Jennifer Lubell

Cost concerns have circulated regarding elective induction of labor, a method that’s become increasingly popular in the United States. Two studies in Obstetrics & Gynecology, however, offer no consensus on the cost burden of this method.

dimarik/iStock/Getty Images

A retrospective analysis of a large cohort in California reported higher costs for induction, compared with spontaneous labor, after accounting for variables such as parity, mode of delivery, and gestational age. A prospective study of five Utah hospitals found no significant cost differences between induction and expectant management.

The ARRIVE trial (A Randomized Trial of Induction versus Expectant Management), a multicenter study that compared elective labor induction at 39 weeks of gestation with spontaneous labor in low-risk nulliparous women, suggests that induction may have some benefits. While its researchers found no differences in perinatal outcomes, induction cases had fewer cesareans, fewer hypertensive disorders, and fewer newborns requiring respiratory support.

One key question that remains following ARRIVE is whether this practice should be implemented universally, Alyssa R. Hersh, MD, MPH, lead author of the California study, said in an interview. Quantifying the costs associated with elective labor is important because “health care in the United States is already much more expensive than in other countries, and [elective labor] could have a dramatic impact on annual health care costs.”

In a retrospective analysis, Dr. Hersh, of the Oregon Health & Science University, Portland, and her colleagues examined data from more than 1.2 million women in California with singleton, nonanomalous births. They excluded for multiple factors such as medically indicated induction of labor, placenta previa, breech presentation, or planned cesarean delivery.

Estimating cost differences between elective induction and spontaneous labor for mothers and neonates, they stratified results by vaginal or cesarean delivery, parity, gestational age at delivery, and geographic location. Elective induced labor represented 15% of the overall cohort of 1.2 million women.

Among vaginal deliveries, median maternal hospitalization costs were $10,175 in the induction group and $9,462 in the spontaneous labor group. For cesarean deliveries, the median costs were $20,294 with induction of labor and $18,812 with spontaneous labor.

Costs of maternal hospitalization with elective induction of labor were significantly higher than that of spontaneous labor, regardless of parity, mode of delivery, and gestational age at delivery, the authors reported. Comparing costs at rural and urban areas, the induction group saw higher maternal hospitalization costs and longer lengths of stay regardless of scenario.

Neonatal care was the one metric that incurred lower costs and lengths of stay in the induction group. Fewer adverse outcomes in this group could explain this outlier. “However, because this is observational data, we cannot elucidate what exactly contributed to these decreased costs,” Dr. Hersh and colleagues noted.

Timeliness was another limitation. “It is important to note that our study was conducted between 2007 and 2011, and the patients undergoing elective induction of labor during those years may differ from women undergoing elective induction of labor currently,” the authors acknowledged.

Another study by Brett D. Einerson, MD, MPH, of the University of Utah Health, Salt Lake City, and associates evaluated the actual hospital costs of patients undergoing elective induction and expectant management in a subset of patients from the ARRIVE trial.

“If, medically speaking, induction is equal to expectant management or has some benefit, as the larger ARRIVE trial suggests, we wanted to know: At what cost?” Dr. Einerson said in an interview.

Study participants hailed from five Utah hospitals within two health systems: the University of Utah Health and Intermountain Healthcare. Taking available data for 1,231 enrollees, investigators randomized 608 to labor induction and 623 to spontaneous labor. They measured actual hospital costs using advanced value-based analytics platforms at the Utah hospitals, comparing cost means and reporting the relative difference between induction and expectant management.

Overall, they found no significant differences between the mean total cost of elective induction and expectant management (adjusted mean difference, +4.7%). This was the case for other metrics: Costs did not vary among the five health systems or in most phases of care, including maternal inpatient postpartum care, maternal outpatient care after discharge, neonatal hospital care, and neonatal care after discharge.

The induction group did incur higher maternal inpatient intrapartum and delivery care costs (17%). However, these were offset by savings achieved during outpatient antenatal care (–47%). The assumption was additional costs of time spent on the labor ward might overwhelm cost savings elsewhere (reduced cesarean deliveries, fewer prenatal appointments and tests). “But this was not the case,” Dr. Einerson said.

Ultimately, the study was not large enough to find smaller differences in cost, he noted. It was only large enough to say that cost didn’t differentiate between arms with a margin of +/–7%. “A cost increase (or cost savings) with induction of 7% is meaningful over time and on a national scale,” Dr. Einerson explained.

Taken together, the two studies show that cost is not an insurmountable barrier to elective induced labor, Jeffrey L. Ecker, MD, and Mark A. Clapp, MD, MPH, wrote in an accompanying editorial (Obstet Gynecol. 2020;136[1]:6-7).

“This will be especially true if we are innovative and creatively adapt our facilities and spaces, thinking about where and how some of the required care can be appropriately and more economically offered,” they noted.

“Specifically, strategies to safely reduce labor and delivery time for inductions of labor, including considering and studying outpatient cervical ripening, may make elective induction of labor at 39 weeks of gestation even less costly and even more feasible to offer to all women,” suggested Dr. Ecker and Dr. Clapp, both at Massachusetts General Hospital and Harvard Medical School, both in Boston.

Dr. Hersh and coauthors had no relevant financial disclosures, and there was no external funding for their study. Dr. Einerson and most coauthors reported no relevant financial disclosures; one coauthor reported receiving funds from GestVision as a consultant, and another coauthor reported funds paid to her or her institution from some pharmaceutical companies when she was primary investigator on various trials or a consultant. This study was supported by grants from the Eunice Kennedy Shriver National Institute of Child Health and Human Development. Neither Dr. Ecker nor Dr Clapp had any relevant financial disclosures or received any funding.

SOURCES: Hersh AR et al. Obstet Gynecol. 2020. doi: 10.1097/AOG.0000000000003865; Einerson BD et al. Obstet Gynecol. 2020. doi: 10.1097/AOG.0000000000003930.

Cost concerns have circulated regarding elective induction of labor, a method that’s become increasingly popular in the United States. Two studies in Obstetrics & Gynecology, however, offer no consensus on the cost burden of this method.

dimarik/iStock/Getty Images

A retrospective analysis of a large cohort in California reported higher costs for induction, compared with spontaneous labor, after accounting for variables such as parity, mode of delivery, and gestational age. A prospective study of five Utah hospitals found no significant cost differences between induction and expectant management.

The ARRIVE trial (A Randomized Trial of Induction versus Expectant Management), a multicenter study that compared elective labor induction at 39 weeks of gestation with spontaneous labor in low-risk nulliparous women, suggests that induction may have some benefits. While its researchers found no differences in perinatal outcomes, induction cases had fewer cesareans, fewer hypertensive disorders, and fewer newborns requiring respiratory support.

One key question that remains following ARRIVE is whether this practice should be implemented universally, Alyssa R. Hersh, MD, MPH, lead author of the California study, said in an interview. Quantifying the costs associated with elective labor is important because “health care in the United States is already much more expensive than in other countries, and [elective labor] could have a dramatic impact on annual health care costs.”

In a retrospective analysis, Dr. Hersh, of the Oregon Health & Science University, Portland, and her colleagues examined data from more than 1.2 million women in California with singleton, nonanomalous births. They excluded for multiple factors such as medically indicated induction of labor, placenta previa, breech presentation, or planned cesarean delivery.

Estimating cost differences between elective induction and spontaneous labor for mothers and neonates, they stratified results by vaginal or cesarean delivery, parity, gestational age at delivery, and geographic location. Elective induced labor represented 15% of the overall cohort of 1.2 million women.

Among vaginal deliveries, median maternal hospitalization costs were $10,175 in the induction group and $9,462 in the spontaneous labor group. For cesarean deliveries, the median costs were $20,294 with induction of labor and $18,812 with spontaneous labor.

Costs of maternal hospitalization with elective induction of labor were significantly higher than that of spontaneous labor, regardless of parity, mode of delivery, and gestational age at delivery, the authors reported. Comparing costs at rural and urban areas, the induction group saw higher maternal hospitalization costs and longer lengths of stay regardless of scenario.

Neonatal care was the one metric that incurred lower costs and lengths of stay in the induction group. Fewer adverse outcomes in this group could explain this outlier. “However, because this is observational data, we cannot elucidate what exactly contributed to these decreased costs,” Dr. Hersh and colleagues noted.

Timeliness was another limitation. “It is important to note that our study was conducted between 2007 and 2011, and the patients undergoing elective induction of labor during those years may differ from women undergoing elective induction of labor currently,” the authors acknowledged.

Another study by Brett D. Einerson, MD, MPH, of the University of Utah Health, Salt Lake City, and associates evaluated the actual hospital costs of patients undergoing elective induction and expectant management in a subset of patients from the ARRIVE trial.

“If, medically speaking, induction is equal to expectant management or has some benefit, as the larger ARRIVE trial suggests, we wanted to know: At what cost?” Dr. Einerson said in an interview.

Study participants hailed from five Utah hospitals within two health systems: the University of Utah Health and Intermountain Healthcare. Taking available data for 1,231 enrollees, investigators randomized 608 to labor induction and 623 to spontaneous labor. They measured actual hospital costs using advanced value-based analytics platforms at the Utah hospitals, comparing cost means and reporting the relative difference between induction and expectant management.

Overall, they found no significant differences between the mean total cost of elective induction and expectant management (adjusted mean difference, +4.7%). This was the case for other metrics: Costs did not vary among the five health systems or in most phases of care, including maternal inpatient postpartum care, maternal outpatient care after discharge, neonatal hospital care, and neonatal care after discharge.

The induction group did incur higher maternal inpatient intrapartum and delivery care costs (17%). However, these were offset by savings achieved during outpatient antenatal care (–47%). The assumption was additional costs of time spent on the labor ward might overwhelm cost savings elsewhere (reduced cesarean deliveries, fewer prenatal appointments and tests). “But this was not the case,” Dr. Einerson said.

Ultimately, the study was not large enough to find smaller differences in cost, he noted. It was only large enough to say that cost didn’t differentiate between arms with a margin of +/–7%. “A cost increase (or cost savings) with induction of 7% is meaningful over time and on a national scale,” Dr. Einerson explained.

Taken together, the two studies show that cost is not an insurmountable barrier to elective induced labor, Jeffrey L. Ecker, MD, and Mark A. Clapp, MD, MPH, wrote in an accompanying editorial (Obstet Gynecol. 2020;136[1]:6-7).

“This will be especially true if we are innovative and creatively adapt our facilities and spaces, thinking about where and how some of the required care can be appropriately and more economically offered,” they noted.

“Specifically, strategies to safely reduce labor and delivery time for inductions of labor, including considering and studying outpatient cervical ripening, may make elective induction of labor at 39 weeks of gestation even less costly and even more feasible to offer to all women,” suggested Dr. Ecker and Dr. Clapp, both at Massachusetts General Hospital and Harvard Medical School, both in Boston.

Dr. Hersh and coauthors had no relevant financial disclosures, and there was no external funding for their study. Dr. Einerson and most coauthors reported no relevant financial disclosures; one coauthor reported receiving funds from GestVision as a consultant, and another coauthor reported funds paid to her or her institution from some pharmaceutical companies when she was primary investigator on various trials or a consultant. This study was supported by grants from the Eunice Kennedy Shriver National Institute of Child Health and Human Development. Neither Dr. Ecker nor Dr Clapp had any relevant financial disclosures or received any funding.

SOURCES: Hersh AR et al. Obstet Gynecol. 2020. doi: 10.1097/AOG.0000000000003865; Einerson BD et al. Obstet Gynecol. 2020. doi: 10.1097/AOG.0000000000003930.

Cost concerns have circulated regarding elective induction of labor, a method that’s become increasingly popular in the United States. Two studies in Obstetrics & Gynecology, however, offer no consensus on the cost burden of this method.

dimarik/iStock/Getty Images

A retrospective analysis of a large cohort in California reported higher costs for induction, compared with spontaneous labor, after accounting for variables such as parity, mode of delivery, and gestational age. A prospective study of five Utah hospitals found no significant cost differences between induction and expectant management.

The ARRIVE trial (A Randomized Trial of Induction versus Expectant Management), a multicenter study that compared elective labor induction at 39 weeks of gestation with spontaneous labor in low-risk nulliparous women, suggests that induction may have some benefits. While its researchers found no differences in perinatal outcomes, induction cases had fewer cesareans, fewer hypertensive disorders, and fewer newborns requiring respiratory support.

One key question that remains following ARRIVE is whether this practice should be implemented universally, Alyssa R. Hersh, MD, MPH, lead author of the California study, said in an interview. Quantifying the costs associated with elective labor is important because “health care in the United States is already much more expensive than in other countries, and [elective labor] could have a dramatic impact on annual health care costs.”

In a retrospective analysis, Dr. Hersh, of the Oregon Health & Science University, Portland, and her colleagues examined data from more than 1.2 million women in California with singleton, nonanomalous births. They excluded for multiple factors such as medically indicated induction of labor, placenta previa, breech presentation, or planned cesarean delivery.

Estimating cost differences between elective induction and spontaneous labor for mothers and neonates, they stratified results by vaginal or cesarean delivery, parity, gestational age at delivery, and geographic location. Elective induced labor represented 15% of the overall cohort of 1.2 million women.

Among vaginal deliveries, median maternal hospitalization costs were $10,175 in the induction group and $9,462 in the spontaneous labor group. For cesarean deliveries, the median costs were $20,294 with induction of labor and $18,812 with spontaneous labor.

Costs of maternal hospitalization with elective induction of labor were significantly higher than that of spontaneous labor, regardless of parity, mode of delivery, and gestational age at delivery, the authors reported. Comparing costs at rural and urban areas, the induction group saw higher maternal hospitalization costs and longer lengths of stay regardless of scenario.

Neonatal care was the one metric that incurred lower costs and lengths of stay in the induction group. Fewer adverse outcomes in this group could explain this outlier. “However, because this is observational data, we cannot elucidate what exactly contributed to these decreased costs,” Dr. Hersh and colleagues noted.

Timeliness was another limitation. “It is important to note that our study was conducted between 2007 and 2011, and the patients undergoing elective induction of labor during those years may differ from women undergoing elective induction of labor currently,” the authors acknowledged.

Another study by Brett D. Einerson, MD, MPH, of the University of Utah Health, Salt Lake City, and associates evaluated the actual hospital costs of patients undergoing elective induction and expectant management in a subset of patients from the ARRIVE trial.

“If, medically speaking, induction is equal to expectant management or has some benefit, as the larger ARRIVE trial suggests, we wanted to know: At what cost?” Dr. Einerson said in an interview.

Study participants hailed from five Utah hospitals within two health systems: the University of Utah Health and Intermountain Healthcare. Taking available data for 1,231 enrollees, investigators randomized 608 to labor induction and 623 to spontaneous labor. They measured actual hospital costs using advanced value-based analytics platforms at the Utah hospitals, comparing cost means and reporting the relative difference between induction and expectant management.

Overall, they found no significant differences between the mean total cost of elective induction and expectant management (adjusted mean difference, +4.7%). This was the case for other metrics: Costs did not vary among the five health systems or in most phases of care, including maternal inpatient postpartum care, maternal outpatient care after discharge, neonatal hospital care, and neonatal care after discharge.

The induction group did incur higher maternal inpatient intrapartum and delivery care costs (17%). However, these were offset by savings achieved during outpatient antenatal care (–47%). The assumption was additional costs of time spent on the labor ward might overwhelm cost savings elsewhere (reduced cesarean deliveries, fewer prenatal appointments and tests). “But this was not the case,” Dr. Einerson said.

Ultimately, the study was not large enough to find smaller differences in cost, he noted. It was only large enough to say that cost didn’t differentiate between arms with a margin of +/–7%. “A cost increase (or cost savings) with induction of 7% is meaningful over time and on a national scale,” Dr. Einerson explained.

Taken together, the two studies show that cost is not an insurmountable barrier to elective induced labor, Jeffrey L. Ecker, MD, and Mark A. Clapp, MD, MPH, wrote in an accompanying editorial (Obstet Gynecol. 2020;136[1]:6-7).

“This will be especially true if we are innovative and creatively adapt our facilities and spaces, thinking about where and how some of the required care can be appropriately and more economically offered,” they noted.

“Specifically, strategies to safely reduce labor and delivery time for inductions of labor, including considering and studying outpatient cervical ripening, may make elective induction of labor at 39 weeks of gestation even less costly and even more feasible to offer to all women,” suggested Dr. Ecker and Dr. Clapp, both at Massachusetts General Hospital and Harvard Medical School, both in Boston.

Dr. Hersh and coauthors had no relevant financial disclosures, and there was no external funding for their study. Dr. Einerson and most coauthors reported no relevant financial disclosures; one coauthor reported receiving funds from GestVision as a consultant, and another coauthor reported funds paid to her or her institution from some pharmaceutical companies when she was primary investigator on various trials or a consultant. This study was supported by grants from the Eunice Kennedy Shriver National Institute of Child Health and Human Development. Neither Dr. Ecker nor Dr Clapp had any relevant financial disclosures or received any funding.

SOURCES: Hersh AR et al. Obstet Gynecol. 2020. doi: 10.1097/AOG.0000000000003865; Einerson BD et al. Obstet Gynecol. 2020. doi: 10.1097/AOG.0000000000003930.

Psoriasis Area and Severity Index (PASI 100) scores were reached by one in four patients after 6 months of therapy in a study that examined six different biologic treatments in biologic-naive and biologic-experienced patients.

The study was published in May in the Journal of the European Academy of Dermatology and Venereology.

High efficacy rates, which include PASI 100 scores, have been reported in randomized trials of biologics that include anti–interleukin (IL)–17A therapies (secukinumab and ixekizumab), anti–IL-17A–receptor therapies (brodalumab), and anti–IL-23 therapies (guselkumab and risankizumab), but information on rates in real-world cohorts has been limited. “Real-world evidence provided by registries is only beginning to emerge, and efficacy data have mostly been derived from clinical trials,” senior author Kristian Reich, MD, PhD, professor for translational research in inflammatory skin diseases at the Institute for Health Services Research in Dermatology and Nursing, University Medical Center Hamburg-Eppendorf (Germany), said in an interview.

He and his coinvestigators conducted the PSO-BIO-REAL (Plaque Psoriasis Treated With Biologics in a Real World Setting) prospective trial in five countries, to evaluate the effectiveness of treatments in patients with moderate to severe plaque psoriasis over a year’s time following administration of a biologic therapy. Patients were 18 years of age or older and had either started a biologic for the first time (biologic-naive) or were transitioning to another biologic (biologic-experienced).

Among 846 participants, 32% were in the United States, followed by France (28%), Italy (22%), the United Kingdom (11%), and Germany (8%). Investigators estimated the proportion of patients achieving a PASI 100 (complete skin clearance) 6 months after starting a biologic as a primary objective, and as secondary objectives, PASI 100 scores at 1 year and PASI 100 maintenance from 6 to 12 months.

Nearly 200 patients withdrew during the course of the study, and 108 switched treatments. Therapies varied among patients: 61% received an anti–tumor necrosis factor agent such as etanercept, infliximab, adalimumab, or certolizumab pegol as an initial biologic treatment, 30% received an anti–IL-12/-23 agent (ustekinumab), and 9% received an anti-IL-17 agent (secukinumab). Additionally, 23% received a concomitant psoriasis medication.

PASI assessments were completed in 603 patients at 6 months, and 522 patients at 12 months. At 6 and 12 months respectively, 23% and 26% of the patients had achieved a PASI 100 score. Investigators noted that the rate of complete skin clearance declined as the number of baseline comorbidities and the number of prior biologics increased.

Biologic-experienced patients at study entry had lower PASI 100 response rates (about 20% at 6 and 12 months) than the biologic-naive patients (25% at 6 months, 30% at 12 months). Dr. Reich pointed out that many biologic-experienced patients often have active disease, despite previous use of biologics, and “they’re likely to represent a more difficult-to-treat population.” Factors such as convenience, safety, and the fact that more complicated patients – those with weight issues, more comorbidities and pretreatments, and lower compliance – are treated in real life than in clinical trials, are likely to influence lack of response in real-world data, Dr. Reich said.

The study’s enrollment period took place from 2014 to 2015, so it did not include patients on newer biologics such as brodalumab, guselkumab, ixekizumab, and tildrakizumab. “Some of these newer therapies have shown greater efficacy than drugs such as ustekinumab and etanercept in clinical trials, and patients are more likely to achieve complete skin clearance. Therefore, real-world rates of complete clearance may have improved since this study concluded,” the investigators pointed out.

Possible limitations of the study include selection bias and possible confounders, they noted.

The study was sponsored by Amgen/AstraZeneca; the manuscript was sponsored by LEO Pharma. One author was an AstraZeneca employee, two are LEO pharma employees, one author had no disclosures, and the remaining authors, including Dr. Reich, disclosed serving as an adviser, paid speaker, consultant, and/or investigator for multiple pharmaceutical companies.

SOURCE: Seneschal J et al. J Eur Acad Dermatol Venereol. 2020 May 4. doi: 10.1111/jdv.16568.

Psoriasis Area and Severity Index (PASI 100) scores were reached by one in four patients after 6 months of therapy in a study that examined six different biologic treatments in biologic-naive and biologic-experienced patients.

The study was published in May in the Journal of the European Academy of Dermatology and Venereology.

High efficacy rates, which include PASI 100 scores, have been reported in randomized trials of biologics that include anti–interleukin (IL)–17A therapies (secukinumab and ixekizumab), anti–IL-17A–receptor therapies (brodalumab), and anti–IL-23 therapies (guselkumab and risankizumab), but information on rates in real-world cohorts has been limited. “Real-world evidence provided by registries is only beginning to emerge, and efficacy data have mostly been derived from clinical trials,” senior author Kristian Reich, MD, PhD, professor for translational research in inflammatory skin diseases at the Institute for Health Services Research in Dermatology and Nursing, University Medical Center Hamburg-Eppendorf (Germany), said in an interview.

He and his coinvestigators conducted the PSO-BIO-REAL (Plaque Psoriasis Treated With Biologics in a Real World Setting) prospective trial in five countries, to evaluate the effectiveness of treatments in patients with moderate to severe plaque psoriasis over a year’s time following administration of a biologic therapy. Patients were 18 years of age or older and had either started a biologic for the first time (biologic-naive) or were transitioning to another biologic (biologic-experienced).

Among 846 participants, 32% were in the United States, followed by France (28%), Italy (22%), the United Kingdom (11%), and Germany (8%). Investigators estimated the proportion of patients achieving a PASI 100 (complete skin clearance) 6 months after starting a biologic as a primary objective, and as secondary objectives, PASI 100 scores at 1 year and PASI 100 maintenance from 6 to 12 months.

Nearly 200 patients withdrew during the course of the study, and 108 switched treatments. Therapies varied among patients: 61% received an anti–tumor necrosis factor agent such as etanercept, infliximab, adalimumab, or certolizumab pegol as an initial biologic treatment, 30% received an anti–IL-12/-23 agent (ustekinumab), and 9% received an anti-IL-17 agent (secukinumab). Additionally, 23% received a concomitant psoriasis medication.

PASI assessments were completed in 603 patients at 6 months, and 522 patients at 12 months. At 6 and 12 months respectively, 23% and 26% of the patients had achieved a PASI 100 score. Investigators noted that the rate of complete skin clearance declined as the number of baseline comorbidities and the number of prior biologics increased.

Biologic-experienced patients at study entry had lower PASI 100 response rates (about 20% at 6 and 12 months) than the biologic-naive patients (25% at 6 months, 30% at 12 months). Dr. Reich pointed out that many biologic-experienced patients often have active disease, despite previous use of biologics, and “they’re likely to represent a more difficult-to-treat population.” Factors such as convenience, safety, and the fact that more complicated patients – those with weight issues, more comorbidities and pretreatments, and lower compliance – are treated in real life than in clinical trials, are likely to influence lack of response in real-world data, Dr. Reich said.

The study’s enrollment period took place from 2014 to 2015, so it did not include patients on newer biologics such as brodalumab, guselkumab, ixekizumab, and tildrakizumab. “Some of these newer therapies have shown greater efficacy than drugs such as ustekinumab and etanercept in clinical trials, and patients are more likely to achieve complete skin clearance. Therefore, real-world rates of complete clearance may have improved since this study concluded,” the investigators pointed out.

Possible limitations of the study include selection bias and possible confounders, they noted.

The study was sponsored by Amgen/AstraZeneca; the manuscript was sponsored by LEO Pharma. One author was an AstraZeneca employee, two are LEO pharma employees, one author had no disclosures, and the remaining authors, including Dr. Reich, disclosed serving as an adviser, paid speaker, consultant, and/or investigator for multiple pharmaceutical companies.

SOURCE: Seneschal J et al. J Eur Acad Dermatol Venereol. 2020 May 4. doi: 10.1111/jdv.16568.

Psoriasis Area and Severity Index (PASI 100) scores were reached by one in four patients after 6 months of therapy in a study that examined six different biologic treatments in biologic-naive and biologic-experienced patients.

The study was published in May in the Journal of the European Academy of Dermatology and Venereology.

High efficacy rates, which include PASI 100 scores, have been reported in randomized trials of biologics that include anti–interleukin (IL)–17A therapies (secukinumab and ixekizumab), anti–IL-17A–receptor therapies (brodalumab), and anti–IL-23 therapies (guselkumab and risankizumab), but information on rates in real-world cohorts has been limited. “Real-world evidence provided by registries is only beginning to emerge, and efficacy data have mostly been derived from clinical trials,” senior author Kristian Reich, MD, PhD, professor for translational research in inflammatory skin diseases at the Institute for Health Services Research in Dermatology and Nursing, University Medical Center Hamburg-Eppendorf (Germany), said in an interview.

He and his coinvestigators conducted the PSO-BIO-REAL (Plaque Psoriasis Treated With Biologics in a Real World Setting) prospective trial in five countries, to evaluate the effectiveness of treatments in patients with moderate to severe plaque psoriasis over a year’s time following administration of a biologic therapy. Patients were 18 years of age or older and had either started a biologic for the first time (biologic-naive) or were transitioning to another biologic (biologic-experienced).

Among 846 participants, 32% were in the United States, followed by France (28%), Italy (22%), the United Kingdom (11%), and Germany (8%). Investigators estimated the proportion of patients achieving a PASI 100 (complete skin clearance) 6 months after starting a biologic as a primary objective, and as secondary objectives, PASI 100 scores at 1 year and PASI 100 maintenance from 6 to 12 months.

Nearly 200 patients withdrew during the course of the study, and 108 switched treatments. Therapies varied among patients: 61% received an anti–tumor necrosis factor agent such as etanercept, infliximab, adalimumab, or certolizumab pegol as an initial biologic treatment, 30% received an anti–IL-12/-23 agent (ustekinumab), and 9% received an anti-IL-17 agent (secukinumab). Additionally, 23% received a concomitant psoriasis medication.

PASI assessments were completed in 603 patients at 6 months, and 522 patients at 12 months. At 6 and 12 months respectively, 23% and 26% of the patients had achieved a PASI 100 score. Investigators noted that the rate of complete skin clearance declined as the number of baseline comorbidities and the number of prior biologics increased.

Biologic-experienced patients at study entry had lower PASI 100 response rates (about 20% at 6 and 12 months) than the biologic-naive patients (25% at 6 months, 30% at 12 months). Dr. Reich pointed out that many biologic-experienced patients often have active disease, despite previous use of biologics, and “they’re likely to represent a more difficult-to-treat population.” Factors such as convenience, safety, and the fact that more complicated patients – those with weight issues, more comorbidities and pretreatments, and lower compliance – are treated in real life than in clinical trials, are likely to influence lack of response in real-world data, Dr. Reich said.

The study’s enrollment period took place from 2014 to 2015, so it did not include patients on newer biologics such as brodalumab, guselkumab, ixekizumab, and tildrakizumab. “Some of these newer therapies have shown greater efficacy than drugs such as ustekinumab and etanercept in clinical trials, and patients are more likely to achieve complete skin clearance. Therefore, real-world rates of complete clearance may have improved since this study concluded,” the investigators pointed out.

Possible limitations of the study include selection bias and possible confounders, they noted.

The study was sponsored by Amgen/AstraZeneca; the manuscript was sponsored by LEO Pharma. One author was an AstraZeneca employee, two are LEO pharma employees, one author had no disclosures, and the remaining authors, including Dr. Reich, disclosed serving as an adviser, paid speaker, consultant, and/or investigator for multiple pharmaceutical companies.

SOURCE: Seneschal J et al. J Eur Acad Dermatol Venereol. 2020 May 4. doi: 10.1111/jdv.16568.

E-consults were highly useful, with more than 80% of them resulting in an avoided visit to a specialist, in a study of e-consult use at a large health system.

Studies have shown that e-consults increase access to specialist care and primary care physician (PCP) education, according to research published in the Annals of Internal Medicine (2020. Apr 14. doi: 10.7326/M19-3852) by Salman Ahmed, MD, and colleagues.

These resources are already being frequently used by physicians, but more often by general internists and hospitalists than by subspecialists, according to a recent survey by the American College of Physicians. That survey found that 42% of its respondents are using e-consults and that subspecialists’ use is less common primarily because of the lack of access to e-consult technology.

What hasn’t been widely researched are the effects of large-scale e-consult programs, said Dr. Ahmed, who is associate physician in the renal division at Brigham and Women’s Hospital, Boston, in an interview.

For frontline providers such as PCPs, e-consults are a way to quickly seek out answers to clinical questions from specialists. In turn, the specialist can help a wider pool of participants, he noted.

The findings of Dr. Ahmed’s study, which included several academic centers and hospitals affiliated with Partners HealthCare System, a nonprofit network in eastern Massachusetts that includes Brigham and Women’s Hospital, used several metrics to analyze the appropriateness and utility of e-consults across a range of specialties. An e-consult was considered useful if it resulted in the avoidance of a visit to a specialist, which was defined as the absence of an in-person visit to the type of specialist consulted electronically for 120 days. An e-consult was considered appropriate if it met the following four criteria.

• It could not be answered by referring to society guidelines or widely available, evidence-based summary sources.
• It did not seek logistic information, such as where to have a specific laboratory test done.
• It did not include a question of high urgency.
• The medical complexity of the clinical situation was not substantial enough to warrant an in-person consultation.

The investigators examined e-consult inquiries to mostly physician health care providers in five specialties – hematology, infectious disease, dermatology, rheumatology, and psychiatry – over a year.
 

High rates of appropriateness

The search spanned 6,512 eligible e-consults from 1,096 referring providers to 121 specialist consultants. Narrowing their search to 741 records with complete data, the investigators found that 70.2% of these consults met the criteria for appropriateness. In an analysis of four reviewers blinded to each other’s results, raters agreed on the appropriateness of 94% of e-consults.

Across specialties, more than 81% of e-consults were associated with avoided in-person visits.

The reasons for most e-consults were to seek answers to questions about diagnosis, therapeutics, or patient inquiries, or to request further education by PCPs.

“Across all specialties, the most common reasons an e-consult was not considered appropriate were failing the point-of-care resource test and asking a question of inappropriately high complexity,” the authors summarized.

Physicians and PCPs from tertiary care practices made up the majority of referring providers, with turnaround time for consults averaging 24 hours across specialties.

Rates of appropriateness, content, patient demographics, and timeliness of e-consult responses varied among the four specialties. Those with high avoidance of visits rates tended to have high appropriateness rates, indicating that some specialties may be more conducive to e-consults than others, the authors noted. Psychiatry and hematology had the highest proportion of appropriate e-consults (77.9% and 73.3% respectively). Rheumatology had the lowest proportion of appropriate e-consults and one of the lowest rates of avoided in-person visits, and dermatology had the lowest rate of avoided in-person visits, at 61.9%.

The majority (93%) of e-consults sought in psychiatry were therapy related, whereas 88.4% of the e-consult questions in rheumatology related to diagnosis.

“Questions about diagnosis were less likely to be answerable via e-consult, which suggests that to provide diagnoses, consultants may wish to engage with the patient directly,” Dr. Ahmed said in an interview.

Infectious disease specialists seemed to be the fastest responders, with nearly 90% of their consultations having been answered within a day. Dermatology specialists had the distinction of having the youngest e-consult patients (mean age, 38.6 years).
 

PCPs weigh in on results

Physicians said in interviews that the study data reflects their own positive experiences with e-consults.

“Although I don’t always think [an e-consult] is able to fully prevent the specialist visit, it does allow the specialist to provide recommendations for work-up that can be done prior to the specialist visit,” said Santina Wheat MD, a family physician at Erie Family Health Center in Chicago. This reduces the time in which the consult is placed to when effective treatment can take place.

Patients who may have to wait months or even years to see a specialty doctor, benefit from e-consults, said Dr. Wheat, who is also a member of the editorial advisory board of Family Practice News. “As part of an organization that does e-consults to another hospital with a different electronic medical record, the e-consult increases the likelihood that all of the clinical information reaches the specialists and prevents tests from being repeated.”

Starting an e-consult may also increase the likelihood that the patient quickly sees a specialist at the contracted hospital, she added.

Sarah G. Candler, MD, said in an interview that she also sees e-consults as an essential tool. “When patients present with rare, complex, or atypical pictures, I find it helpful to have specialists weigh in. The e-consult helps me ensure that I work to the top of my abilities as an internist,” said Dr. Candler, who is practice medical director and physician director of academic relations at Iora Primary Care, Northside Clinic, Houston. However, she did not agree with the study’s avoided in-person visits metric for assessing utility.

“In some cases, the end result of an e-consult is a referral for an in-person evaluation, and the role of the e-consult is to ensure that I have done my due diligence as a primary care doctor asking the correct questions, getting the appropriate work-up completed, and referring to the appropriate specialty for next steps, when necessary,” noted Dr. Candler, who also serves on the editorial advisory board of Internal Medicine News.
 

Financial considerations

The study’s authors suggested taking a closer look at standardizing payment for the use of e-consults and developing appropriateness criteria for them.

Health systems could use such criteria to study what makes an e-consult useful and how to best utilize this tool, Dr. Ahmed said in an interview.

“Compensation models that promote high-quality, effective, and efficient e-consults are needed to reinforce the ability of health systems to optimize the mix of e-consults and in-person visits,” Dr. Ahmed and colleagues suggested.

Because not all patient care requires e-consults, the model makes the most sense in practices that already participate in value-based payment programs. In these types of programs, the cost can be shared according to the variable risk and patient need for the service, Dr. Candler explained.

“I have been fortunate to work in two different systems that function in this way, which means that e-consults have been readily available and encouraged-both to improve patient care and decrease overall cost by decreasing unnecessary testing or specialist referral,” she said.

Dr. Wheat said that the managed care organization affiliated with her practice seems to be saving money with e-consults, as it decreases the need to pay for specialist visits in some instances and for repeated work-ups.
 

Future studies

The study’s cohort represented just one large health care system with a shared electronic health record. “Single-system descriptive studies, such as that of Ahmed and colleagues, are particularly useful for local evaluation and quality improvement efforts,” Varsha G. Vimalananda, MD, and B. Graeme Fincke, MD, both of the Center for Healthcare Organization and Implementation Research at Bedford (Mass.) Veterans Affairs Hospital, wrote in a related editorial.

“However, we need innovative approaches to evaluation that estimate the effect of e-consults on quality and cost of care across health care systems and over time. Implementation studies can help to identify key contributors to success,” the editorialists wrote.

One of the study authors, reported receiving personal fees from Bayer outside the submitted work. The other authors of the paper and the authors of the editorial reported no conflicts of interest. Dr. Candler said her employer contracts with an e-consult service, but that she is not compensated for use of the service. She is also a coeditor of Annals of Internal Medicine’s blog, “Fresh Look.”

SOURCE: Ahmed S et al. Ann Intern Med. 2020 Apr 14. doi: 10.7326/M19-3852.

E-consults were highly useful, with more than 80% of them resulting in an avoided visit to a specialist, in a study of e-consult use at a large health system.

Studies have shown that e-consults increase access to specialist care and primary care physician (PCP) education, according to research published in the Annals of Internal Medicine (2020. Apr 14. doi: 10.7326/M19-3852) by Salman Ahmed, MD, and colleagues.

These resources are already being frequently used by physicians, but more often by general internists and hospitalists than by subspecialists, according to a recent survey by the American College of Physicians. That survey found that 42% of its respondents are using e-consults and that subspecialists’ use is less common primarily because of the lack of access to e-consult technology.

What hasn’t been widely researched are the effects of large-scale e-consult programs, said Dr. Ahmed, who is associate physician in the renal division at Brigham and Women’s Hospital, Boston, in an interview.

For frontline providers such as PCPs, e-consults are a way to quickly seek out answers to clinical questions from specialists. In turn, the specialist can help a wider pool of participants, he noted.

The findings of Dr. Ahmed’s study, which included several academic centers and hospitals affiliated with Partners HealthCare System, a nonprofit network in eastern Massachusetts that includes Brigham and Women’s Hospital, used several metrics to analyze the appropriateness and utility of e-consults across a range of specialties. An e-consult was considered useful if it resulted in the avoidance of a visit to a specialist, which was defined as the absence of an in-person visit to the type of specialist consulted electronically for 120 days. An e-consult was considered appropriate if it met the following four criteria.

• It could not be answered by referring to society guidelines or widely available, evidence-based summary sources.
• It did not seek logistic information, such as where to have a specific laboratory test done.
• It did not include a question of high urgency.
• The medical complexity of the clinical situation was not substantial enough to warrant an in-person consultation.

The investigators examined e-consult inquiries to mostly physician health care providers in five specialties – hematology, infectious disease, dermatology, rheumatology, and psychiatry – over a year.
 

High rates of appropriateness

The search spanned 6,512 eligible e-consults from 1,096 referring providers to 121 specialist consultants. Narrowing their search to 741 records with complete data, the investigators found that 70.2% of these consults met the criteria for appropriateness. In an analysis of four reviewers blinded to each other’s results, raters agreed on the appropriateness of 94% of e-consults.

Across specialties, more than 81% of e-consults were associated with avoided in-person visits.

The reasons for most e-consults were to seek answers to questions about diagnosis, therapeutics, or patient inquiries, or to request further education by PCPs.

“Across all specialties, the most common reasons an e-consult was not considered appropriate were failing the point-of-care resource test and asking a question of inappropriately high complexity,” the authors summarized.

Physicians and PCPs from tertiary care practices made up the majority of referring providers, with turnaround time for consults averaging 24 hours across specialties.

Rates of appropriateness, content, patient demographics, and timeliness of e-consult responses varied among the four specialties. Those with high avoidance of visits rates tended to have high appropriateness rates, indicating that some specialties may be more conducive to e-consults than others, the authors noted. Psychiatry and hematology had the highest proportion of appropriate e-consults (77.9% and 73.3% respectively). Rheumatology had the lowest proportion of appropriate e-consults and one of the lowest rates of avoided in-person visits, and dermatology had the lowest rate of avoided in-person visits, at 61.9%.

The majority (93%) of e-consults sought in psychiatry were therapy related, whereas 88.4% of the e-consult questions in rheumatology related to diagnosis.

“Questions about diagnosis were less likely to be answerable via e-consult, which suggests that to provide diagnoses, consultants may wish to engage with the patient directly,” Dr. Ahmed said in an interview.

Infectious disease specialists seemed to be the fastest responders, with nearly 90% of their consultations having been answered within a day. Dermatology specialists had the distinction of having the youngest e-consult patients (mean age, 38.6 years).
 

PCPs weigh in on results

Physicians said in interviews that the study data reflects their own positive experiences with e-consults.

“Although I don’t always think [an e-consult] is able to fully prevent the specialist visit, it does allow the specialist to provide recommendations for work-up that can be done prior to the specialist visit,” said Santina Wheat MD, a family physician at Erie Family Health Center in Chicago. This reduces the time in which the consult is placed to when effective treatment can take place.

Patients who may have to wait months or even years to see a specialty doctor, benefit from e-consults, said Dr. Wheat, who is also a member of the editorial advisory board of Family Practice News. “As part of an organization that does e-consults to another hospital with a different electronic medical record, the e-consult increases the likelihood that all of the clinical information reaches the specialists and prevents tests from being repeated.”

Starting an e-consult may also increase the likelihood that the patient quickly sees a specialist at the contracted hospital, she added.

Sarah G. Candler, MD, said in an interview that she also sees e-consults as an essential tool. “When patients present with rare, complex, or atypical pictures, I find it helpful to have specialists weigh in. The e-consult helps me ensure that I work to the top of my abilities as an internist,” said Dr. Candler, who is practice medical director and physician director of academic relations at Iora Primary Care, Northside Clinic, Houston. However, she did not agree with the study’s avoided in-person visits metric for assessing utility.

“In some cases, the end result of an e-consult is a referral for an in-person evaluation, and the role of the e-consult is to ensure that I have done my due diligence as a primary care doctor asking the correct questions, getting the appropriate work-up completed, and referring to the appropriate specialty for next steps, when necessary,” noted Dr. Candler, who also serves on the editorial advisory board of Internal Medicine News.
 

Financial considerations

The study’s authors suggested taking a closer look at standardizing payment for the use of e-consults and developing appropriateness criteria for them.

Health systems could use such criteria to study what makes an e-consult useful and how to best utilize this tool, Dr. Ahmed said in an interview.

“Compensation models that promote high-quality, effective, and efficient e-consults are needed to reinforce the ability of health systems to optimize the mix of e-consults and in-person visits,” Dr. Ahmed and colleagues suggested.

Because not all patient care requires e-consults, the model makes the most sense in practices that already participate in value-based payment programs. In these types of programs, the cost can be shared according to the variable risk and patient need for the service, Dr. Candler explained.

“I have been fortunate to work in two different systems that function in this way, which means that e-consults have been readily available and encouraged-both to improve patient care and decrease overall cost by decreasing unnecessary testing or specialist referral,” she said.

Dr. Wheat said that the managed care organization affiliated with her practice seems to be saving money with e-consults, as it decreases the need to pay for specialist visits in some instances and for repeated work-ups.
 

Future studies

The study’s cohort represented just one large health care system with a shared electronic health record. “Single-system descriptive studies, such as that of Ahmed and colleagues, are particularly useful for local evaluation and quality improvement efforts,” Varsha G. Vimalananda, MD, and B. Graeme Fincke, MD, both of the Center for Healthcare Organization and Implementation Research at Bedford (Mass.) Veterans Affairs Hospital, wrote in a related editorial.

“However, we need innovative approaches to evaluation that estimate the effect of e-consults on quality and cost of care across health care systems and over time. Implementation studies can help to identify key contributors to success,” the editorialists wrote.

One of the study authors, reported receiving personal fees from Bayer outside the submitted work. The other authors of the paper and the authors of the editorial reported no conflicts of interest. Dr. Candler said her employer contracts with an e-consult service, but that she is not compensated for use of the service. She is also a coeditor of Annals of Internal Medicine’s blog, “Fresh Look.”

SOURCE: Ahmed S et al. Ann Intern Med. 2020 Apr 14. doi: 10.7326/M19-3852.

E-consults were highly useful, with more than 80% of them resulting in an avoided visit to a specialist, in a study of e-consult use at a large health system.

Studies have shown that e-consults increase access to specialist care and primary care physician (PCP) education, according to research published in the Annals of Internal Medicine (2020. Apr 14. doi: 10.7326/M19-3852) by Salman Ahmed, MD, and colleagues.

These resources are already being frequently used by physicians, but more often by general internists and hospitalists than by subspecialists, according to a recent survey by the American College of Physicians. That survey found that 42% of its respondents are using e-consults and that subspecialists’ use is less common primarily because of the lack of access to e-consult technology.

What hasn’t been widely researched are the effects of large-scale e-consult programs, said Dr. Ahmed, who is associate physician in the renal division at Brigham and Women’s Hospital, Boston, in an interview.

For frontline providers such as PCPs, e-consults are a way to quickly seek out answers to clinical questions from specialists. In turn, the specialist can help a wider pool of participants, he noted.

The findings of Dr. Ahmed’s study, which included several academic centers and hospitals affiliated with Partners HealthCare System, a nonprofit network in eastern Massachusetts that includes Brigham and Women’s Hospital, used several metrics to analyze the appropriateness and utility of e-consults across a range of specialties. An e-consult was considered useful if it resulted in the avoidance of a visit to a specialist, which was defined as the absence of an in-person visit to the type of specialist consulted electronically for 120 days. An e-consult was considered appropriate if it met the following four criteria.

• It could not be answered by referring to society guidelines or widely available, evidence-based summary sources.
• It did not seek logistic information, such as where to have a specific laboratory test done.
• It did not include a question of high urgency.
• The medical complexity of the clinical situation was not substantial enough to warrant an in-person consultation.

The investigators examined e-consult inquiries to mostly physician health care providers in five specialties – hematology, infectious disease, dermatology, rheumatology, and psychiatry – over a year.
 

High rates of appropriateness

The search spanned 6,512 eligible e-consults from 1,096 referring providers to 121 specialist consultants. Narrowing their search to 741 records with complete data, the investigators found that 70.2% of these consults met the criteria for appropriateness. In an analysis of four reviewers blinded to each other’s results, raters agreed on the appropriateness of 94% of e-consults.

Across specialties, more than 81% of e-consults were associated with avoided in-person visits.

The reasons for most e-consults were to seek answers to questions about diagnosis, therapeutics, or patient inquiries, or to request further education by PCPs.

“Across all specialties, the most common reasons an e-consult was not considered appropriate were failing the point-of-care resource test and asking a question of inappropriately high complexity,” the authors summarized.

Physicians and PCPs from tertiary care practices made up the majority of referring providers, with turnaround time for consults averaging 24 hours across specialties.

Rates of appropriateness, content, patient demographics, and timeliness of e-consult responses varied among the four specialties. Those with high avoidance of visits rates tended to have high appropriateness rates, indicating that some specialties may be more conducive to e-consults than others, the authors noted. Psychiatry and hematology had the highest proportion of appropriate e-consults (77.9% and 73.3% respectively). Rheumatology had the lowest proportion of appropriate e-consults and one of the lowest rates of avoided in-person visits, and dermatology had the lowest rate of avoided in-person visits, at 61.9%.

The majority (93%) of e-consults sought in psychiatry were therapy related, whereas 88.4% of the e-consult questions in rheumatology related to diagnosis.

“Questions about diagnosis were less likely to be answerable via e-consult, which suggests that to provide diagnoses, consultants may wish to engage with the patient directly,” Dr. Ahmed said in an interview.

Infectious disease specialists seemed to be the fastest responders, with nearly 90% of their consultations having been answered within a day. Dermatology specialists had the distinction of having the youngest e-consult patients (mean age, 38.6 years).
 

PCPs weigh in on results

Physicians said in interviews that the study data reflects their own positive experiences with e-consults.

“Although I don’t always think [an e-consult] is able to fully prevent the specialist visit, it does allow the specialist to provide recommendations for work-up that can be done prior to the specialist visit,” said Santina Wheat MD, a family physician at Erie Family Health Center in Chicago. This reduces the time in which the consult is placed to when effective treatment can take place.

Patients who may have to wait months or even years to see a specialty doctor, benefit from e-consults, said Dr. Wheat, who is also a member of the editorial advisory board of Family Practice News. “As part of an organization that does e-consults to another hospital with a different electronic medical record, the e-consult increases the likelihood that all of the clinical information reaches the specialists and prevents tests from being repeated.”

Starting an e-consult may also increase the likelihood that the patient quickly sees a specialist at the contracted hospital, she added.

Sarah G. Candler, MD, said in an interview that she also sees e-consults as an essential tool. “When patients present with rare, complex, or atypical pictures, I find it helpful to have specialists weigh in. The e-consult helps me ensure that I work to the top of my abilities as an internist,” said Dr. Candler, who is practice medical director and physician director of academic relations at Iora Primary Care, Northside Clinic, Houston. However, she did not agree with the study’s avoided in-person visits metric for assessing utility.

“In some cases, the end result of an e-consult is a referral for an in-person evaluation, and the role of the e-consult is to ensure that I have done my due diligence as a primary care doctor asking the correct questions, getting the appropriate work-up completed, and referring to the appropriate specialty for next steps, when necessary,” noted Dr. Candler, who also serves on the editorial advisory board of Internal Medicine News.
 

Financial considerations

The study’s authors suggested taking a closer look at standardizing payment for the use of e-consults and developing appropriateness criteria for them.

Health systems could use such criteria to study what makes an e-consult useful and how to best utilize this tool, Dr. Ahmed said in an interview.

“Compensation models that promote high-quality, effective, and efficient e-consults are needed to reinforce the ability of health systems to optimize the mix of e-consults and in-person visits,” Dr. Ahmed and colleagues suggested.

Because not all patient care requires e-consults, the model makes the most sense in practices that already participate in value-based payment programs. In these types of programs, the cost can be shared according to the variable risk and patient need for the service, Dr. Candler explained.

“I have been fortunate to work in two different systems that function in this way, which means that e-consults have been readily available and encouraged-both to improve patient care and decrease overall cost by decreasing unnecessary testing or specialist referral,” she said.

Dr. Wheat said that the managed care organization affiliated with her practice seems to be saving money with e-consults, as it decreases the need to pay for specialist visits in some instances and for repeated work-ups.
 

Future studies

The study’s cohort represented just one large health care system with a shared electronic health record. “Single-system descriptive studies, such as that of Ahmed and colleagues, are particularly useful for local evaluation and quality improvement efforts,” Varsha G. Vimalananda, MD, and B. Graeme Fincke, MD, both of the Center for Healthcare Organization and Implementation Research at Bedford (Mass.) Veterans Affairs Hospital, wrote in a related editorial.

“However, we need innovative approaches to evaluation that estimate the effect of e-consults on quality and cost of care across health care systems and over time. Implementation studies can help to identify key contributors to success,” the editorialists wrote.

One of the study authors, reported receiving personal fees from Bayer outside the submitted work. The other authors of the paper and the authors of the editorial reported no conflicts of interest. Dr. Candler said her employer contracts with an e-consult service, but that she is not compensated for use of the service. She is also a coeditor of Annals of Internal Medicine’s blog, “Fresh Look.”

SOURCE: Ahmed S et al. Ann Intern Med. 2020 Apr 14. doi: 10.7326/M19-3852.

Unifying allopathic (MD) and osteopathic (DO) applicants for the first time in a single matching program, 2020’s Match Day results underscored the continuing growth of DOs in the field, boosting numbers in primary care medicine and the Match as a whole.

Gains, trends in 2020 match

Growth in U.S. DO senior participation also pushed this year’s Match to record highs. There were 6,581 U.S. DO medical school seniors who submitted rank order lists, 1,103 more than in 2019. Among those seniors, 90.7% matched to PGY-1 positions, driving the match rate for U.S. DO seniors up 2.6 percentage points from 2019.

Since 2016, the number of U.S. DO seniors seeking positions has risen by 3,599 or 120%. “Of course, the number of U.S. MD seniors who submitted program choices was also record-high: 19,326, an increase of 401 over 2019. The 93.7% match rate to first-year positions for this group has remained very consistent for many years,” Dr. Lamb said.

Among individual specialties, the NRMP reported extremely high fill rates for dermatology, medicine-emergency medicine, neurological surgery, physical medicine and rehabilitation (categorical), integrated plastic surgery, and thoracic surgery. Other competitive specialties included medicine-pediatrics, orthopedic surgery, otolaryngology, and vascular surgery.

Participation of international medical school students and graduates (IMGs) went up in 2020, breaking a 3-year cycle of decline. More than 61% matched to first-year positions, 2.5 percentage points higher than 2019 – and the highest match rate since 1990. “IMGs generally are having the most success matching to primary care specialties, including internal medicine, family medicine, and pediatrics,” Dr. Lamb said.
 

Primary care benefits from DO growth

DO candidates also helped drive up the numbers in primary care.

Internal medicine offered 8,697 categorical positions, 581 more than in 2019, reflecting a fill rate of 95.7%. More than 40% of these slots were filled by U.S. MD seniors, a category that’s seen decreases over the last 5 years, due in part to administrative and financial burdens associated with primary care internal medicine.

“In addition, the steady growth of internal medicine has increased the overall number of training positions available, and with the growth of other specialties in parallel, it has also likely had some effect on decreasing the percentage of U.S. graduates entering the field,” Phil Masters, MD, vice president of membership and global engagement at the American College of Physicians, said in an interview.

However, fill rates for U.S. DO seniors reached 16% in 2020, a notable rise from 6.9% in 2016. “As the number of osteopathic trainees increases, we are happy that more are choosing internal medicine as a career path,” Dr. Masters said, adding that the slightly different training and practice orientation of osteopathic physicians “complements that of their allopathic colleagues, and add richness to the many different practice settings that internal medicine encompasses.”

A record number of DO seniors also matched in family medicine (1,392), accounting for nearly 30% of all applicants. The single match led to an important net increase in filled family medicine residency positions, Clif Knight, MD, senior vice president for education at the American Academy of Family Physicians, said in an interview.

Overall, family medicine filled 92.5% of its 4,662 positions, 555 more than in 2019. The results show that family medicine and primary care are on solid footing, Dr. Knight said. “We are excited that the number of filled family medicine residency positions increased from last year. This is important as we work to meet the significant primary care workforce shortage,” he added.

In other specialties:

• Pediatrics filled more than 98% of its 2,864 categorical positions, 17 more than in 2019. U.S. MD seniors filled 1,731 (60.4%) of those slots. “We’re very excited about our newly matched pediatricians,” Sara “Sally” H. Goza, MD, president of the American Academy of Pediatrics, said in an interview. “The coronavirus outbreak has shown us how valuable the pediatric workforce is and how much we’re needed.’’
• Dermatology offered 478 positions, achieving a fill rate of 98.1%. “Looking at our own program’s Match results, I feel very satisfied that we are accomplishing our specific aim to serve rural populations and to create a diverse workforce in dermatology,” Erik Stratman, MD, an expert on dermatologic education in U.S. medical schools/residency programs, and a member of the American Academy of Dermatology, said in an interview. “It’s nice to see the fruits of the specialty’s expanding efforts to get the right people in the specialty who reflect those populations we serve.”
• Obstetrics-gynecology offered 1,433 first-year positions – 48 more than in 2019 – achieving a fill rate of 99.8%, with U.S. MD seniors filling more than 75% of those slots.
• Neurology filled more than 97.5% of 682 offered positions in 2020. However, U.S. MD seniors represented just under half of those filled positions (46.5%).
• Psychiatry offered 1,858 positions in 2020, achieving an overall fill rate of 98.9%, 61.2% for U.S. MD seniors.
• Emergency Medicine filled 99.5% of the 2,665 positions offered this year. In this profession, the U.S. MD fill rate was 64.3%. These new interns are sorely needed at a time when EM physicians are on the front lines of a pandemic, Hannah R. Hughes, MD, president of the Emergency Medicine Residents’ Association, said in an interview.

Unifying allopathic (MD) and osteopathic (DO) applicants for the first time in a single matching program, 2020’s Match Day results underscored the continuing growth of DOs in the field, boosting numbers in primary care medicine and the Match as a whole.

Gains, trends in 2020 match

Growth in U.S. DO senior participation also pushed this year’s Match to record highs. There were 6,581 U.S. DO medical school seniors who submitted rank order lists, 1,103 more than in 2019. Among those seniors, 90.7% matched to PGY-1 positions, driving the match rate for U.S. DO seniors up 2.6 percentage points from 2019.

Since 2016, the number of U.S. DO seniors seeking positions has risen by 3,599 or 120%. “Of course, the number of U.S. MD seniors who submitted program choices was also record-high: 19,326, an increase of 401 over 2019. The 93.7% match rate to first-year positions for this group has remained very consistent for many years,” Dr. Lamb said.

Among individual specialties, the NRMP reported extremely high fill rates for dermatology, medicine-emergency medicine, neurological surgery, physical medicine and rehabilitation (categorical), integrated plastic surgery, and thoracic surgery. Other competitive specialties included medicine-pediatrics, orthopedic surgery, otolaryngology, and vascular surgery.

Participation of international medical school students and graduates (IMGs) went up in 2020, breaking a 3-year cycle of decline. More than 61% matched to first-year positions, 2.5 percentage points higher than 2019 – and the highest match rate since 1990. “IMGs generally are having the most success matching to primary care specialties, including internal medicine, family medicine, and pediatrics,” Dr. Lamb said.
 

Primary care benefits from DO growth

DO candidates also helped drive up the numbers in primary care.

Internal medicine offered 8,697 categorical positions, 581 more than in 2019, reflecting a fill rate of 95.7%. More than 40% of these slots were filled by U.S. MD seniors, a category that’s seen decreases over the last 5 years, due in part to administrative and financial burdens associated with primary care internal medicine.

“In addition, the steady growth of internal medicine has increased the overall number of training positions available, and with the growth of other specialties in parallel, it has also likely had some effect on decreasing the percentage of U.S. graduates entering the field,” Phil Masters, MD, vice president of membership and global engagement at the American College of Physicians, said in an interview.

However, fill rates for U.S. DO seniors reached 16% in 2020, a notable rise from 6.9% in 2016. “As the number of osteopathic trainees increases, we are happy that more are choosing internal medicine as a career path,” Dr. Masters said, adding that the slightly different training and practice orientation of osteopathic physicians “complements that of their allopathic colleagues, and add richness to the many different practice settings that internal medicine encompasses.”

A record number of DO seniors also matched in family medicine (1,392), accounting for nearly 30% of all applicants. The single match led to an important net increase in filled family medicine residency positions, Clif Knight, MD, senior vice president for education at the American Academy of Family Physicians, said in an interview.

Overall, family medicine filled 92.5% of its 4,662 positions, 555 more than in 2019. The results show that family medicine and primary care are on solid footing, Dr. Knight said. “We are excited that the number of filled family medicine residency positions increased from last year. This is important as we work to meet the significant primary care workforce shortage,” he added.

In other specialties:

• Pediatrics filled more than 98% of its 2,864 categorical positions, 17 more than in 2019. U.S. MD seniors filled 1,731 (60.4%) of those slots. “We’re very excited about our newly matched pediatricians,” Sara “Sally” H. Goza, MD, president of the American Academy of Pediatrics, said in an interview. “The coronavirus outbreak has shown us how valuable the pediatric workforce is and how much we’re needed.’’
• Dermatology offered 478 positions, achieving a fill rate of 98.1%. “Looking at our own program’s Match results, I feel very satisfied that we are accomplishing our specific aim to serve rural populations and to create a diverse workforce in dermatology,” Erik Stratman, MD, an expert on dermatologic education in U.S. medical schools/residency programs, and a member of the American Academy of Dermatology, said in an interview. “It’s nice to see the fruits of the specialty’s expanding efforts to get the right people in the specialty who reflect those populations we serve.”
• Obstetrics-gynecology offered 1,433 first-year positions – 48 more than in 2019 – achieving a fill rate of 99.8%, with U.S. MD seniors filling more than 75% of those slots.
• Neurology filled more than 97.5% of 682 offered positions in 2020. However, U.S. MD seniors represented just under half of those filled positions (46.5%).
• Psychiatry offered 1,858 positions in 2020, achieving an overall fill rate of 98.9%, 61.2% for U.S. MD seniors.
• Emergency Medicine filled 99.5% of the 2,665 positions offered this year. In this profession, the U.S. MD fill rate was 64.3%. These new interns are sorely needed at a time when EM physicians are on the front lines of a pandemic, Hannah R. Hughes, MD, president of the Emergency Medicine Residents’ Association, said in an interview.

Unifying allopathic (MD) and osteopathic (DO) applicants for the first time in a single matching program, 2020’s Match Day results underscored the continuing growth of DOs in the field, boosting numbers in primary care medicine and the Match as a whole.

Gains, trends in 2020 match

Growth in U.S. DO senior participation also pushed this year’s Match to record highs. There were 6,581 U.S. DO medical school seniors who submitted rank order lists, 1,103 more than in 2019. Among those seniors, 90.7% matched to PGY-1 positions, driving the match rate for U.S. DO seniors up 2.6 percentage points from 2019.

Since 2016, the number of U.S. DO seniors seeking positions has risen by 3,599 or 120%. “Of course, the number of U.S. MD seniors who submitted program choices was also record-high: 19,326, an increase of 401 over 2019. The 93.7% match rate to first-year positions for this group has remained very consistent for many years,” Dr. Lamb said.

Among individual specialties, the NRMP reported extremely high fill rates for dermatology, medicine-emergency medicine, neurological surgery, physical medicine and rehabilitation (categorical), integrated plastic surgery, and thoracic surgery. Other competitive specialties included medicine-pediatrics, orthopedic surgery, otolaryngology, and vascular surgery.

Participation of international medical school students and graduates (IMGs) went up in 2020, breaking a 3-year cycle of decline. More than 61% matched to first-year positions, 2.5 percentage points higher than 2019 – and the highest match rate since 1990. “IMGs generally are having the most success matching to primary care specialties, including internal medicine, family medicine, and pediatrics,” Dr. Lamb said.
 

Primary care benefits from DO growth

DO candidates also helped drive up the numbers in primary care.

Internal medicine offered 8,697 categorical positions, 581 more than in 2019, reflecting a fill rate of 95.7%. More than 40% of these slots were filled by U.S. MD seniors, a category that’s seen decreases over the last 5 years, due in part to administrative and financial burdens associated with primary care internal medicine.

“In addition, the steady growth of internal medicine has increased the overall number of training positions available, and with the growth of other specialties in parallel, it has also likely had some effect on decreasing the percentage of U.S. graduates entering the field,” Phil Masters, MD, vice president of membership and global engagement at the American College of Physicians, said in an interview.

However, fill rates for U.S. DO seniors reached 16% in 2020, a notable rise from 6.9% in 2016. “As the number of osteopathic trainees increases, we are happy that more are choosing internal medicine as a career path,” Dr. Masters said, adding that the slightly different training and practice orientation of osteopathic physicians “complements that of their allopathic colleagues, and add richness to the many different practice settings that internal medicine encompasses.”

A record number of DO seniors also matched in family medicine (1,392), accounting for nearly 30% of all applicants. The single match led to an important net increase in filled family medicine residency positions, Clif Knight, MD, senior vice president for education at the American Academy of Family Physicians, said in an interview.

Overall, family medicine filled 92.5% of its 4,662 positions, 555 more than in 2019. The results show that family medicine and primary care are on solid footing, Dr. Knight said. “We are excited that the number of filled family medicine residency positions increased from last year. This is important as we work to meet the significant primary care workforce shortage,” he added.

In other specialties:

• Pediatrics filled more than 98% of its 2,864 categorical positions, 17 more than in 2019. U.S. MD seniors filled 1,731 (60.4%) of those slots. “We’re very excited about our newly matched pediatricians,” Sara “Sally” H. Goza, MD, president of the American Academy of Pediatrics, said in an interview. “The coronavirus outbreak has shown us how valuable the pediatric workforce is and how much we’re needed.’’
• Dermatology offered 478 positions, achieving a fill rate of 98.1%. “Looking at our own program’s Match results, I feel very satisfied that we are accomplishing our specific aim to serve rural populations and to create a diverse workforce in dermatology,” Erik Stratman, MD, an expert on dermatologic education in U.S. medical schools/residency programs, and a member of the American Academy of Dermatology, said in an interview. “It’s nice to see the fruits of the specialty’s expanding efforts to get the right people in the specialty who reflect those populations we serve.”
• Obstetrics-gynecology offered 1,433 first-year positions – 48 more than in 2019 – achieving a fill rate of 99.8%, with U.S. MD seniors filling more than 75% of those slots.
• Neurology filled more than 97.5% of 682 offered positions in 2020. However, U.S. MD seniors represented just under half of those filled positions (46.5%).
• Psychiatry offered 1,858 positions in 2020, achieving an overall fill rate of 98.9%, 61.2% for U.S. MD seniors.
• Emergency Medicine filled 99.5% of the 2,665 positions offered this year. In this profession, the U.S. MD fill rate was 64.3%. These new interns are sorely needed at a time when EM physicians are on the front lines of a pandemic, Hannah R. Hughes, MD, president of the Emergency Medicine Residents’ Association, said in an interview.

The third Friday in March usually marks a time when medical students across the United States participate in envelope-opening ceremonies with peers and family members. This year, the ruthless onslaught of coronavirus has forced residency programs to rethink their celebrations, leveraging social media platforms and other technologies to toast Match Day in cyberspace.

In the absence of ceremonies taking place due to restrictions on mass gatherings, “we anticipate that students may be more emotional than they expect,” Hannah R. Hughes, MD, president of the Emergency Medicine Residents’ Association (EMRA) said in an interview. To support these students on their journey to residency, EMRA has launched a social media campaign, asking medical students “to share with us their envelope-opening moments – either a selfie, photo, or video – that we can share with our online networks,” Dr. Hughes said.

EMRA is also asking program coordinators to forward photos and congratulatory messages to their new residents “so that we can share them with our networks at large,” she added.

Going virtual, it seems, has become the new norm.

At the University of California, San Francisco, the medical school decided to cancel its Match Day celebration for new interns, echoing many other programs across the United States. “We always send out a welcome email and make phone calls to all of our new interns,” said Rebecca Berman, MD, director of UCSF’s internal medicine residency program, which houses 63 medicine interns and 181 residents. Traditionally, the program has hosted the celebration for current residents. That, of course, had to change this year.

Current interns like to join in the fun, “since it means their internship is rapidly coming to a close,” said Dr. Berman, who at press time was considering a virtual toast via Zoom as a possible alternative. “These are difficult times for everyone, and we are doing our best to make our residents feel united and connected while they take care of patients in the era of social distancing.”

Melissa Held, MD, associate dean of medical student affairs at the University of Connecticut’s School of Medicine, Farmington, had been planning a celebration in the school’s academic rotunda with food and champagne. “Students typically come with their family members or significant others. The dean and I usually say a few words and then at noon, students get envelopes and can open them to find out where they matched for residency,” Dr. Held said. This year, the school will be uploading Match letters to its online system. Students can remotely find out where they matched at noon. “I plan to put together a slide show of pictures and congratulatory remarks from faculty and staff that will be sent to them around 11:30 a.m.,” Dr. Held said.

Mark Miceli, EdD, who oversees Match Day for the 130-plus medical students at the University of Massachusetts Medical School, Worcester, is inviting faculty and staff to submit short videos of congratulations, which it will post on its student affairs Match Day Instagram account. Like other schools, it will share results with students in an email, said Dr. Miceli, assistant vice provost of student life. “This message will be more personalized to our school than the NRMP [National Resident Matching Program] message, and will also include links to our match stats, a map of our matched student locations, and a list of where folks matched,” he said.

Students can opt out of the list if they want to. The communications department has also provided templates for signs students can print out. “They can write in where they matched, and take pictures for social media. We are encouraging the use of various hashtags to help build a virtual community,” Dr. Miceli said.

In a state hit particularly hard by coronavirus, the University of Washington School of Medicine is spreading Match Day cheer through online meeting platforms and celebratory graphics. This five-state school, representing students from Washington, Wyoming, Alaska, Montana, and Idaho, usually hosts several events across the different states and students have their pick of which to attend, according to Sarah Wood, associate director of student affairs.

In lieu of in-person events, some states are hosting a Zoom online celebration, others are using social media networking systems. “We’re inviting everyone to take part in an online event ... where we’ll do a slide show of photos that one of our students put together,” Ms. Wood said.

Students are disappointed in this change of plans, she said. To make things more festive, Ms. Wood is adding graphics such as fireworks and photos to the emails containing the Match results. “I want this to be more exciting for them than just a basic letter,” she said.

For now, Ms. Wood is trying to focus on the Match Day celebration, but admits that “my bigger fear is if we have to cancel graduation – and what that might look like.”

The third Friday in March usually marks a time when medical students across the United States participate in envelope-opening ceremonies with peers and family members. This year, the ruthless onslaught of coronavirus has forced residency programs to rethink their celebrations, leveraging social media platforms and other technologies to toast Match Day in cyberspace.

In the absence of ceremonies taking place due to restrictions on mass gatherings, “we anticipate that students may be more emotional than they expect,” Hannah R. Hughes, MD, president of the Emergency Medicine Residents’ Association (EMRA) said in an interview. To support these students on their journey to residency, EMRA has launched a social media campaign, asking medical students “to share with us their envelope-opening moments – either a selfie, photo, or video – that we can share with our online networks,” Dr. Hughes said.

EMRA is also asking program coordinators to forward photos and congratulatory messages to their new residents “so that we can share them with our networks at large,” she added.

Going virtual, it seems, has become the new norm.

At the University of California, San Francisco, the medical school decided to cancel its Match Day celebration for new interns, echoing many other programs across the United States. “We always send out a welcome email and make phone calls to all of our new interns,” said Rebecca Berman, MD, director of UCSF’s internal medicine residency program, which houses 63 medicine interns and 181 residents. Traditionally, the program has hosted the celebration for current residents. That, of course, had to change this year.

Current interns like to join in the fun, “since it means their internship is rapidly coming to a close,” said Dr. Berman, who at press time was considering a virtual toast via Zoom as a possible alternative. “These are difficult times for everyone, and we are doing our best to make our residents feel united and connected while they take care of patients in the era of social distancing.”

Melissa Held, MD, associate dean of medical student affairs at the University of Connecticut’s School of Medicine, Farmington, had been planning a celebration in the school’s academic rotunda with food and champagne. “Students typically come with their family members or significant others. The dean and I usually say a few words and then at noon, students get envelopes and can open them to find out where they matched for residency,” Dr. Held said. This year, the school will be uploading Match letters to its online system. Students can remotely find out where they matched at noon. “I plan to put together a slide show of pictures and congratulatory remarks from faculty and staff that will be sent to them around 11:30 a.m.,” Dr. Held said.

Mark Miceli, EdD, who oversees Match Day for the 130-plus medical students at the University of Massachusetts Medical School, Worcester, is inviting faculty and staff to submit short videos of congratulations, which it will post on its student affairs Match Day Instagram account. Like other schools, it will share results with students in an email, said Dr. Miceli, assistant vice provost of student life. “This message will be more personalized to our school than the NRMP [National Resident Matching Program] message, and will also include links to our match stats, a map of our matched student locations, and a list of where folks matched,” he said.

Students can opt out of the list if they want to. The communications department has also provided templates for signs students can print out. “They can write in where they matched, and take pictures for social media. We are encouraging the use of various hashtags to help build a virtual community,” Dr. Miceli said.

In a state hit particularly hard by coronavirus, the University of Washington School of Medicine is spreading Match Day cheer through online meeting platforms and celebratory graphics. This five-state school, representing students from Washington, Wyoming, Alaska, Montana, and Idaho, usually hosts several events across the different states and students have their pick of which to attend, according to Sarah Wood, associate director of student affairs.

In lieu of in-person events, some states are hosting a Zoom online celebration, others are using social media networking systems. “We’re inviting everyone to take part in an online event ... where we’ll do a slide show of photos that one of our students put together,” Ms. Wood said.

Students are disappointed in this change of plans, she said. To make things more festive, Ms. Wood is adding graphics such as fireworks and photos to the emails containing the Match results. “I want this to be more exciting for them than just a basic letter,” she said.

For now, Ms. Wood is trying to focus on the Match Day celebration, but admits that “my bigger fear is if we have to cancel graduation – and what that might look like.”

The third Friday in March usually marks a time when medical students across the United States participate in envelope-opening ceremonies with peers and family members. This year, the ruthless onslaught of coronavirus has forced residency programs to rethink their celebrations, leveraging social media platforms and other technologies to toast Match Day in cyberspace.

In the absence of ceremonies taking place due to restrictions on mass gatherings, “we anticipate that students may be more emotional than they expect,” Hannah R. Hughes, MD, president of the Emergency Medicine Residents’ Association (EMRA) said in an interview. To support these students on their journey to residency, EMRA has launched a social media campaign, asking medical students “to share with us their envelope-opening moments – either a selfie, photo, or video – that we can share with our online networks,” Dr. Hughes said.

EMRA is also asking program coordinators to forward photos and congratulatory messages to their new residents “so that we can share them with our networks at large,” she added.

Going virtual, it seems, has become the new norm.

At the University of California, San Francisco, the medical school decided to cancel its Match Day celebration for new interns, echoing many other programs across the United States. “We always send out a welcome email and make phone calls to all of our new interns,” said Rebecca Berman, MD, director of UCSF’s internal medicine residency program, which houses 63 medicine interns and 181 residents. Traditionally, the program has hosted the celebration for current residents. That, of course, had to change this year.

Current interns like to join in the fun, “since it means their internship is rapidly coming to a close,” said Dr. Berman, who at press time was considering a virtual toast via Zoom as a possible alternative. “These are difficult times for everyone, and we are doing our best to make our residents feel united and connected while they take care of patients in the era of social distancing.”

Melissa Held, MD, associate dean of medical student affairs at the University of Connecticut’s School of Medicine, Farmington, had been planning a celebration in the school’s academic rotunda with food and champagne. “Students typically come with their family members or significant others. The dean and I usually say a few words and then at noon, students get envelopes and can open them to find out where they matched for residency,” Dr. Held said. This year, the school will be uploading Match letters to its online system. Students can remotely find out where they matched at noon. “I plan to put together a slide show of pictures and congratulatory remarks from faculty and staff that will be sent to them around 11:30 a.m.,” Dr. Held said.

Mark Miceli, EdD, who oversees Match Day for the 130-plus medical students at the University of Massachusetts Medical School, Worcester, is inviting faculty and staff to submit short videos of congratulations, which it will post on its student affairs Match Day Instagram account. Like other schools, it will share results with students in an email, said Dr. Miceli, assistant vice provost of student life. “This message will be more personalized to our school than the NRMP [National Resident Matching Program] message, and will also include links to our match stats, a map of our matched student locations, and a list of where folks matched,” he said.

Students can opt out of the list if they want to. The communications department has also provided templates for signs students can print out. “They can write in where they matched, and take pictures for social media. We are encouraging the use of various hashtags to help build a virtual community,” Dr. Miceli said.

In a state hit particularly hard by coronavirus, the University of Washington School of Medicine is spreading Match Day cheer through online meeting platforms and celebratory graphics. This five-state school, representing students from Washington, Wyoming, Alaska, Montana, and Idaho, usually hosts several events across the different states and students have their pick of which to attend, according to Sarah Wood, associate director of student affairs.

In lieu of in-person events, some states are hosting a Zoom online celebration, others are using social media networking systems. “We’re inviting everyone to take part in an online event ... where we’ll do a slide show of photos that one of our students put together,” Ms. Wood said.

Students are disappointed in this change of plans, she said. To make things more festive, Ms. Wood is adding graphics such as fireworks and photos to the emails containing the Match results. “I want this to be more exciting for them than just a basic letter,” she said.

For now, Ms. Wood is trying to focus on the Match Day celebration, but admits that “my bigger fear is if we have to cancel graduation – and what that might look like.”