physicians through their smartphones.

The review is being led by the US academic, geneticist, and cardiologist Eric Topol, MD, who is also editor-in-chief of Medscape. The review team includes experts in AI, digital medicine, genomics, education, and health economics. It is being facilitated by Health Education England (HEE). An interim report will be delivered to Health and Social Care Secretary Jeremy Hunt this summer, with a final report due by the end of the year.

Hunt wants to make sure the NHS and its staff are “digital ready.” In a news release, he said: “Every week we hear about exciting new developments surfacing in the NHS which could help provide answers to some of our greatest challenges, such as cancer or chronic illness.

“These give us a glimpse of what the future of the whole NHS could be, which is why in the year of the NHS’ 70th birthday I want to empower staff to offer patients modern healthcare more widely and more quickly. I’m delighted that Dr Topol is kicking off this review — ensuring the NHS is at the forefront of lifesaving, life-changing care across the globe for decades to come.”

“Transformative”

“There’s these new technologies — genomics, digital medicine, AI — really coming all together online, and it’s really transformative,” Topol told Medscape News UK. “So we have two major things. One is that the patient at the center of all this will derive considerable benefit to help empowerment, and being able to have much more charge of their care, and most importantly, restoring the patient-doctor relationship by the gift of time from this enhanced productivity.

“The second, of course, is to use these technologies to truly harness their potential — using the productivity, accuracy, the machine aspect of all these things to really rev up the way we do medicine and handle all these data, handle the tasks that are far better done by machines than by humans,” Topol said.

Last year, a report by an independent health think tank, the Nuffield Trust, concluded: “Despite the fact there is good understanding of the issues obstructing innovation in the NHS, it is still slow to adopt new technological ideas.” However, Topol believes the NHS is receptive to change: “What’s distinguished the NHS vs anywhere else in the world is that no one has done this, no one has brought in all these experts in all these areas, and they include not just the AI, digital, genomics but [also] the ethicists, the economists, the educators, the futurists, all together for multiple days and to start this process.

“This has never been done before. So it’s a start. The fact that the NHS has organized this tells you a lot about the progressive nature. It really is an impressive organization to have this vision that I’m just helping to pull together.”

So has the NHS welcomed an outsider from the United States, where the healthcare system is organized and funded much differently? “Absolutely. We’ll see with the final report, but right now, it’s a very warm welcome,” Topol said.

Case Studies

The review team will look at current examples of technology that demonstrate improved patient outcomes. These include the following:

  • Smartphone video consultations and virtual clinics to avoid some face-to-face appointments

  • Robotic-assisted surgery that offers greater precision

  • The 100,000 Genomes Project, which provides insights into genetic diseases

  • Stem cell treatment that is helping to restore sight in patients who have wet age-related macular degeneration

  • A smartphone app linked to a Bluetooth-enabled blood glucose meter to help women self-manage gestational diabetes and reduce clinic appointments

  • Continuous glucose monitoring systems linked to insulin pumps for better diabetes management and to avoid insulin injections

  • The Google-backed DeepMind AI and machine learning deployed at Moorfields Eye Hospital, London, England, to accurately detect eye diseases through optical coherence tomography and to reduce delays in diagnosis

  • A robotics company based in Bristol, England, that has developed 3D-printed artificial arms and bionics for amputees

  • Digital otoscopes deployed in general practice to take videos and images inside patients’ ears, which can then be sent to ear-nose-throat consultants for review

  • A smartphone app and sensor to identify atrial fibrillation

The review comes nearly 12 months after a ransomware cyber-attack caused some UK hospitals to cancel appointments and operations and that exposed weaknesses in computer systems and pockets of outdated systems. So is the NHS ready for technologic change?

“I think that this is different,” Topol said. “There’s so much happening simultaneously, and they’re interdependent. They’re all data-driven stories — to sequence, microbiome, genomics, apps and sensors, and telemedicine, and then you have AI, data analytics, robotics — it’s all happening at the same time. You can’t turn your back on this. This is just extraordinary. The fact that these are all happening in parallel, there’s never been any time like this in the history of medicine or healthcare.”

There’s never been any time like this in the history of medicine or healthcare.
Dr Eric Topol

The review group acknowledges that already, pockets of innovation are being driven locally. Topol said the review will look at technologies used by patients themselves as well as by healthcare professionals and others: “And that means all different types [of providers] — the GPs, the specialists, the nurses, the pharmacists — all the way through, and includes the nonclinical staff like the administrative people, and the coders, and people working in back office functions. And then, of course, the future of education — the medical students and all the other healthcare trainees.

“And then lastly, it’s the health system and hospitals, it’s trying these same tools in the hospital setting,” Topol said, “whether it’s to reduce the need for hospitals per se or to make them far more error-free, and improving the workflow with things like machine vision. We’ve got so many different things we can improve with these tools.”

No review of the future of the NHS can take place without addressing the question of funding, and the review group includes a health economist. Can the NHS afford new technology, given that some areas of basic care are currently underfunded?

“I think that’s being pursued independent of this,” Topol explained. “There is a lot of work going on, as I understand it, to secure funding for the next decade for the NHS and its expansion. But I also think this represents a very special opportunity. In the past, new technology always was correlated with higher costs. Now we’re talking about technology which is actually cheap overall. AI is software. Sensors are chips that are cheap. Genomics is getting less expensive every day. These are not like the big-ticket items of the past. This is like Moore’s law coming to medicine. The hope is you can actually improve the economic landscape with technology, and that’s somewhat different than the experience of the past.”

An HEE news release that announced the launch of the review states that “tens of thousands of NHS staff will be trained to use robotics and artificial intelligence.” Topol has a reassuring message for clinicians nervous about the pace of change: “I don’t think that robotics is going to apply to many apart from assisting surgeons at this point. So it’s limited.

“Doctors are always resistant to change, perhaps more so here than some other places. But we’ll emphasize in our report the validation requirement, the evidence, whether from randomized trials or real-world, strong, compelling evidence. So we don’t recommend these things until that evidence basis is established. By the time we get there…then I think the clinicians will move forward and be willing, embrace, adapt, and implement.”

Dr Topol is editor-in-chief of Medscape.

For more news, join us on Facebook and Twitter



Source link

Pain Rehab Program Signals 'Profound' Treatment Shift

Pain Rehab Program Signals 'Profound' Treatment Shift


VANCOUVER, British Columbia — Patients with chronic pain completing a comprehensive, multidisciplinary pain rehabilitation program use significantly fewer healthcare resources except in the area of behavioral health, new research shows

“We were surprised to see such a profound change” in use of health resources even within the first few months of completing the pain rehab program, study author Christy Hunt, DO, resident physician, Physical Medicine and Rehabilitation, Mayo Clinic, Rochester, Minnesota, told Medscape Medical News.

The study was presented here at the American Academy of Pain Medicine (AAPM) 2018 Annual Meeting.

Costly Problem

Over half of Americans report having chronic pain, defined as pain that lasts at least 3 months.

“We know that chronic noncancer pain is a costly problem and a significant burden to patients,” said Hunt. “As caregivers, we are always looking to how we can best take care of these patients in the most appropriate fashion.”

Many patients who enroll in a pain rehabilitation program have chronic noncancer pain that is very refractory to treatment.

“These are patients who despite lots of procedures, despite medications including opioids, are just not getting better,” said Hunt.

Throughout the intensive 3-week outpatient pain rehab program, patients access physical, occupational, and medical therapies and taper their opioid doses. In addition, they address any comorbid conditions they may have, including depression, trauma, anxiety, and poor sleep.

A previous study showed that participation in such a rehab program can reduce medical costs, but it didn’t examine behavioral health utilization, diagnostic procedures, or therapeutic injections or surgeries, said Hunt.

For this new study, researchers looked at healthcare utilization of 25 patients at 3, 6, 12, and 18 months before and after participation in the pain rehab program.

From data extracted from electronic health records, they examined the number of health-related visits: to primary care doctors, to specialists including pain practitioners, to physical therapists (physiotherapists, occupational therapists, chiropractors), to emergency departments and urgent care centers, and to behavior health experts (for example social workers, psychologists, and counsellors).

The researchers also looked at various categories of medications, including psychoactive drugs such as antidepressants, sleep medicines, and analgesics (including opioids).

Strong Statistical Evidence

In addition, researchers examined diagnostic procedures (eg, electrocardiography for atypical chest pain) and therapeutic procedures (including surgeries and injections).

They were not able to look at healthcare expenditures.

At all four time points, the overall utilization patterns showed increased use of behavioral health resources and decreases in other care categories, said Hunt.

“Even in a study with only 25 patients, we see strong statistical significance all the way through 18 months.”

For example, in a comparison of findings from 18 months after the program to those 18 months before the program, there were a significant decline in visits to primary care doctors and specialists (P < .0001) and in therapeutic procedures (P < .05) and an increase in behavioral health services (P < .0001). 

But the biggest jump in behavioral health resources was in the first 3-month comparison period.

“It’s likely that these patients were not being adequately treated for comorbid depression, anxiety, and trauma,” before enrolling in the program, said Hunt.

This shift toward behavioral treatments may address the impact of pain and promote improved functioning and quality of life, but is this cost-effective?

That question can only be definitively answered with access to cost data, said Hunt.

However, she stressed that while it’s important to reduce costs, “it’s also important that patients are still getting good care.”

These results are encouraging enough to warrant a larger study using a matched cohort that could possibly look at costs as well as health service use, she said.

Substantial Shift

Commenting on the study for Medscape Medical News, Patrick J. Tighe, MD, associate professor of anesthesiology, and program director, Perioperative Analytics Group, University of Florida, Gainesville, said it “represents a substantial shift” in caring for pain patients.

And it looks like it’s a shift in the right direction.

Tighe noted that many of the pain care modalities used less often by study patients completing the pain program “carry very high personal costs as well as financial costs that are borne by patients, their caregivers and the health system at large.”

Behavioral health services are not without costs, but, said Tighe, study patients who accessed these services “may have received great benefit from those encounters.”

The shift in pain care approaches highlighted by the study “looks very favorable,” but “more work needs to be done to learn more,”  he said.

No funding sources or conflicts of interest were reported.

American Academy of Pain Medicine (AAPM) 2018 Annual Meeting. Abstract 293. Presented April 27, 2018.

For more Medscape Neurology news, join us on Facebook and Twitter



Source link

First Risk Tool for 30-Day TAVR Readmission Shows Potential

First Risk Tool for 30-Day TAVR Readmission Shows Potential


A simple risk predictor may identify patients at higher risk for an unplanned readmission within 30 days of transcatheter aortic valve replacement (TAVR), a new study suggests.

The Centers for Medicare & Medicaid Services (CMS) “has their own all-cause readmission tools, hospitals have their own EPIC readmission risk scores, but I don’t really think we use them specifically for TAVI patients right now,” lead study author, Sahil Khera, MD, MPH, Massachusetts General Hospital, Harvard Medical School, Boston, told theheart.org | Medscape Cardiology. “They’re generic readmission tools.”

“But this one I would want to use for my patients to understand their risk of coming back and how intensive my transition of care should be,” he said. “It’s something geared towards TAVI patients.”

The investigators recently reported that 15% to 20% of patients are readmitted within 30 days of TAVR, driven by noncardiac causes in more than 60% of cases. Though several risk models and apps are available to assess TAVR in-hospital mortality risk, this is the first tool designed to predict these readmissions.

To fill the data gap, investigators examined data on 39,305 patients in the Nationwide Readmissions Database (NRD) who underwent TAVR between January 2013 and August 2015. Of these, 6380 patients (16.2%) were readmitted within 30 days, Khera reported at the Society for Cardiovascular Angiography and Interventions (SCAI) 2018 Scientific Sessions.

A nomogram was developed based on parameters identified through univariable and logistic regression analyses, with model calibration performed with bootstrapping. Internal validation was done with K-fold cross-validation.

The final risk model includes nine variables scored on a 350-point scale: anemia, atrial fibrillation, chronic liver disease, chronic lung disease, chronic kidney disease, end-stage renal disease on dialysis, length of stay 5 days or more, acute kidney injury, and discharge disposition.

“The beauty of this tool is, because we made it using administrative datasets, it’s very easy to use,” Khera said. “You can pull out any chart from your patient’s record and will find these variables. You don’t need to do any complex GFR [glomerular filtration rate] calculations, any STS [Society of Thoracic Surgeons] calculations. So case managers, administrators, nurses, anyone can calculate this.”

For example, an 82-year-old woman with chronic obstructive pulmonary disease, atrial fibrillation, and chronic kidney disease who developed acute kidney injury after TAVR and required 6 days of hospitalization would receive 182 points and thus have more than a 25% risk for 30-day readmission.

A score of more than 212 points predicts a greater than 30% risk for 30-day readmission (C-statistic, 0.63).

The C-statistic mirrors those for the acute myocardial infarction, heart failure, and pneumonia measures CMS currently uses (0.61 – 0.63), noted Khera. “All the administrative datasets usually have C-statistics that are on the lower end because they lack more granular data,” he said. “It is also possible that social determinants that are not routinely captured in administrative datasets influence readmissions.”

Indeed, the investigators acknowledge they lacked data on STS score, drug therapy, echocardiographic variables, valve type, and paravalvular leak. In addition, they intentionally excluded vascular and bleeding complications from the model because the vast number of ICD-9 codes for these events would have made it difficult for users to easily incorporate, Khera said.

On the other hand, he observed that the model includes chronic liver disease, which is an important predictor of readmission that falls out of many surgical scores, including the STS cardiac surgery risk score.

“Clearly the C-statistic is not very strong but it is strong enough to help us make an association, to give us a signal that this patient is sick and may require additional attention,” Khera said.

Commenting for theheart.org | Medscape Cardiology, Chandan Devireddy, MD, from Emory University School of Medicine, Atlanta, Georgia, who was not involved in the study, said, “I think having a procedural score such as this is a good start; I don’t know that this is a finished product.”

He noted that bleeding complications can have a large impact on outcomes and said using other databases, such as the STS/American College of Cardiology TVT registry, may be useful to refine the model.

“Nevertheless, including periprocedural and perihospitalization data does serve a purpose in helping to stratify patients for additional resources they may need,” Devireddy said. “But I would ask the question, ‘Is the use of the scale best-suited to identify patients before, during the procedure, or both?’ and maybe it’s both.”

He observed that today’s TAVR patients are vastly different from the high-risk candidates screened in the early days of TAVR. “But you can still have a patient who is extraordinarily healthy and for whatever reason experiences challenges with the procedure that takes them on a very different trajectory than what they may expect postprocedure,” he added. “In that case, this would be very helpful.”

Khera said they are working on validating the algorithm in their institution and creating an Apple app but stressed it should not be used to deny a patient TAVR and can only be calculated after the procedure, when discharge planning starts.

“If the case manager is doing the discharge planning and knows the patient has a higher risk score, perhaps they will want to talk to the primary care provider or the nursing care facility, or provide home nursing care, or use telemonitoring,” he said. “What we want to promote is better transition of care.”

“In the end, we want to give these patients a better quality of life. Because whenever you have a patient that’s coming in again and again, you’re taking away the quality of life.”

Khera has disclosed no relevant financial relationships. Devireddy reported serving on a scientific advisory board for Medtronic and receiving travel and logistical funding for meetings from Edwards Lifesciences.

Follow Patrice Wendling on Twitter: @pwendl. For more from theheart.org, follow us on Twitter and Facebook.



Source link

Education, Slow Approach Help Patients Successfully Taper Opioids

Education, Slow Approach Help Patients Successfully Taper Opioids


VANCOUVER, British Columbia — New research challenges the perception that patients with chronic pain receiving long-term opioid therapy don’t want to get off these drugs, or can’t do so without experiencing increased pain.

Patients who completed a 4-month tapering program cut their opioid dose in half — and some came off opioids completely — with no increased pain.

The study showed that many patients with chronic pain are keen to reduce their opioids, but it often takes more than a few months to achieve this.

“This suggests that current tapering algorithms may be too aggressive,” author Beth Darnall, PhD, clinical professor, Department of Anesthesiology and Perioperative and Pain Medicine, Division of Pain Medicine, Stanford University, California, told delegates attending the American Academy of Pain Medicine (AAPM) 2018 Annual Meeting.

Following decades of overprescribing opioids, which has led to unintentional overdoses and deaths, clinicians are being urged to “de-prescribe” these drugs, said Darnall.

Fear a Major Barrier

One of the biggest fears of patients receiving opioids is increased pain if they go off these drugs, she said.

“This fear is standing as a barrier to opioid reduction; it’s not the only barrier, but it’s an important one to consider.”

Research shows that a multidisciplinary program can reduce opioid use among inpatient veterans without increasing their pain. The investigators wanted to know if this was the case for “everyday, real-world patients in the community setting,” Darnall said.

A common “misperception” is that reducing opioid doses in the outpatient setting requires “a lot of resources similar to the inpatient setting,” she said.

Other misperceptions, she added, are that efforts to reduce opioids in long-time users, or those taking high doses of the drugs, are unlikely to be successful.

There’s not much in the way of guidance for community-based opioid tapering. Guidelines that do exist “are perhaps too aggressive and have contributed to failed tapers, withdrawal symptoms and perpetuating the misperception that reducing opioids leads to increased pain in the outpatient setting,” said Darnall.

Of the 110 patients who were invited to participate in the program, 82% expressed interest. A total of 68 patients actually enrolled and 51 remained in the program.

Participants had an average age of 52 years and 55% were female. They had been receiving opioids for a mean of 6 years and had moderate pain intensity.

There were no differences between those who remained in the study and those who dropped out, except that those who dropped out were more likely to have higher levels of depressive symptoms.

Patients in the program received a self-help book and education about the benefits of reducing opioids. They partnered with their physician to develop a tailored program to taper opioids.

“It’s important to note that the goal was not no opioids; the goal was to get as low as possible in as comfortable a manner as possible, over the 4-month study period,” said Darnall.

She emphasized that the program was voluntary and that the study included a “mixed etiology” of chronic pain sufferers. “Anyone taking opioids was invited to be part of this project,” she said.

Keys to Success

At baseline and at 4 months, patients completed online assessments and provided data on demographic characteristics, opioid use, pain, and psychosocial measures.

Researchers converted opioid doses to a standard morphine equivalent daily dose (MEDD).

Among the 51 completers, the baseline median MEDD of 288 was reduced almost by half to 150 (P = .002) at the 4-month follow-up.

“Patients who remained in the program successfully reduced their opioid dose in a statistically significant and clinically meaningful way,” said Darnall.

“Sixteen patients reduced their opioid dose to below 90 mg daily, and four patients tapered off the drug entirely.”

Pain intensity (P = .29) and pain interference (P = .44) did not increase with opioid reduction. 

The investigators also found that the initial opioid dose did not predict taper response.

“Again, this challenges a common perception that patients on moderate, high, or very high doses of opioids are unlikely to succeed in reducing opioids on an outpatient basis,” said Darnall.

The “key” to the success of the program is providing patients with education and tapering opioids slowly, making sure that patients “are in control” and can “pause” or “drop out” at any time, she said.

She noted that while the opioid dose decreased, not many of the psychosocial variables “budged.”

Darnell said she has secured funding to carry out a trial of 1300 patients in four states that will compare two evidence-based psycho-behavioral treatments “within the context of voluntary opioid tailoring” to see if such supports will further improve taper response, she said.

“Paradigm Shift”

Commenting on the study for Medscape Medical News, James C. Watson, MD, associate professor, and vice chair, Department of Neurology, Mayo Clinic, Rochester, Minnesota, who is board certified in pain medicine as well as neurology, clinical neurophysiology, and neuromuscular disease, said the study is important in the context of the current environment, where opioid use is being discouraged.

He referred to the “paradigm shift” in the United States to greater recognition of the adverse effects of opioids, including respiratory depression and death.

At the same time, new guidelines have “redefined” the appropriate role of opioids, and some insurance companies have put caps on opioid prescriptions, said Watson.

With this background, it’s important that an opioid tapering program can effectively lower drug doses — in some cases cutting it in half —  “without worsening pain and without worsening comorbid conditions, including depression and anxiety,” said Watson.

“The study is also important because it was done in a community setting and took all comers, so it’s applicable to real-world practice,” he said.

The authors and Watson have disclosed no relevant financial relationships.

American Academy of Pain Medicine (AAPM) 2018 Annual Meeting. Abstract 190. Presented Friday April 27, 2018.

For more Medscape Neurology news, join us on Facebook and Twitter



Source link

Inability to Multitask in MS Indicator of Depression Severity

Inability to Multitask in MS Indicator of Depression Severity


LOS ANGELES — People with multiple sclerosis (MS) who have greater difficulty multitasking are more likely to have more severe depression, according to findings that suggest interventions to treat mood could improve cognition in this patient population.

In addition, investigators linked a lower ability to multitask to smaller volumes of the rostral prefrontal cortex (PFC), an area of the brain involved in higher-order executive functioning.

Both studies were presented here at the American Academy of Neurology (AAN) 2018 Annual Meeting.

Novel Assessment Tool

“MS patients with depression frequently report cognitive dysfunction. However, when we send them for neuropsychiatric evaluation, the results are often average or normal,” said Daniel Kurz, MD, a fellow at the Corinne Goldsmith Dickinson Center for Multiple Sclerosis at the Icahn School of Medicine at Mount Sinai in New York City. “We thought perhaps current testing procedures do not accurately reflect the dysfunction and disability our patients are reporting.”

As an alternative, Kurz and his team evaluated whether a new tool developed by colleague James Sumowski, MD, would offer better discrimination. They assessed 150 participants in the RESERVE Study of Early Multiple Sclerosis using Sumowski’s Decision Speed Task.

Patients look at rows of four objects, represented by emojis, and choose the one that is the largest in real life. Investigators recorded the number of correct responses in 100 seconds for each participant.

Researchers next combined the Decision Speed Test with a simultaneous auditory task, one where participants had to note when they heard certain words (the one-back test). Again, they calculated performance based on the number of correct answers in 100 seconds. They adjusted results for factors including age, IQ, and education.

Higher depression scores on the Beck Depression Inventory, the Mental Health Index, and the Stroop task correlated with fewer correct answers. In addition, in a stepwise regression, they found “that multitasking was the only independent predictor of worse depression,” Kurz said.

When researchers stratified patients by depression severity — none, mild, moderate, or severe — the relationship still held. Again, more severe depression correlated with fewer correctly identified objects on the multitasking evaluation, he said.

“We could look at this in the future to see if an intervention for depression could affect or improve cognitive impairment, which has been difficult to treat in MS patients.”

Commenting on the findings for Medscape Medical News, poster discussion session moderator Nancy L. Sicotte, MD, director of the Multiple Sclerosis Program at Cedars-Sinai Medical Center in Los Angeles, California, said they are “clinically useful in the sense that what we hear from patients is that they are having a hard time with multitasking. And it makes sense because the disease is a white matter disease and that is what is connecting all the different areas of the brain. What their study is showing — and this is a bit different — is that this is also related to depression.”

“We’ve done some work in our lab looking at the hippocampus, a very important cortical structure for memory as well as cognitive function,” she said. “We know that depression is really common [and] we know that cognitive problems are very common, and we’ve shown that those come together in the hippocampus.”

An unanswered question from the current research is whether MRI findings would show a correlation between brain structural changes and worse depression in patients with MS, she added.

Early Screen for MS?

Worse performance at multitasking was also associated with smaller volumes of the rostral PFC on three-dimensional T1 MRI, according to a separate poster presented at the AAN conference.

A smaller volume of the rostral PFC independently predicted worse multitasking performance (rp = 0.333; P < .0001). Rostral PFC volumes were also smaller among patients who were normatively impaired in multitasking compared with unimpaired participants (t [129] = 2.27; P = .025).

A lot of neurocognitive science literature attributes the PFC and the rostral portion in particular with higher-order functioning. This executive functioning includes tasks such as planning and divided attention, said Christina Lewis, BS, head research coordinator for the RESERVE Early MS Cohort at the Icahn School of Medicine at Mount Sinai.

“I was curious if our multitasking task, which is a very difficult task, had any correlation with our patients’ gray matter in that area, and it did,” she said.

A total 131 patients performed the primary task as fast and as accurately as they could, and then repeated it alongside a secondary auditory one-back task. “We looked at the difference in the accuracy scores, which I call the ‘performance cost.’ Basically, there was less performance cost the larger that Brodmann area 10 [also known as the rostral PFC] volume.”

“People were definitely not able to perform as well if there was more than one thing going on,” she said.

When asked whether the findings could contribute to an early screen for MS, she said, “That’s the hope. One of the aims of the whole RESERVE study is looking at total gray matter volume as a potential biomarker.”

Both studies were supported through National Institutes of Health grants. Kurz and Lewis have disclosed no relevant financial relationships.

American Academy of Neurology (AAN) 2018 Annual Meeting. Abstracts P4.196 and P5.028. Presented April 25 and 26, 2018.

For more Medscape Neurology news, join us on Facebook and Twitter



Source link

Community Oncology in US Continues to Disappear

Community Oncology in US Continues to Disappear


Non-hospital-affiliated, community-based oncology practices remain under duress in the United States, according to a 2018 report from the Community Oncology Alliance (COA).

Since 2008, 1653 community oncology clinics or practices have closed, been acquired by hospitals, undergone corporate mergers, or struggled financially, reveals the latest COA practice impact report.

Currently, there are about 2000 community practices or clinics in the United States, said Ted Okon, the COA’s executive director. Community practices and clinics range from large groups, such as Florida Cancer Specialists, which has 80 sites, to small, one-clinic practices. The COA has not determined the exact number of community-based practices and related clinic sites.

However, the COA does count clinic closings. During the past 2 years, an average of 3.5 community oncology practices have closed per month.

But the overall toll is higher. Each month since 2008, an average of 13.8 practices have been affected by closings, hospital acquisitions, or corporate mergers, the COA says.

Since 2008, a total of 658 practices have been acquired by hospitals, which the COA says is a “dramatic shift” of community cancer care into the more expensive hospital setting.

There’s been “a clear and negative dismantling” of the community-based cancer care system during the past decade, said Okon in a press statement.

The table below lists events of concern in the new report. Some terms, such as “clinics closed,” “struggling financially,” and “acquired by hospital,” are self-explanatory. The term “sending patients elsewhere” means the clinic is referring Medicare and Medicaid patients to other providers because of low government reimbursement. “Merged and acquired” means that two or more practices have merged or that a large nonhospital entity, such as US Oncology, acquired a practice.

Since the last COA report in 2016, there has been an 11.3% increase in the number of community cancer clinics that have closed and an 8% increase in the number of consolidations into the hospital setting.

However, the report also reveals that the trend has slowed.

Although the total number of relevant events, such as closings, jumped by nearly 400 from 2010 to 2012, only 72 such events occurred from 2016 to 2018.

“There are glimmers of light that the darkest times are hopefully over,” Okon told Medscape Medical News.

Table. Increasing Troubles (Cumulative Totals)

Year 2010 2012 2014 2016 2018
Clinics closed 172 241 313 380 423
Struggling financially 323 442 395 390 359
Sending patients elsewhere 44 47 46 45 45
Acquired by hospital 224 392 544 609 658
Merged or acquired 102 132 149 157 168
Totals 865 1254 1447 1581 1653

 

Since the last COA report in 2016, there has been an 11.3% increase in the number of community cancer clinics that have closed and an 8% increase in the number of consolidations into the hospital setting.

However, the report also reveals that the trend has slowed.

Although the total number of relevant events, such as closings, jumped by nearly 400 from 2010 to 2012, only 72 such events occurred from 2016 to 2018.

“There are glimmers of light that the darkest times are hopefully over,” Okon told Medscape Medical News.

Some Bright Spots

These trends are “reflective of the push-pull of misguided public policies on cancer care,” the COA says in its report.

Community-based practices have “enormous” operating pressures, says the COA, because of the ongoing 2% sequester payment cut to Medicare enacted by the Centers for Medicare & Medicaid Services (CMS) in 2013.

At the same time, community oncology practices have become desirable acquisitions by hospitals because of a lawful misuse of 340B Drug Pricing Program. Through the program, hospitals and hospital-owned practices make significant profits by exploiting extra payments intended to benefit poor patients in need, as reported by Medscape Medical News.

A recent study of the program published online in January in the New England Journal of Medicine concluded that “the 340B Program has been associated with hospital-physician consolidation in hematology-oncology and with more hospital-based administration of parenteral drugs in hematology-oncology.”

Despite these problems, Okon says that “community oncologists are more upbeat than I have seen in a while.”

Community oncologists are more upbeat than I have seen in a while.
Ted Okon, COA

Oncologists are optimistic about a number of things, he said. For example, there is the growing awareness of the misuse of the 340B program, and awareness of problems associated with pharmacy benefit managers is increasing. Also, multiple community-based practices are participating in — and benefiting from — the Oncology Care Model, which is an experimental payment model involving both CMS and private payers. The model financially rewards clinical efficiency and thoroughness.

Despite these good signs, Okon is worried about physician demographics and their impact on the number of community oncology practices. “I am concerned about the trend of retiring oncologists. There is an increasing demand but a diminishing supply among all oncologists,” he said.

Follow Medscape senior journalist Nick Mulcahy on Twitter: @MulcahyNick

For more from Medscape Oncology, follow us on Twitter: @MedscapeOnc



Source link

Minggu, 29 April 2018

Simple Alert Increases Uptake of Prenatal Tdap Vaccine

Simple Alert Increases Uptake of Prenatal Tdap Vaccine


AUSTIN, Texas — A pop-up reminder in electronic medical records increased uptake of the prenatal Tdap vaccine by more than a third, a new study found.

“Preintervention vaccination rates were very low — less than 50% — and that is consistent with national rates over the past few years,” said lead author Katie Keepers, MD, a resident at the University of Kansas Medical Center in Kansas City.

“We thought this was a simple intervention to make a significant impact for my patients,” she told Medscape Medical News here at American College of Obstetricians and Gynecologists (ACOG) 2018 Annual Meeting, where the research was presented.

The Centers for Disease Control and Prevention (CDC) recommends that women receive a Tdap vaccination between 27 and 36 weeks’ gestation in every pregnancy, so that the fetus receives a transfer of maternal antibodies against pertussis. The highest risk for death from pertussis is in a child’s first 2 months, but infants do not receive their first vaccination against pertussis until they are 2 months old.

Rates of prenatal Tdap vaccination have lagged nationally since the recommendation was made in October 2012, despite evidence that the vaccine does protect infants against pertussis infection ( Clin Infect Dis. 2017;65:1977-1983). However, coverage has risen from 27.0% in 2014 to 48.8% in 2016, according to the CDC.

For the current study, a best practice advisory pop-up message was created for the hospital clinic’s electronic medical record system to remind providers of the CDC recommendation. The provider was then given the option to order the vaccine directly from the message screen or to acknowledge the reason for not doing so (Patient Declines, Other [comment], Not Indicated).

The pop-up could be dismissed, but unless the physician selected one of the options, it would continue to appear at every visit for all patients between 27 and 36 weeks of pregnancy.

It took a few months to design the pop-up because the researchers wanted to be sure it was functional by linking directly to orders, said Keepers.

“We all know you should be vaccinating, but we have a large resident population,” she explained. “I think it’s nice that it will come up for nurses too, when they check in the patient, so the nurse can say, ‘Your doctor might talk to you about Tdap today.’ I think it increased a lot of communication during the visit for multiple providers.”

The researchers then reviewed charts for all deliveries between September and December 2016, before the pop-up implementation, and deliveries between September and December 2017, after implementation, to compare Tdap vaccine uptake.

They compared the same 4 calendar months to reduce the likelihood that seasonality would influence rates, Keepers told Medscape Medical News.

In the 2016 study period, just 44.6% of 531 patients between 27 and 36 weeks’ gestation received a Tdap vaccination. In the 2017 period, after implementation of the alert, coverage was 60.3% of 574 patients (P < .0001). No differences in patient characteristics were found between those who did and did not receive the vaccine.

The average patient age was 28.1 years preimplementation and 28.8 years postimplementation. Nulliparity was also similar: 36.2% in 2016 and 37.2% in 2017. There were too many variables for the researchers to be able to compare differences in insurance status or other payer factors, said Keepers.

Biggest Change in First Month

The first month postimplementation saw the biggest change in vaccine uptake, but that was also the month with the lowest uptake in 2016.

“I thought it was really interesting that the first month was so much higher, but I think that first month might have been an outlier,” Lois Brustman, MD, a professor of obstetrics, gynecology and reproductive science at the Icahn School of Medicine in New York City, told Medscape Medical News.

The average increase in vaccine uptake across all the months is what is most important, she added.

Tronya Hawkins, MD, from St. Vincent’s Women’s Hospital in Indianapolis, Indiana, said she also was curious about the bigger improvement in that first month.

“I’m impressed that the screener took the opportunity to evaluate uptake before, the fact that they were able to implement in their [electronic medical records], and that there was a significant improvement after the intervention,” Hawkins told Medscape Medical News.

“My question, though, would be what happened after the first month?” She wondered whether the uptake remain consistent after the months reported by the study, whether the pop-ups continued, and whether anything else changed.

Keeper told Medscape Medical News that she suspects pop-up fatigue may explain the tapering off of rates after the first month.

Maram Said, DO, from St. Vincent’s Carmel in Indianapolis, agreed: “People might start to exit without even looking at it,” she told Medscape Medical News.

Overall, however, she found it a “clever and easy intervention” to bring up vaccination rates.

Need for More Patient Education

It was a well-designed study with a worthwhile quality improvement implementation that could be implemented elsewhere, added Brustman.

“I think it’s a very easy intervention for other people to do, no matter how much more improvement you get,” she said, but she would like to see even greater improvement.

“It shows that we need to educate more, so now you have to say, How do you make it better?” she told Medscape Medical News.

Perhaps a second intervention could involve providing patients with a pamphlet or spending extra time educating patients about the rationale for the vaccine.

“I think women are reluctant to take it, and that you really do have to spend the time to explain to them in lay terms why they’re getting the vaccine,” said Brustman.

“There’s always going to be a percentage of women who are going to say no,” she said, but she has found that taking an extra 5 minutes to explain the physiology behind the vaccine often shifts women’s initial reluctance into acceptance.

Vaccines are hard to sell nowadays.
Dr Tronya Hawkins

Hawkins agreed with the need for more patient education, but added that she would like to see more resources for providers to help them in educating women.

“Vaccines are hard to sell nowadays,” given the litigiousness of society and people’s fears about serious adverse events, she told Medscape Medical News. “I think it’s more about patients being misinformed or educated against what I’m recommending that is a barrier, more so than, or as much as, [providers] not remembering to offer it.”

Hawkins would like to see more information for providers from the CDC that explains how long protection lasts in infants and offers strategies for speaking to pregnant women about the vaccine.

“I do think this is a great way to get more women vaccinated, and we definitely talk about it, even with their spouses,” she said. “But we definitely don’t get every patient every time, and that’s what we’re striving for.”

The study did not use external funding. Keepers, Hawkins, Said, and Brustman have disclosed no relevant financial relationships.

American College of Obstetricians and Gynecologists (ACOG) 2018 Annual Meeting: Abstract 8L. Presented April 28, 2018.



Source link