Hospitalist News (Archived)

(This column is the first in a three-part series.)

Question: Which of the following statements about state medical boards is best?

A. They are made up exclusively of doctors.

B. Disciplinary actions are on the rise.

C. They investigate narrowly defined areas of clinical practice.

D. They usually end with physician suspension.

E. They are insufficiently vigilant, according to critics.

Answer: E. The 10th Amendment of the U.S. Constitution authorizes states to establish laws protecting the health, safety, and general welfare of their citizens.

All 50 states have enacted legislation under the Medical Practice Act authorizing medical boards to issue licenses and regulate physician conduct. The structure and authority of these boards vary from state to state, with some retaining all licensing and disciplinary powers, while others are more advisory in nature and report to the department of health.

Medical boards consist primarily of appointed volunteer physicians and may employ an administrative staff that includes an executive officer and support personnel.¹

State statutes, rules, and regulations govern the disciplinary function of medical boards, which receive, review, and investigate complaints directly from patients and other sources.

There are six main categories of complaints: substandard patient care, alcohol and substance abuse, fraud and other criminal conduct, dishonesty, sexual misconduct, and failure to meet CME requirements. Whether a board can sanction a physician for misconduct outside the realm of medical practice is frequently at issue.

In Maryland, for example, conduct that has merely a general or associative relationship to the physician in his or her capacity as a member of the medical profession is not sanctionable by the state board of physicians.

On the other hand, if it relates to the effective delivery of patient care, then the misconduct can be said to occur in the “practice of medicine,” even if there is no issue of the individual’s grasp of particular technical skills.

However, the term “practice of medicine” is liberally construed in most jurisdictions, and both boards and courts tend to take a dim view of physician dishonesty and lack of integrity.

For example, the California Court of Appeals in Windham v. Board of Medical Quality Assurance rejected a defendant’s position that his conviction for tax evasion was not the type of transgression that reflected on his professional standing.² Instead, the court held that such dishonesty necessarily involves moral turpitude, and is sufficiently related to the practice of medicine as to justify revocation of licensure.

The court stated that it was difficult to “compartmentalize dishonesty in such a way that a person who is willing to cheat his government out of $65,000 in taxes may yet be considered honest in his dealings with his patients.”

Likewise, the Washington Supreme Court in an older case upheld the suspension of a doctor’s license following his conviction for tax fraud.³ In taking a broad view of the requirement that improper conduct relates to the practice of medicine, the court held that conviction for tax fraud, which goes to the issue of trustworthiness, is a valid reason for taking disciplinary action against a physician.

The number of adverse actions taken by boards nationwide appears to be stabilizing. In 2009, they affected some 4,560 errant physicians. In some states, both the number of complaints and actions may even be subsiding.

For example, the 2014 report by the Texas Medical Board showed that the number of complaints had fallen 17% after reaching a peak in 2009. In 2012, the year with the latest published nationwide data, there were 9,219 total board actions affecting 4,479 physicians. However, only a minority – some 275 doctors – faced the most severe disciplinary sanction, i.e., license revocation. The others either saw their licenses denied (170) or suspended (739), or faced lesser sanctions such as reprimands, probations, restrictions, and fines.

Critics have labeled medical boards “a good old boys network” where any private admonition is never made public. A stinging report of medical licensing and discipline in the state of New York, using data from 1982 through 1989, concluded, “the structure and functioning of the process as they now exist are seriously deficient in these areas and that major reforms are urgently needed.”⁴

The consumer group Public Citizen has bemoaned the fact that most states are not living up to their obligations to protect patients from doctors who are practicing medicine in a substandard manner. Advocacy groups worry about insufficient vigilance, and cite the case of Dr. Farid Fata, an oncologist whose license was finally removed by the Michigan board in 2013 for giving chemotherapy to healthy patients. The board had received an earlier complaint from a nurse in 2010, but it took no action until federal authorities charged the doctor following a tip from a whistleblower.⁵

To be sure, there are troubling observations. For one thing, there is an inexplicably wide variability in the rates of disciplinary actions. During 2007-2009, for example, Minnesota had the lowest rate per 1,000 physicians (1.07), whereas Alaska had the highest rate of 7.89, some seven times higher. State rankings also change drastically from year to year without apparent good reason.

For another, criminal convictions for insurance fraud and violation of controlled substances prescriptions frequently end up with only mild or modest discipline.

In 1999, Public Citizen began publishing yearly rankings that purportedly showed each board’s effectiveness, based on its number of “serious actions.” The rankings were based on yearly data released by the Federation of State Medical Boards (FSMB), a national nonprofit organization that represents the 70 medical and osteopathic boards of the United States and its territories.

The federation protested the way its data were being used, but the rankings apparently caused some board executives to lose their jobs. In 2012, the FSMB stopped reporting state actions, thus ending this type of public disclosure.

To be seen as unbiased guardians of the public trust, boards now have nonphysician members, some of whom are health care attorneys. The state governor who appoints the board members is answerable to the voters for any delay or decision that permits a rogue physician to keep on practicing.

Accordingly, Michigan has instituted a process that allows it to overrule a disciplinary decision by the board, which raises an issue of due process rights. Theoretically, physicians would clear themselves in a formal hearing and be officially exonerated by the board, only to see the decision overruled by an administrative department.

Some medical boards have been accused of going too far. In Rhode Island, state legislator Rep. Michael W. Chippendale (R) is heading a commission to look into its medical board. The controversy arose from an “outlandish” and “personal” accusation against a physician in a gastroenterology group, which was forced to stop work for a week.

All the facts have not been made public, but a civil suit against the complainant is apparently in the works. The accused physician reportedly had to undergo three board-ordered psychiatric evaluations, and a fourth is pending.

Elsewhere, Oklahoma state lawmaker Rep. Richard Morrissette (D) is said to be introducing legislation limiting the powers of Oklahoma’s medical board.⁶

These are probably isolated events, however, and may not necessarily signal the development of any backlash across the country.

References

1. U.S. Medical Regulatory Trends and Actions, May 2014.

2. Windham v. Board of Medical Quality Assurance, 104 Cal. App.3d 461 (1980).

3. In Re Kindschi, 52 Wn.2d 8 (1958).

4. Post, J. “Medical Discipline and Licensing in the State of New York: A Critical Review.” Bull NY Acad Med. 1991;67:66-98.

5. “One nurse’s gutsy effort to protect patients.” Detroit News, Feb. 6, 2015.

6. “The Black Cloud of a Medical Board Investigation.” Medscape, Dec. 23, 2015.

Dr. Tan is emeritus professor of medicine and a former adjunct professor of law at the University of Hawaii. This article is meant to be educational and does not constitute medical, ethical, or legal advice. Some of the articles in this series are adapted from the author’s 2006 book, “Medical Malpractice: Understanding the Law, Managing the Risk,” and his 2012 Halsbury treatise, “Medical Negligence and Professional Misconduct.” For additional information, readers may contact the author at [email protected].

(This column is the first in a three-part series.)

Question: Which of the following statements about state medical boards is best?

A. They are made up exclusively of doctors.

B. Disciplinary actions are on the rise.

C. They investigate narrowly defined areas of clinical practice.

D. They usually end with physician suspension.

E. They are insufficiently vigilant, according to critics.

Answer: E. The 10th Amendment of the U.S. Constitution authorizes states to establish laws protecting the health, safety, and general welfare of their citizens.

All 50 states have enacted legislation under the Medical Practice Act authorizing medical boards to issue licenses and regulate physician conduct. The structure and authority of these boards vary from state to state, with some retaining all licensing and disciplinary powers, while others are more advisory in nature and report to the department of health.

Medical boards consist primarily of appointed volunteer physicians and may employ an administrative staff that includes an executive officer and support personnel.¹

State statutes, rules, and regulations govern the disciplinary function of medical boards, which receive, review, and investigate complaints directly from patients and other sources.

There are six main categories of complaints: substandard patient care, alcohol and substance abuse, fraud and other criminal conduct, dishonesty, sexual misconduct, and failure to meet CME requirements. Whether a board can sanction a physician for misconduct outside the realm of medical practice is frequently at issue.

In Maryland, for example, conduct that has merely a general or associative relationship to the physician in his or her capacity as a member of the medical profession is not sanctionable by the state board of physicians.

On the other hand, if it relates to the effective delivery of patient care, then the misconduct can be said to occur in the “practice of medicine,” even if there is no issue of the individual’s grasp of particular technical skills.

However, the term “practice of medicine” is liberally construed in most jurisdictions, and both boards and courts tend to take a dim view of physician dishonesty and lack of integrity.

For example, the California Court of Appeals in Windham v. Board of Medical Quality Assurance rejected a defendant’s position that his conviction for tax evasion was not the type of transgression that reflected on his professional standing.² Instead, the court held that such dishonesty necessarily involves moral turpitude, and is sufficiently related to the practice of medicine as to justify revocation of licensure.

The court stated that it was difficult to “compartmentalize dishonesty in such a way that a person who is willing to cheat his government out of $65,000 in taxes may yet be considered honest in his dealings with his patients.”

Likewise, the Washington Supreme Court in an older case upheld the suspension of a doctor’s license following his conviction for tax fraud.³ In taking a broad view of the requirement that improper conduct relates to the practice of medicine, the court held that conviction for tax fraud, which goes to the issue of trustworthiness, is a valid reason for taking disciplinary action against a physician.

The number of adverse actions taken by boards nationwide appears to be stabilizing. In 2009, they affected some 4,560 errant physicians. In some states, both the number of complaints and actions may even be subsiding.

For example, the 2014 report by the Texas Medical Board showed that the number of complaints had fallen 17% after reaching a peak in 2009. In 2012, the year with the latest published nationwide data, there were 9,219 total board actions affecting 4,479 physicians. However, only a minority – some 275 doctors – faced the most severe disciplinary sanction, i.e., license revocation. The others either saw their licenses denied (170) or suspended (739), or faced lesser sanctions such as reprimands, probations, restrictions, and fines.

Critics have labeled medical boards “a good old boys network” where any private admonition is never made public. A stinging report of medical licensing and discipline in the state of New York, using data from 1982 through 1989, concluded, “the structure and functioning of the process as they now exist are seriously deficient in these areas and that major reforms are urgently needed.”⁴

The consumer group Public Citizen has bemoaned the fact that most states are not living up to their obligations to protect patients from doctors who are practicing medicine in a substandard manner. Advocacy groups worry about insufficient vigilance, and cite the case of Dr. Farid Fata, an oncologist whose license was finally removed by the Michigan board in 2013 for giving chemotherapy to healthy patients. The board had received an earlier complaint from a nurse in 2010, but it took no action until federal authorities charged the doctor following a tip from a whistleblower.⁵

To be sure, there are troubling observations. For one thing, there is an inexplicably wide variability in the rates of disciplinary actions. During 2007-2009, for example, Minnesota had the lowest rate per 1,000 physicians (1.07), whereas Alaska had the highest rate of 7.89, some seven times higher. State rankings also change drastically from year to year without apparent good reason.

For another, criminal convictions for insurance fraud and violation of controlled substances prescriptions frequently end up with only mild or modest discipline.

In 1999, Public Citizen began publishing yearly rankings that purportedly showed each board’s effectiveness, based on its number of “serious actions.” The rankings were based on yearly data released by the Federation of State Medical Boards (FSMB), a national nonprofit organization that represents the 70 medical and osteopathic boards of the United States and its territories.

The federation protested the way its data were being used, but the rankings apparently caused some board executives to lose their jobs. In 2012, the FSMB stopped reporting state actions, thus ending this type of public disclosure.

To be seen as unbiased guardians of the public trust, boards now have nonphysician members, some of whom are health care attorneys. The state governor who appoints the board members is answerable to the voters for any delay or decision that permits a rogue physician to keep on practicing.

Accordingly, Michigan has instituted a process that allows it to overrule a disciplinary decision by the board, which raises an issue of due process rights. Theoretically, physicians would clear themselves in a formal hearing and be officially exonerated by the board, only to see the decision overruled by an administrative department.

Some medical boards have been accused of going too far. In Rhode Island, state legislator Rep. Michael W. Chippendale (R) is heading a commission to look into its medical board. The controversy arose from an “outlandish” and “personal” accusation against a physician in a gastroenterology group, which was forced to stop work for a week.

All the facts have not been made public, but a civil suit against the complainant is apparently in the works. The accused physician reportedly had to undergo three board-ordered psychiatric evaluations, and a fourth is pending.

Elsewhere, Oklahoma state lawmaker Rep. Richard Morrissette (D) is said to be introducing legislation limiting the powers of Oklahoma’s medical board.⁶

These are probably isolated events, however, and may not necessarily signal the development of any backlash across the country.

References

1. U.S. Medical Regulatory Trends and Actions, May 2014.

2. Windham v. Board of Medical Quality Assurance, 104 Cal. App.3d 461 (1980).

3. In Re Kindschi, 52 Wn.2d 8 (1958).

4. Post, J. “Medical Discipline and Licensing in the State of New York: A Critical Review.” Bull NY Acad Med. 1991;67:66-98.

5. “One nurse’s gutsy effort to protect patients.” Detroit News, Feb. 6, 2015.

6. “The Black Cloud of a Medical Board Investigation.” Medscape, Dec. 23, 2015.

Dr. Tan is emeritus professor of medicine and a former adjunct professor of law at the University of Hawaii. This article is meant to be educational and does not constitute medical, ethical, or legal advice. Some of the articles in this series are adapted from the author’s 2006 book, “Medical Malpractice: Understanding the Law, Managing the Risk,” and his 2012 Halsbury treatise, “Medical Negligence and Professional Misconduct.” For additional information, readers may contact the author at [email protected].

(This column is the first in a three-part series.)

Question: Which of the following statements about state medical boards is best?

A. They are made up exclusively of doctors.

B. Disciplinary actions are on the rise.

C. They investigate narrowly defined areas of clinical practice.

D. They usually end with physician suspension.

E. They are insufficiently vigilant, according to critics.

Answer: E. The 10th Amendment of the U.S. Constitution authorizes states to establish laws protecting the health, safety, and general welfare of their citizens.

All 50 states have enacted legislation under the Medical Practice Act authorizing medical boards to issue licenses and regulate physician conduct. The structure and authority of these boards vary from state to state, with some retaining all licensing and disciplinary powers, while others are more advisory in nature and report to the department of health.

Medical boards consist primarily of appointed volunteer physicians and may employ an administrative staff that includes an executive officer and support personnel.¹

State statutes, rules, and regulations govern the disciplinary function of medical boards, which receive, review, and investigate complaints directly from patients and other sources.

There are six main categories of complaints: substandard patient care, alcohol and substance abuse, fraud and other criminal conduct, dishonesty, sexual misconduct, and failure to meet CME requirements. Whether a board can sanction a physician for misconduct outside the realm of medical practice is frequently at issue.

In Maryland, for example, conduct that has merely a general or associative relationship to the physician in his or her capacity as a member of the medical profession is not sanctionable by the state board of physicians.

On the other hand, if it relates to the effective delivery of patient care, then the misconduct can be said to occur in the “practice of medicine,” even if there is no issue of the individual’s grasp of particular technical skills.

However, the term “practice of medicine” is liberally construed in most jurisdictions, and both boards and courts tend to take a dim view of physician dishonesty and lack of integrity.

For example, the California Court of Appeals in Windham v. Board of Medical Quality Assurance rejected a defendant’s position that his conviction for tax evasion was not the type of transgression that reflected on his professional standing.² Instead, the court held that such dishonesty necessarily involves moral turpitude, and is sufficiently related to the practice of medicine as to justify revocation of licensure.

The court stated that it was difficult to “compartmentalize dishonesty in such a way that a person who is willing to cheat his government out of $65,000 in taxes may yet be considered honest in his dealings with his patients.”

Likewise, the Washington Supreme Court in an older case upheld the suspension of a doctor’s license following his conviction for tax fraud.³ In taking a broad view of the requirement that improper conduct relates to the practice of medicine, the court held that conviction for tax fraud, which goes to the issue of trustworthiness, is a valid reason for taking disciplinary action against a physician.

The number of adverse actions taken by boards nationwide appears to be stabilizing. In 2009, they affected some 4,560 errant physicians. In some states, both the number of complaints and actions may even be subsiding.

For example, the 2014 report by the Texas Medical Board showed that the number of complaints had fallen 17% after reaching a peak in 2009. In 2012, the year with the latest published nationwide data, there were 9,219 total board actions affecting 4,479 physicians. However, only a minority – some 275 doctors – faced the most severe disciplinary sanction, i.e., license revocation. The others either saw their licenses denied (170) or suspended (739), or faced lesser sanctions such as reprimands, probations, restrictions, and fines.

Critics have labeled medical boards “a good old boys network” where any private admonition is never made public. A stinging report of medical licensing and discipline in the state of New York, using data from 1982 through 1989, concluded, “the structure and functioning of the process as they now exist are seriously deficient in these areas and that major reforms are urgently needed.”⁴

The consumer group Public Citizen has bemoaned the fact that most states are not living up to their obligations to protect patients from doctors who are practicing medicine in a substandard manner. Advocacy groups worry about insufficient vigilance, and cite the case of Dr. Farid Fata, an oncologist whose license was finally removed by the Michigan board in 2013 for giving chemotherapy to healthy patients. The board had received an earlier complaint from a nurse in 2010, but it took no action until federal authorities charged the doctor following a tip from a whistleblower.⁵

To be sure, there are troubling observations. For one thing, there is an inexplicably wide variability in the rates of disciplinary actions. During 2007-2009, for example, Minnesota had the lowest rate per 1,000 physicians (1.07), whereas Alaska had the highest rate of 7.89, some seven times higher. State rankings also change drastically from year to year without apparent good reason.

For another, criminal convictions for insurance fraud and violation of controlled substances prescriptions frequently end up with only mild or modest discipline.

In 1999, Public Citizen began publishing yearly rankings that purportedly showed each board’s effectiveness, based on its number of “serious actions.” The rankings were based on yearly data released by the Federation of State Medical Boards (FSMB), a national nonprofit organization that represents the 70 medical and osteopathic boards of the United States and its territories.

The federation protested the way its data were being used, but the rankings apparently caused some board executives to lose their jobs. In 2012, the FSMB stopped reporting state actions, thus ending this type of public disclosure.

To be seen as unbiased guardians of the public trust, boards now have nonphysician members, some of whom are health care attorneys. The state governor who appoints the board members is answerable to the voters for any delay or decision that permits a rogue physician to keep on practicing.

Accordingly, Michigan has instituted a process that allows it to overrule a disciplinary decision by the board, which raises an issue of due process rights. Theoretically, physicians would clear themselves in a formal hearing and be officially exonerated by the board, only to see the decision overruled by an administrative department.

Some medical boards have been accused of going too far. In Rhode Island, state legislator Rep. Michael W. Chippendale (R) is heading a commission to look into its medical board. The controversy arose from an “outlandish” and “personal” accusation against a physician in a gastroenterology group, which was forced to stop work for a week.

All the facts have not been made public, but a civil suit against the complainant is apparently in the works. The accused physician reportedly had to undergo three board-ordered psychiatric evaluations, and a fourth is pending.

Elsewhere, Oklahoma state lawmaker Rep. Richard Morrissette (D) is said to be introducing legislation limiting the powers of Oklahoma’s medical board.⁶

These are probably isolated events, however, and may not necessarily signal the development of any backlash across the country.

References

1. U.S. Medical Regulatory Trends and Actions, May 2014.

2. Windham v. Board of Medical Quality Assurance, 104 Cal. App.3d 461 (1980).

3. In Re Kindschi, 52 Wn.2d 8 (1958).

4. Post, J. “Medical Discipline and Licensing in the State of New York: A Critical Review.” Bull NY Acad Med. 1991;67:66-98.

5. “One nurse’s gutsy effort to protect patients.” Detroit News, Feb. 6, 2015.

6. “The Black Cloud of a Medical Board Investigation.” Medscape, Dec. 23, 2015.

Dr. Tan is emeritus professor of medicine and a former adjunct professor of law at the University of Hawaii. This article is meant to be educational and does not constitute medical, ethical, or legal advice. Some of the articles in this series are adapted from the author’s 2006 book, “Medical Malpractice: Understanding the Law, Managing the Risk,” and his 2012 Halsbury treatise, “Medical Negligence and Professional Misconduct.” For additional information, readers may contact the author at [email protected].

Some of the Affordable Care Act’s insurance marketplaces are in turmoil as the fourth open enrollment season approaches this fall, but what’s ahead for consumers very much depends on where they live.

Competition on these exchanges will be diminished next year when three of the nation’s largest health insurers – Aetna, UnitedHealthcare and Humana – will sell individual plans in many fewer markets. So too will several Blue Cross and Blue Shield plans in various states. That’s on top of the 16 nonprofit co-ops that have closed since January 2015.

The announcements, however, apply generally only to the individual market. The much larger market of employer-sponsored insurance is not part of the health law exchanges.

Aetna’s exit announcement Aug. 15 that blamed financial losses on its marketplace plans gave Obamacare opponents who have from the start predicted the ACA’s failure a fresh chance to proclaim “I told you so.”

That story line got more complicated Aug. 17 after the Huffington Post reported that Aetna CEO Mark Bertolini sent a letter to the Department of Justice (DOJ) on July 5 threatening to withdraw from the Obamacare marketplaces if the DOJ sued to block his company’s planned merger with Humana. The DOJ did just that a couple weeks later.

But most marketplace consumers won’t see any ill effects from insurers’ withdrawals, according to ACA advocates and independent experts.

“The effect on consumers is going to be mixed around the country,” said Katherine Hempstead, PhD, a senior adviser at the nonpartisan Robert Wood Johnson Foundation. “Most of these marketplaces are not dependent on” the large national carriers.

Many major metropolitan areas, such as those in California, New York, and Texas, will still have several insurers for individual health insurance consumers to choose from. In Texas, all major metro areas – including Austin, Dallas, Houston, and San Antonio – will have at least three insurers after Aetna and UnitedHealthcare exit.

That’s true also for most urban exchange customers living in the Northwest, the Midwest, and New England.

Most hurt will be marketplace consumers in Arizona, North and South Carolina, Georgia, and parts of Florida, where only one or two insurers will be left when open enrollment season begins Nov. 15.

Remaining insurers might raise their monthly premiums as a result, but more than eight in 10 consumers on the marketplaces who get government subsidies would be insulated. Subsidies increase as premiums rise.

Still, health experts worry that with less competition, insurers may tighten their provider networks and give these consumers fewer choices of hospitals and doctors. That trend started several years ago, and some states have responded with regulations requiring insurers to provide customers with reasonable access to doctors and hospitals in each county where they sell plans.

Nearly 13 million people signed up for Obamacare marketplace policies for 2016. Aetna, UnitedHealthcare, and Humana have 2 million members in total, but their exit from certain states is predicted to affect between 1 million and 1.5 million people who will have to choose new carriers.

While changing plans can force people to find new doctors, it’s also the best way for consumers get the best deals on coverage.

Aetna will exit 11 of 15 states where it sells plans on the exchanges. UnitedHealthcare has said it will quit 22 of 34 states, and Humana will leave 4 of the 15 states where it operates.

In late May, the Kaiser Family Foundation estimated the number of rural counties at risk of having one insurer on the exchanges would triple in 2017. That was before Humana and Aetna detailed their plans. (KHN is an editorially independent project of the foundation.)

Now, “we could be looking at about one in four counties in the U.S. with just one exchange insurer next year, though this could change between now and open enrollment in November,” said Cynthia Cox, associate director for the Kaiser Family Foundation Program for the Study of Health Reform and Private Insurance.

Overshadowed by the big insurers’ withdrawals is the prospect that other carriers will enter markets the three giants are leaving. Smaller insurers Molina and Centene have said they’re doing fine on the exchanges. And Cigna, a larger insurer, has said it will move into some North Carolina counties for 2017.

North Carolina will be left with just one or two plans in most of the state after it loses UnitedHealthcare and Aetna plans. Health insurance experts say three insurers are needed for a healthy competitive market.

“We’ve had a very robust enrollment under the ACA and hope consumers will still see benefits of having coverage even if they have fewer options,” said Ciara Zachary, health policy analyst for the North Carolina Justice Center’s Health Access Coalition.

Rural Americans had few health insurers to choose from even before Obamacare, but some suburban and urban parts of the Southeast will be in the same fix next year. In southeast Florida, consumers in counties near Naples and Fort Myers will have only one marketplace insurer – Florida Blue – next year, unless other insurers step in.

“There are some headwinds, but it’s not a question of whether the market will stabilize but how quickly and how well,” said Dr. Hempstead.

Strong winds are already blowing toward Arizona’s Pinal County, southeast of Phoenix, health care advocates say. Nearly 10,000 people enrolled in Obamacare marketplace policies this year and about 85% received a federal subsidy.

In 2017, Pinal stands to lose its only two insurers – UnitedHealthcare and Blue Cross and Blue Shield of Arizona.

“Clearly this is a big concern for consumers,” said Allen Gjersvig, director of navigator and enrollment services for the Arizona Alliance for Community Health Centers. He said he is hopeful, but not confident, that another insurer will step in.

Neighboring Maricopa County, which includes Phoenix, is expected to have just two relatively small insurers left on its marketplace next year. Mr. Gjersvig said that he questions whether those two – Cigna and Phoenix Health Plan – will have enough doctors and hospitals under contract to handle their new members after larger rival Blue Cross and Blue Shield of Arizona gives up its 40,000 customers.

At least a dozen other counties in Arizona will be left with just one health insurer, he said.

Arizona had eight insurers operating in various parts of the state this year, but four are leaving entirely – Aetna, UnitedHealthcare, Humana, and Health Choice. Two more, Blue Cross Blue Shield and Health Net, are scaling back their participation.

Despite the problems with the marketplaces, Mr. Gjersvig said thousands of people have gained coverage through them and he is confident they will survive.

“We do not see this as a death knell for the marketplace,” he said.

Tammie King, an insurance agent in Columbia, S.C., is less sure how insurer departures will affect consumers in the Palmetto State. Pullouts by UnitedHealthcare and Aetna mean only one carrier in the state in 2017 – Blue Cross and Blue Shield of South Carolina.

That’s a concern in Columbia, S.C., because the Blue Cross plan does not include one of the biggest hospitals, Lexington Medical Center, and its affiliated physicians, she said.

“People will be left unable to see the doctors they are now using,” she added.

Ms. King said she worried the Blue Cross plan will use its monopoly power to further reduce the number of doctors and hospitals in its network and limit its choice of prescription drugs. “You can’t blame them because … they have to do something to control costs,” she said.

This story appears courtesy of Kaiser Health News, a national health policy news service that is part of the nonpartisan Henry J. Kaiser Family Foundation.

Some of the Affordable Care Act’s insurance marketplaces are in turmoil as the fourth open enrollment season approaches this fall, but what’s ahead for consumers very much depends on where they live.

Competition on these exchanges will be diminished next year when three of the nation’s largest health insurers – Aetna, UnitedHealthcare and Humana – will sell individual plans in many fewer markets. So too will several Blue Cross and Blue Shield plans in various states. That’s on top of the 16 nonprofit co-ops that have closed since January 2015.

The announcements, however, apply generally only to the individual market. The much larger market of employer-sponsored insurance is not part of the health law exchanges.

Aetna’s exit announcement Aug. 15 that blamed financial losses on its marketplace plans gave Obamacare opponents who have from the start predicted the ACA’s failure a fresh chance to proclaim “I told you so.”

That story line got more complicated Aug. 17 after the Huffington Post reported that Aetna CEO Mark Bertolini sent a letter to the Department of Justice (DOJ) on July 5 threatening to withdraw from the Obamacare marketplaces if the DOJ sued to block his company’s planned merger with Humana. The DOJ did just that a couple weeks later.

But most marketplace consumers won’t see any ill effects from insurers’ withdrawals, according to ACA advocates and independent experts.

“The effect on consumers is going to be mixed around the country,” said Katherine Hempstead, PhD, a senior adviser at the nonpartisan Robert Wood Johnson Foundation. “Most of these marketplaces are not dependent on” the large national carriers.

Many major metropolitan areas, such as those in California, New York, and Texas, will still have several insurers for individual health insurance consumers to choose from. In Texas, all major metro areas – including Austin, Dallas, Houston, and San Antonio – will have at least three insurers after Aetna and UnitedHealthcare exit.

That’s true also for most urban exchange customers living in the Northwest, the Midwest, and New England.

Most hurt will be marketplace consumers in Arizona, North and South Carolina, Georgia, and parts of Florida, where only one or two insurers will be left when open enrollment season begins Nov. 15.

Remaining insurers might raise their monthly premiums as a result, but more than eight in 10 consumers on the marketplaces who get government subsidies would be insulated. Subsidies increase as premiums rise.

Still, health experts worry that with less competition, insurers may tighten their provider networks and give these consumers fewer choices of hospitals and doctors. That trend started several years ago, and some states have responded with regulations requiring insurers to provide customers with reasonable access to doctors and hospitals in each county where they sell plans.

Nearly 13 million people signed up for Obamacare marketplace policies for 2016. Aetna, UnitedHealthcare, and Humana have 2 million members in total, but their exit from certain states is predicted to affect between 1 million and 1.5 million people who will have to choose new carriers.

While changing plans can force people to find new doctors, it’s also the best way for consumers get the best deals on coverage.

Aetna will exit 11 of 15 states where it sells plans on the exchanges. UnitedHealthcare has said it will quit 22 of 34 states, and Humana will leave 4 of the 15 states where it operates.

In late May, the Kaiser Family Foundation estimated the number of rural counties at risk of having one insurer on the exchanges would triple in 2017. That was before Humana and Aetna detailed their plans. (KHN is an editorially independent project of the foundation.)

Now, “we could be looking at about one in four counties in the U.S. with just one exchange insurer next year, though this could change between now and open enrollment in November,” said Cynthia Cox, associate director for the Kaiser Family Foundation Program for the Study of Health Reform and Private Insurance.

Overshadowed by the big insurers’ withdrawals is the prospect that other carriers will enter markets the three giants are leaving. Smaller insurers Molina and Centene have said they’re doing fine on the exchanges. And Cigna, a larger insurer, has said it will move into some North Carolina counties for 2017.

North Carolina will be left with just one or two plans in most of the state after it loses UnitedHealthcare and Aetna plans. Health insurance experts say three insurers are needed for a healthy competitive market.

“We’ve had a very robust enrollment under the ACA and hope consumers will still see benefits of having coverage even if they have fewer options,” said Ciara Zachary, health policy analyst for the North Carolina Justice Center’s Health Access Coalition.

Rural Americans had few health insurers to choose from even before Obamacare, but some suburban and urban parts of the Southeast will be in the same fix next year. In southeast Florida, consumers in counties near Naples and Fort Myers will have only one marketplace insurer – Florida Blue – next year, unless other insurers step in.

“There are some headwinds, but it’s not a question of whether the market will stabilize but how quickly and how well,” said Dr. Hempstead.

Strong winds are already blowing toward Arizona’s Pinal County, southeast of Phoenix, health care advocates say. Nearly 10,000 people enrolled in Obamacare marketplace policies this year and about 85% received a federal subsidy.

In 2017, Pinal stands to lose its only two insurers – UnitedHealthcare and Blue Cross and Blue Shield of Arizona.

“Clearly this is a big concern for consumers,” said Allen Gjersvig, director of navigator and enrollment services for the Arizona Alliance for Community Health Centers. He said he is hopeful, but not confident, that another insurer will step in.

Neighboring Maricopa County, which includes Phoenix, is expected to have just two relatively small insurers left on its marketplace next year. Mr. Gjersvig said that he questions whether those two – Cigna and Phoenix Health Plan – will have enough doctors and hospitals under contract to handle their new members after larger rival Blue Cross and Blue Shield of Arizona gives up its 40,000 customers.

At least a dozen other counties in Arizona will be left with just one health insurer, he said.

Arizona had eight insurers operating in various parts of the state this year, but four are leaving entirely – Aetna, UnitedHealthcare, Humana, and Health Choice. Two more, Blue Cross Blue Shield and Health Net, are scaling back their participation.

Despite the problems with the marketplaces, Mr. Gjersvig said thousands of people have gained coverage through them and he is confident they will survive.

“We do not see this as a death knell for the marketplace,” he said.

Tammie King, an insurance agent in Columbia, S.C., is less sure how insurer departures will affect consumers in the Palmetto State. Pullouts by UnitedHealthcare and Aetna mean only one carrier in the state in 2017 – Blue Cross and Blue Shield of South Carolina.

That’s a concern in Columbia, S.C., because the Blue Cross plan does not include one of the biggest hospitals, Lexington Medical Center, and its affiliated physicians, she said.

“People will be left unable to see the doctors they are now using,” she added.

Ms. King said she worried the Blue Cross plan will use its monopoly power to further reduce the number of doctors and hospitals in its network and limit its choice of prescription drugs. “You can’t blame them because … they have to do something to control costs,” she said.

This story appears courtesy of Kaiser Health News, a national health policy news service that is part of the nonpartisan Henry J. Kaiser Family Foundation.

Some of the Affordable Care Act’s insurance marketplaces are in turmoil as the fourth open enrollment season approaches this fall, but what’s ahead for consumers very much depends on where they live.

Competition on these exchanges will be diminished next year when three of the nation’s largest health insurers – Aetna, UnitedHealthcare and Humana – will sell individual plans in many fewer markets. So too will several Blue Cross and Blue Shield plans in various states. That’s on top of the 16 nonprofit co-ops that have closed since January 2015.

The announcements, however, apply generally only to the individual market. The much larger market of employer-sponsored insurance is not part of the health law exchanges.

Aetna’s exit announcement Aug. 15 that blamed financial losses on its marketplace plans gave Obamacare opponents who have from the start predicted the ACA’s failure a fresh chance to proclaim “I told you so.”

That story line got more complicated Aug. 17 after the Huffington Post reported that Aetna CEO Mark Bertolini sent a letter to the Department of Justice (DOJ) on July 5 threatening to withdraw from the Obamacare marketplaces if the DOJ sued to block his company’s planned merger with Humana. The DOJ did just that a couple weeks later.

But most marketplace consumers won’t see any ill effects from insurers’ withdrawals, according to ACA advocates and independent experts.

“The effect on consumers is going to be mixed around the country,” said Katherine Hempstead, PhD, a senior adviser at the nonpartisan Robert Wood Johnson Foundation. “Most of these marketplaces are not dependent on” the large national carriers.

Many major metropolitan areas, such as those in California, New York, and Texas, will still have several insurers for individual health insurance consumers to choose from. In Texas, all major metro areas – including Austin, Dallas, Houston, and San Antonio – will have at least three insurers after Aetna and UnitedHealthcare exit.

That’s true also for most urban exchange customers living in the Northwest, the Midwest, and New England.

Most hurt will be marketplace consumers in Arizona, North and South Carolina, Georgia, and parts of Florida, where only one or two insurers will be left when open enrollment season begins Nov. 15.

Remaining insurers might raise their monthly premiums as a result, but more than eight in 10 consumers on the marketplaces who get government subsidies would be insulated. Subsidies increase as premiums rise.

Still, health experts worry that with less competition, insurers may tighten their provider networks and give these consumers fewer choices of hospitals and doctors. That trend started several years ago, and some states have responded with regulations requiring insurers to provide customers with reasonable access to doctors and hospitals in each county where they sell plans.

Nearly 13 million people signed up for Obamacare marketplace policies for 2016. Aetna, UnitedHealthcare, and Humana have 2 million members in total, but their exit from certain states is predicted to affect between 1 million and 1.5 million people who will have to choose new carriers.

While changing plans can force people to find new doctors, it’s also the best way for consumers get the best deals on coverage.

Aetna will exit 11 of 15 states where it sells plans on the exchanges. UnitedHealthcare has said it will quit 22 of 34 states, and Humana will leave 4 of the 15 states where it operates.

In late May, the Kaiser Family Foundation estimated the number of rural counties at risk of having one insurer on the exchanges would triple in 2017. That was before Humana and Aetna detailed their plans. (KHN is an editorially independent project of the foundation.)

Now, “we could be looking at about one in four counties in the U.S. with just one exchange insurer next year, though this could change between now and open enrollment in November,” said Cynthia Cox, associate director for the Kaiser Family Foundation Program for the Study of Health Reform and Private Insurance.

Overshadowed by the big insurers’ withdrawals is the prospect that other carriers will enter markets the three giants are leaving. Smaller insurers Molina and Centene have said they’re doing fine on the exchanges. And Cigna, a larger insurer, has said it will move into some North Carolina counties for 2017.

North Carolina will be left with just one or two plans in most of the state after it loses UnitedHealthcare and Aetna plans. Health insurance experts say three insurers are needed for a healthy competitive market.

“We’ve had a very robust enrollment under the ACA and hope consumers will still see benefits of having coverage even if they have fewer options,” said Ciara Zachary, health policy analyst for the North Carolina Justice Center’s Health Access Coalition.

Rural Americans had few health insurers to choose from even before Obamacare, but some suburban and urban parts of the Southeast will be in the same fix next year. In southeast Florida, consumers in counties near Naples and Fort Myers will have only one marketplace insurer – Florida Blue – next year, unless other insurers step in.

“There are some headwinds, but it’s not a question of whether the market will stabilize but how quickly and how well,” said Dr. Hempstead.

Strong winds are already blowing toward Arizona’s Pinal County, southeast of Phoenix, health care advocates say. Nearly 10,000 people enrolled in Obamacare marketplace policies this year and about 85% received a federal subsidy.

In 2017, Pinal stands to lose its only two insurers – UnitedHealthcare and Blue Cross and Blue Shield of Arizona.

“Clearly this is a big concern for consumers,” said Allen Gjersvig, director of navigator and enrollment services for the Arizona Alliance for Community Health Centers. He said he is hopeful, but not confident, that another insurer will step in.

Neighboring Maricopa County, which includes Phoenix, is expected to have just two relatively small insurers left on its marketplace next year. Mr. Gjersvig said that he questions whether those two – Cigna and Phoenix Health Plan – will have enough doctors and hospitals under contract to handle their new members after larger rival Blue Cross and Blue Shield of Arizona gives up its 40,000 customers.

At least a dozen other counties in Arizona will be left with just one health insurer, he said.

Arizona had eight insurers operating in various parts of the state this year, but four are leaving entirely – Aetna, UnitedHealthcare, Humana, and Health Choice. Two more, Blue Cross Blue Shield and Health Net, are scaling back their participation.

Despite the problems with the marketplaces, Mr. Gjersvig said thousands of people have gained coverage through them and he is confident they will survive.

“We do not see this as a death knell for the marketplace,” he said.

Tammie King, an insurance agent in Columbia, S.C., is less sure how insurer departures will affect consumers in the Palmetto State. Pullouts by UnitedHealthcare and Aetna mean only one carrier in the state in 2017 – Blue Cross and Blue Shield of South Carolina.

That’s a concern in Columbia, S.C., because the Blue Cross plan does not include one of the biggest hospitals, Lexington Medical Center, and its affiliated physicians, she said.

“People will be left unable to see the doctors they are now using,” she added.

Ms. King said she worried the Blue Cross plan will use its monopoly power to further reduce the number of doctors and hospitals in its network and limit its choice of prescription drugs. “You can’t blame them because … they have to do something to control costs,” she said.

This story appears courtesy of Kaiser Health News, a national health policy news service that is part of the nonpartisan Henry J. Kaiser Family Foundation.

DENVER – Evidence continues to mount that ankylosing spondylitis patients are at increased risk for developing various comorbidities, compared with the general adult population.

Patients newly diagnosed with ankylosing spondylitis (AS) had twice the rate of new-onset depression during the first 3 years following diagnosis, compared with matched people from the general population in a study of more than 21,000 American adults. Patients with newly diagnosed AS also had a 60% higher rate of developing a new cardiovascular disease, compared with the matched general population, Jessica A. Walsh, MD, said at the annual meeting of the Spondyloarthritis Research and Treatment Network.

Mitchel L. Zoler/Frontine Medical News

“We need to figure out what to do about all the comorbidities. Rheumatologists need to either screen their AS patients for comorbidities, or they need to be sure their patients are plugged in with another physician who will screen them,” said Dr. Walsh, director of the spondyloarthritis clinic at the University of Utah in Salt Lake City.

Her analysis used data from the Truven Health MarketScan databases for U.S. patients covered by Medicare or commercial health insurance, and included 6,370 patients with newly diagnosed AS and 14,988 adults matched by age and sex. The analysis only included AS patients who were free from comorbidities during the 2 years prior to their AS diagnosis. The average age of the people in the study was 52 years, and 54% were men.

During an average follow-up of 2.9 years following initial AS diagnosis, the most common comorbidity among the AS patients was uveitis, which occurred nearly 15-fold more frequently among the AS patients than in the controls. Other common incident comorbidities included inflammatory bowel disease, nearly sixfold more common among the AS patients, and osteoporosis, which was nearly threefold more common during follow-up after AS diagnosis, compared with the controls.

Other comorbidities with increased incidence in the AS patients included sleep apnea (80% more common among the AS patients during follow-up), asthma (50% more often), hypertension (44% more common), malignancy (23% more common), diabetes (20% more common), and dyslipidemia (11% more common). All these incidence rates represented statistically significant increases in the AS patients, compared with the controls.

A related analysis reported by Dr. Walsh also used data from the Truven Health databases for a somewhat larger group of AS patients, 6,679 followed for 1 year after their AS diagnosis, and 19,951 matched controls. The AS patients had a significantly higher rate of hospital admissions – 12%, compared with 6% among the controls – and a significantly higher rate of emergency department visits, at 23%, compared with 15% among the controls. The AS patients also had double the rate of physician office visits and prescribed medications.

“Obviously, the AS patients are not as healthy,” Dr. Walsh said in an interview. “We adjusted for their comorbidities, but that did not affect the hospitalization rates. We need to look into this more; I don’t know why the AS patients are being hospitalized. Typically AS itself does not lead to hospitalization, so I suspect it’s because of comorbidities, or perhaps because of adverse events from treatment.”

Dr. Walsh is a consultant to AbbVie and Novartis.

[email protected]

On Twitter @mitchelzoler

DENVER – Evidence continues to mount that ankylosing spondylitis patients are at increased risk for developing various comorbidities, compared with the general adult population.

Patients newly diagnosed with ankylosing spondylitis (AS) had twice the rate of new-onset depression during the first 3 years following diagnosis, compared with matched people from the general population in a study of more than 21,000 American adults. Patients with newly diagnosed AS also had a 60% higher rate of developing a new cardiovascular disease, compared with the matched general population, Jessica A. Walsh, MD, said at the annual meeting of the Spondyloarthritis Research and Treatment Network.

Mitchel L. Zoler/Frontine Medical News

“We need to figure out what to do about all the comorbidities. Rheumatologists need to either screen their AS patients for comorbidities, or they need to be sure their patients are plugged in with another physician who will screen them,” said Dr. Walsh, director of the spondyloarthritis clinic at the University of Utah in Salt Lake City.

Her analysis used data from the Truven Health MarketScan databases for U.S. patients covered by Medicare or commercial health insurance, and included 6,370 patients with newly diagnosed AS and 14,988 adults matched by age and sex. The analysis only included AS patients who were free from comorbidities during the 2 years prior to their AS diagnosis. The average age of the people in the study was 52 years, and 54% were men.

During an average follow-up of 2.9 years following initial AS diagnosis, the most common comorbidity among the AS patients was uveitis, which occurred nearly 15-fold more frequently among the AS patients than in the controls. Other common incident comorbidities included inflammatory bowel disease, nearly sixfold more common among the AS patients, and osteoporosis, which was nearly threefold more common during follow-up after AS diagnosis, compared with the controls.

Other comorbidities with increased incidence in the AS patients included sleep apnea (80% more common among the AS patients during follow-up), asthma (50% more often), hypertension (44% more common), malignancy (23% more common), diabetes (20% more common), and dyslipidemia (11% more common). All these incidence rates represented statistically significant increases in the AS patients, compared with the controls.

A related analysis reported by Dr. Walsh also used data from the Truven Health databases for a somewhat larger group of AS patients, 6,679 followed for 1 year after their AS diagnosis, and 19,951 matched controls. The AS patients had a significantly higher rate of hospital admissions – 12%, compared with 6% among the controls – and a significantly higher rate of emergency department visits, at 23%, compared with 15% among the controls. The AS patients also had double the rate of physician office visits and prescribed medications.

“Obviously, the AS patients are not as healthy,” Dr. Walsh said in an interview. “We adjusted for their comorbidities, but that did not affect the hospitalization rates. We need to look into this more; I don’t know why the AS patients are being hospitalized. Typically AS itself does not lead to hospitalization, so I suspect it’s because of comorbidities, or perhaps because of adverse events from treatment.”

Dr. Walsh is a consultant to AbbVie and Novartis.

[email protected]

On Twitter @mitchelzoler

DENVER – Evidence continues to mount that ankylosing spondylitis patients are at increased risk for developing various comorbidities, compared with the general adult population.

Patients newly diagnosed with ankylosing spondylitis (AS) had twice the rate of new-onset depression during the first 3 years following diagnosis, compared with matched people from the general population in a study of more than 21,000 American adults. Patients with newly diagnosed AS also had a 60% higher rate of developing a new cardiovascular disease, compared with the matched general population, Jessica A. Walsh, MD, said at the annual meeting of the Spondyloarthritis Research and Treatment Network.

Mitchel L. Zoler/Frontine Medical News

“We need to figure out what to do about all the comorbidities. Rheumatologists need to either screen their AS patients for comorbidities, or they need to be sure their patients are plugged in with another physician who will screen them,” said Dr. Walsh, director of the spondyloarthritis clinic at the University of Utah in Salt Lake City.

Her analysis used data from the Truven Health MarketScan databases for U.S. patients covered by Medicare or commercial health insurance, and included 6,370 patients with newly diagnosed AS and 14,988 adults matched by age and sex. The analysis only included AS patients who were free from comorbidities during the 2 years prior to their AS diagnosis. The average age of the people in the study was 52 years, and 54% were men.

During an average follow-up of 2.9 years following initial AS diagnosis, the most common comorbidity among the AS patients was uveitis, which occurred nearly 15-fold more frequently among the AS patients than in the controls. Other common incident comorbidities included inflammatory bowel disease, nearly sixfold more common among the AS patients, and osteoporosis, which was nearly threefold more common during follow-up after AS diagnosis, compared with the controls.

Other comorbidities with increased incidence in the AS patients included sleep apnea (80% more common among the AS patients during follow-up), asthma (50% more often), hypertension (44% more common), malignancy (23% more common), diabetes (20% more common), and dyslipidemia (11% more common). All these incidence rates represented statistically significant increases in the AS patients, compared with the controls.

A related analysis reported by Dr. Walsh also used data from the Truven Health databases for a somewhat larger group of AS patients, 6,679 followed for 1 year after their AS diagnosis, and 19,951 matched controls. The AS patients had a significantly higher rate of hospital admissions – 12%, compared with 6% among the controls – and a significantly higher rate of emergency department visits, at 23%, compared with 15% among the controls. The AS patients also had double the rate of physician office visits and prescribed medications.

“Obviously, the AS patients are not as healthy,” Dr. Walsh said in an interview. “We adjusted for their comorbidities, but that did not affect the hospitalization rates. We need to look into this more; I don’t know why the AS patients are being hospitalized. Typically AS itself does not lead to hospitalization, so I suspect it’s because of comorbidities, or perhaps because of adverse events from treatment.”

Dr. Walsh is a consultant to AbbVie and Novartis.

[email protected]

On Twitter @mitchelzoler

Influenza-attributable mortality was significantly greater in children with influenza B, compared with influenza A, investigators found.

Among those with influenza B, patients aged 10-16 years were most likely to require ICU admission, suggesting this subpopulation may be a target for immunization programs.

©PhotoEuphoria/Thinkstock

The percentage of clinical cases attributed to influenza B range from less than 1% to 44%, according to data published by the Centers for Disease Control and Prevention. However, influenza B is considered less virulent and less capable of causing pandemics and has therefore been less studied and outcomes of its disease less characterized, Dat Tran, MD, MSc, of the Hospital for Sick Children in Canada and his associates reported (Pediatrics. 2016 August. doi: 10.1542/peds.2015-4643).

The purpose of this study was to further understand the prevalence and severity of influenza B cases in comparison with influenza A and to identify pediatric subpopulations most at risk for contracting influenza B.

Children aged 16 years or younger hospitalized from laboratory-confirmed influenza A or B from September 2004 to June 2013 (excluding the pandemic year 2009-2010) were identified through active surveillance of admissions at the 12 pediatric referral centers of the Canadian Immunization Monitoring Program Active (IMPACT), a national surveillance initiative. Information regarding demographics, health status, vaccination status, presenting signs and symptoms, illness severity and mortality, treatment regimens, and ICU admission were collected and analyzed.

Of 4,155 influenza-related admissions during this time period, influenza B accounted for 1,510 (36.3%) cases and influenza A accounted for 2,645 (63.7%) cases.

Children admitted with influenza B tended to be older with a median age 3.9 years (interquartile range, 1.4-7.2), compared with a median of 2 years (IQR, 0.6-4.8 years) for children admitted with influenza A.

Children admitted with influenza B, compared with influenza A, had higher odds of having a vaccine-indicated condition (odds ratio, 1.30; 95% confidence interval, 1.14-1.47) and lower odds of having no underlying medical condition (OR, 0.80; 95% CI, 0.71-0.91), Dr. Tran and his associates reported.

“Compared with influenza A cases, children admitted with influenza B had greater adjusted odds of presenting with headache, abdominal pain, and myalgia, ranging from 1.38 for abdominal pain to 3.19 for myalgia,” they added. “There were no significant differences in antiviral or antibiotic prescription or use between influenza A and B cases.”

There was no significant difference in the proportion of influenza A or B patients admitted to the ICU (12.7% vs. 12.6%). Rather, multivariate modeling identified age and presence of an underlying condition as independent predictors of ICU admission.

Finally, influenza-attributable mortality was significantly greater in children with influenza B (adjusted OR, 2.65; 95% CI, 1.18-5.94). Influenza-attributable mortality occurred in 16 (1.1%) children with influenza B and only 10 (0.4%) children with influenza A. All-cause mortality followed a similar trend.

“Among hospitalized children, influenza A and B infections resulted in similar morbidity while mortality was greater for influenza B disease. Among healthy children hospitalized with influenza B, those aged 10-16 years were most likely to require ICU admission,” the investigators summarized.

“These children should be considered at high risk for complicated influenza B infection and be specifically targeted by immunization programs to receive influenza vaccination, and in particular, a [quadrivalent influenza vaccine],” they recommended.

This study was funded by GlaxoSmithKline Biologicals SA. The Canadian Immunization Monitoring Program Active is funded by the Public Health Agency of Canada. The investigators reported having no relevant disclosures.

Influenza-attributable mortality was significantly greater in children with influenza B, compared with influenza A, investigators found.

Among those with influenza B, patients aged 10-16 years were most likely to require ICU admission, suggesting this subpopulation may be a target for immunization programs.

©PhotoEuphoria/Thinkstock

The percentage of clinical cases attributed to influenza B range from less than 1% to 44%, according to data published by the Centers for Disease Control and Prevention. However, influenza B is considered less virulent and less capable of causing pandemics and has therefore been less studied and outcomes of its disease less characterized, Dat Tran, MD, MSc, of the Hospital for Sick Children in Canada and his associates reported (Pediatrics. 2016 August. doi: 10.1542/peds.2015-4643).

The purpose of this study was to further understand the prevalence and severity of influenza B cases in comparison with influenza A and to identify pediatric subpopulations most at risk for contracting influenza B.

Children aged 16 years or younger hospitalized from laboratory-confirmed influenza A or B from September 2004 to June 2013 (excluding the pandemic year 2009-2010) were identified through active surveillance of admissions at the 12 pediatric referral centers of the Canadian Immunization Monitoring Program Active (IMPACT), a national surveillance initiative. Information regarding demographics, health status, vaccination status, presenting signs and symptoms, illness severity and mortality, treatment regimens, and ICU admission were collected and analyzed.

Of 4,155 influenza-related admissions during this time period, influenza B accounted for 1,510 (36.3%) cases and influenza A accounted for 2,645 (63.7%) cases.

Children admitted with influenza B tended to be older with a median age 3.9 years (interquartile range, 1.4-7.2), compared with a median of 2 years (IQR, 0.6-4.8 years) for children admitted with influenza A.

Children admitted with influenza B, compared with influenza A, had higher odds of having a vaccine-indicated condition (odds ratio, 1.30; 95% confidence interval, 1.14-1.47) and lower odds of having no underlying medical condition (OR, 0.80; 95% CI, 0.71-0.91), Dr. Tran and his associates reported.

“Compared with influenza A cases, children admitted with influenza B had greater adjusted odds of presenting with headache, abdominal pain, and myalgia, ranging from 1.38 for abdominal pain to 3.19 for myalgia,” they added. “There were no significant differences in antiviral or antibiotic prescription or use between influenza A and B cases.”

There was no significant difference in the proportion of influenza A or B patients admitted to the ICU (12.7% vs. 12.6%). Rather, multivariate modeling identified age and presence of an underlying condition as independent predictors of ICU admission.

Finally, influenza-attributable mortality was significantly greater in children with influenza B (adjusted OR, 2.65; 95% CI, 1.18-5.94). Influenza-attributable mortality occurred in 16 (1.1%) children with influenza B and only 10 (0.4%) children with influenza A. All-cause mortality followed a similar trend.

“Among hospitalized children, influenza A and B infections resulted in similar morbidity while mortality was greater for influenza B disease. Among healthy children hospitalized with influenza B, those aged 10-16 years were most likely to require ICU admission,” the investigators summarized.

“These children should be considered at high risk for complicated influenza B infection and be specifically targeted by immunization programs to receive influenza vaccination, and in particular, a [quadrivalent influenza vaccine],” they recommended.

This study was funded by GlaxoSmithKline Biologicals SA. The Canadian Immunization Monitoring Program Active is funded by the Public Health Agency of Canada. The investigators reported having no relevant disclosures.

Influenza-attributable mortality was significantly greater in children with influenza B, compared with influenza A, investigators found.

Among those with influenza B, patients aged 10-16 years were most likely to require ICU admission, suggesting this subpopulation may be a target for immunization programs.

©PhotoEuphoria/Thinkstock

The percentage of clinical cases attributed to influenza B range from less than 1% to 44%, according to data published by the Centers for Disease Control and Prevention. However, influenza B is considered less virulent and less capable of causing pandemics and has therefore been less studied and outcomes of its disease less characterized, Dat Tran, MD, MSc, of the Hospital for Sick Children in Canada and his associates reported (Pediatrics. 2016 August. doi: 10.1542/peds.2015-4643).

The purpose of this study was to further understand the prevalence and severity of influenza B cases in comparison with influenza A and to identify pediatric subpopulations most at risk for contracting influenza B.

Children aged 16 years or younger hospitalized from laboratory-confirmed influenza A or B from September 2004 to June 2013 (excluding the pandemic year 2009-2010) were identified through active surveillance of admissions at the 12 pediatric referral centers of the Canadian Immunization Monitoring Program Active (IMPACT), a national surveillance initiative. Information regarding demographics, health status, vaccination status, presenting signs and symptoms, illness severity and mortality, treatment regimens, and ICU admission were collected and analyzed.

Of 4,155 influenza-related admissions during this time period, influenza B accounted for 1,510 (36.3%) cases and influenza A accounted for 2,645 (63.7%) cases.

Children admitted with influenza B tended to be older with a median age 3.9 years (interquartile range, 1.4-7.2), compared with a median of 2 years (IQR, 0.6-4.8 years) for children admitted with influenza A.

Children admitted with influenza B, compared with influenza A, had higher odds of having a vaccine-indicated condition (odds ratio, 1.30; 95% confidence interval, 1.14-1.47) and lower odds of having no underlying medical condition (OR, 0.80; 95% CI, 0.71-0.91), Dr. Tran and his associates reported.

“Compared with influenza A cases, children admitted with influenza B had greater adjusted odds of presenting with headache, abdominal pain, and myalgia, ranging from 1.38 for abdominal pain to 3.19 for myalgia,” they added. “There were no significant differences in antiviral or antibiotic prescription or use between influenza A and B cases.”

There was no significant difference in the proportion of influenza A or B patients admitted to the ICU (12.7% vs. 12.6%). Rather, multivariate modeling identified age and presence of an underlying condition as independent predictors of ICU admission.

Finally, influenza-attributable mortality was significantly greater in children with influenza B (adjusted OR, 2.65; 95% CI, 1.18-5.94). Influenza-attributable mortality occurred in 16 (1.1%) children with influenza B and only 10 (0.4%) children with influenza A. All-cause mortality followed a similar trend.

“Among hospitalized children, influenza A and B infections resulted in similar morbidity while mortality was greater for influenza B disease. Among healthy children hospitalized with influenza B, those aged 10-16 years were most likely to require ICU admission,” the investigators summarized.

“These children should be considered at high risk for complicated influenza B infection and be specifically targeted by immunization programs to receive influenza vaccination, and in particular, a [quadrivalent influenza vaccine],” they recommended.

This study was funded by GlaxoSmithKline Biologicals SA. The Canadian Immunization Monitoring Program Active is funded by the Public Health Agency of Canada. The investigators reported having no relevant disclosures.

The Meaningful Use (MU) program as doctors know it may soon be ending, but audits of past attestations are slated to continue for at least the next 6 years.

Experts offer the following guidance on how to successfully manage audits and subsequent appeals.

1. Expect an audit.

Assume that at some point, you will be audited, said Joshua J. Freemire, a health law attorney based in Baltimore who specializes in regulatory compliance matters.

“Have good procedures in place to ensure the audit is brought to the attention of management and responded to promptly,” Mr. Freemire said in an interview. “Similarly, it is important that practices understand, in advance, how information created by their EHR is stored and managed.”

Audits are not limited to the current or most recent year, he noted. Being able to promptly access the appropriate information is an important part of drafting appropriate responses.

2. Save records

Keep all relevant records electronically for at least 6 years after attestation, advised Carmiña Nitzki, a senior consultant with GE Healthcare Camden Group.

Some documentation, such as your security risk analysis, should be maintained in paper form, she added. It is also helpful to take screen shots of certain measures that address the functionality of your system.

Records should follow when a physician moves a practice or changes employment. Ms. Nitzki recently assisted a case in which an early adopter physician dissolved his practice, became employed, and moved offices. His 2011 attestation was later audited, and he did not have all of the requested information. The doctor came to Ms. Nitzki after failing an audit and being assessed an $18,000 recoupment payment. Together, they were able to recreate and locate much of the necessary records through old emails and past documentation.

“We won the appeal,” said Ms. Nitzki, who spoke about meaningful use audits at a recent American Bar Association meeting. “The takeaway is if you’re going to respond to an audit, make sure you understand everything that they’re asking for and that you’re confident that you’re responding with all of the appropriate documentation,” she said.

3. Meet deadlines

Promptly responding to audits and quickly addressing failed audits are critical, Mr. Freemire said.

“The [MU] program is very strict with regard to deadlines, and an appeal cannot be filed once the applicable deadline has passed,” he said.

Mr. Freemire said that he routinely encounters health providers who have missed deadlines or let too much time lapse after being contacted by the government. Failure to meet deadlines can result from various reasons, including that notices are not promptly brought to the physician’s attention, delays investigating the availability of requested materials, or a false assumption that the requested information is readily at hand, he said.

Ensure that all audit deadlines are recorded and work with staff and leadership to file responses on time. Factor in additional time if there could be difficulty in locating records, experts stressed.

“I see difficulty in effectively responding to audits where records are simply not maintained,” he said. “Again, this can happen for many reasons, including personnel turnover, but it can be difficult or impossible to effectively respond to audit requests” in this situation.

4. Appeal effectively

Swiftly and thoroughly appeal a failed audit.

When a doctor fails an audit, it’s usually because of incomplete responses or missing information, Ms. Nitzki said. Only those measures that were rejected or that failed to meet standards need to be addressed during an appeal. Sending a cover letter to CMS with the appeal, explaining why the doctor may have failed initially can strengthen the case, she said.

“The appeals process is done directly with CMS, so they’re a little more reasonable,” she said. “They tend to look at things on broader scale.”

Don’t wait to appeal, Mr. Freemire said. Practices have 30 days from the date of an adverse audit determination letter to submit an appeal. If time runs out, physicians must pay back any money requested by auditors, and CMS expects the recoupment in full.

“Following a negative decision, the most important step is prompt attention,” he said. “The sooner that process begins, the sooner it can be completed. The time line for audit appeals is not generous and providers need to ensure they react promptly to a negative finding.”

5. Get help

Ms. Nitzki recommends that physicians obtain professional assistance when responding to an audit.

Practices can hire a consulting company or find audit resources from their specialty society or state medical association. The American Academy of Family Physicians provides a tip sheet on responding to audits. Some state organizations, such as the Texas Medical Association, offer a helpline for doctors to call and ask questions related to meaningful use.

“Unless they have a very savvy person in their office who has taken care all of their meaningful use attestations and documentation, we recommend they get help because it’s in the details where they could fail,” she said.

Seeking help after a failed audit is also essential, notes Mr. Freemire. Experts who are familiar with the program and its requirements and procedures can be of great assistance when it comes organizing the facts into a persuasive argument, he said.

“A cost/benefit is necessary – as it is with all service providers,” he said. “But a provider’s chances for a successful appeal are increased when that appeal is prepared by someone who understands the history and intention behind program requirements, who can best identify and present the necessary evidence of compliance, and who can make a compelling argument as to the provider’s satisfaction of program requirements.”

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On Twitter @legal_med

The Meaningful Use (MU) program as doctors know it may soon be ending, but audits of past attestations are slated to continue for at least the next 6 years.

Experts offer the following guidance on how to successfully manage audits and subsequent appeals.

1. Expect an audit.

Assume that at some point, you will be audited, said Joshua J. Freemire, a health law attorney based in Baltimore who specializes in regulatory compliance matters.

“Have good procedures in place to ensure the audit is brought to the attention of management and responded to promptly,” Mr. Freemire said in an interview. “Similarly, it is important that practices understand, in advance, how information created by their EHR is stored and managed.”

Audits are not limited to the current or most recent year, he noted. Being able to promptly access the appropriate information is an important part of drafting appropriate responses.

2. Save records

Keep all relevant records electronically for at least 6 years after attestation, advised Carmiña Nitzki, a senior consultant with GE Healthcare Camden Group.

Some documentation, such as your security risk analysis, should be maintained in paper form, she added. It is also helpful to take screen shots of certain measures that address the functionality of your system.

Records should follow when a physician moves a practice or changes employment. Ms. Nitzki recently assisted a case in which an early adopter physician dissolved his practice, became employed, and moved offices. His 2011 attestation was later audited, and he did not have all of the requested information. The doctor came to Ms. Nitzki after failing an audit and being assessed an $18,000 recoupment payment. Together, they were able to recreate and locate much of the necessary records through old emails and past documentation.

“We won the appeal,” said Ms. Nitzki, who spoke about meaningful use audits at a recent American Bar Association meeting. “The takeaway is if you’re going to respond to an audit, make sure you understand everything that they’re asking for and that you’re confident that you’re responding with all of the appropriate documentation,” she said.

3. Meet deadlines

Promptly responding to audits and quickly addressing failed audits are critical, Mr. Freemire said.

“The [MU] program is very strict with regard to deadlines, and an appeal cannot be filed once the applicable deadline has passed,” he said.

Mr. Freemire said that he routinely encounters health providers who have missed deadlines or let too much time lapse after being contacted by the government. Failure to meet deadlines can result from various reasons, including that notices are not promptly brought to the physician’s attention, delays investigating the availability of requested materials, or a false assumption that the requested information is readily at hand, he said.

Ensure that all audit deadlines are recorded and work with staff and leadership to file responses on time. Factor in additional time if there could be difficulty in locating records, experts stressed.

“I see difficulty in effectively responding to audits where records are simply not maintained,” he said. “Again, this can happen for many reasons, including personnel turnover, but it can be difficult or impossible to effectively respond to audit requests” in this situation.

4. Appeal effectively

Swiftly and thoroughly appeal a failed audit.

When a doctor fails an audit, it’s usually because of incomplete responses or missing information, Ms. Nitzki said. Only those measures that were rejected or that failed to meet standards need to be addressed during an appeal. Sending a cover letter to CMS with the appeal, explaining why the doctor may have failed initially can strengthen the case, she said.

“The appeals process is done directly with CMS, so they’re a little more reasonable,” she said. “They tend to look at things on broader scale.”

Don’t wait to appeal, Mr. Freemire said. Practices have 30 days from the date of an adverse audit determination letter to submit an appeal. If time runs out, physicians must pay back any money requested by auditors, and CMS expects the recoupment in full.

“Following a negative decision, the most important step is prompt attention,” he said. “The sooner that process begins, the sooner it can be completed. The time line for audit appeals is not generous and providers need to ensure they react promptly to a negative finding.”

5. Get help

Ms. Nitzki recommends that physicians obtain professional assistance when responding to an audit.

Practices can hire a consulting company or find audit resources from their specialty society or state medical association. The American Academy of Family Physicians provides a tip sheet on responding to audits. Some state organizations, such as the Texas Medical Association, offer a helpline for doctors to call and ask questions related to meaningful use.

“Unless they have a very savvy person in their office who has taken care all of their meaningful use attestations and documentation, we recommend they get help because it’s in the details where they could fail,” she said.

Seeking help after a failed audit is also essential, notes Mr. Freemire. Experts who are familiar with the program and its requirements and procedures can be of great assistance when it comes organizing the facts into a persuasive argument, he said.

“A cost/benefit is necessary – as it is with all service providers,” he said. “But a provider’s chances for a successful appeal are increased when that appeal is prepared by someone who understands the history and intention behind program requirements, who can best identify and present the necessary evidence of compliance, and who can make a compelling argument as to the provider’s satisfaction of program requirements.”

[email protected]

On Twitter @legal_med

The Meaningful Use (MU) program as doctors know it may soon be ending, but audits of past attestations are slated to continue for at least the next 6 years.

Experts offer the following guidance on how to successfully manage audits and subsequent appeals.

1. Expect an audit.

Assume that at some point, you will be audited, said Joshua J. Freemire, a health law attorney based in Baltimore who specializes in regulatory compliance matters.

“Have good procedures in place to ensure the audit is brought to the attention of management and responded to promptly,” Mr. Freemire said in an interview. “Similarly, it is important that practices understand, in advance, how information created by their EHR is stored and managed.”

Audits are not limited to the current or most recent year, he noted. Being able to promptly access the appropriate information is an important part of drafting appropriate responses.

2. Save records

Keep all relevant records electronically for at least 6 years after attestation, advised Carmiña Nitzki, a senior consultant with GE Healthcare Camden Group.

Some documentation, such as your security risk analysis, should be maintained in paper form, she added. It is also helpful to take screen shots of certain measures that address the functionality of your system.

Records should follow when a physician moves a practice or changes employment. Ms. Nitzki recently assisted a case in which an early adopter physician dissolved his practice, became employed, and moved offices. His 2011 attestation was later audited, and he did not have all of the requested information. The doctor came to Ms. Nitzki after failing an audit and being assessed an $18,000 recoupment payment. Together, they were able to recreate and locate much of the necessary records through old emails and past documentation.

“We won the appeal,” said Ms. Nitzki, who spoke about meaningful use audits at a recent American Bar Association meeting. “The takeaway is if you’re going to respond to an audit, make sure you understand everything that they’re asking for and that you’re confident that you’re responding with all of the appropriate documentation,” she said.

3. Meet deadlines

Promptly responding to audits and quickly addressing failed audits are critical, Mr. Freemire said.

“The [MU] program is very strict with regard to deadlines, and an appeal cannot be filed once the applicable deadline has passed,” he said.

Mr. Freemire said that he routinely encounters health providers who have missed deadlines or let too much time lapse after being contacted by the government. Failure to meet deadlines can result from various reasons, including that notices are not promptly brought to the physician’s attention, delays investigating the availability of requested materials, or a false assumption that the requested information is readily at hand, he said.

Ensure that all audit deadlines are recorded and work with staff and leadership to file responses on time. Factor in additional time if there could be difficulty in locating records, experts stressed.

“I see difficulty in effectively responding to audits where records are simply not maintained,” he said. “Again, this can happen for many reasons, including personnel turnover, but it can be difficult or impossible to effectively respond to audit requests” in this situation.

4. Appeal effectively

Swiftly and thoroughly appeal a failed audit.

When a doctor fails an audit, it’s usually because of incomplete responses or missing information, Ms. Nitzki said. Only those measures that were rejected or that failed to meet standards need to be addressed during an appeal. Sending a cover letter to CMS with the appeal, explaining why the doctor may have failed initially can strengthen the case, she said.

“The appeals process is done directly with CMS, so they’re a little more reasonable,” she said. “They tend to look at things on broader scale.”

Don’t wait to appeal, Mr. Freemire said. Practices have 30 days from the date of an adverse audit determination letter to submit an appeal. If time runs out, physicians must pay back any money requested by auditors, and CMS expects the recoupment in full.

“Following a negative decision, the most important step is prompt attention,” he said. “The sooner that process begins, the sooner it can be completed. The time line for audit appeals is not generous and providers need to ensure they react promptly to a negative finding.”

5. Get help

Ms. Nitzki recommends that physicians obtain professional assistance when responding to an audit.

Practices can hire a consulting company or find audit resources from their specialty society or state medical association. The American Academy of Family Physicians provides a tip sheet on responding to audits. Some state organizations, such as the Texas Medical Association, offer a helpline for doctors to call and ask questions related to meaningful use.

“Unless they have a very savvy person in their office who has taken care all of their meaningful use attestations and documentation, we recommend they get help because it’s in the details where they could fail,” she said.

Seeking help after a failed audit is also essential, notes Mr. Freemire. Experts who are familiar with the program and its requirements and procedures can be of great assistance when it comes organizing the facts into a persuasive argument, he said.

“A cost/benefit is necessary – as it is with all service providers,” he said. “But a provider’s chances for a successful appeal are increased when that appeal is prepared by someone who understands the history and intention behind program requirements, who can best identify and present the necessary evidence of compliance, and who can make a compelling argument as to the provider’s satisfaction of program requirements.”

[email protected]

On Twitter @legal_med

Angina is underrecognized by cardiologists in clinic visits, compared with assessments made by the patients themselves, suggesting that a standard screening tool be used to improve accuracy.

Researchers conducted a survey of 1,257 patients and their 155 doctors at 25 cardiology outpatient practices in 19 states. All patients had documented coronary artery disease and completed the Seattle Angina Questionnaire (SAQ) before their office visits to assess angina symptoms and frequency. Right after they left, their cardiologists estimated and recorded their idea of how often their patients had heart pain and what their symptoms were.

Patient and physician estimates didn’t match: 411 patients (33%) reported at least one bout of angina in the previous month, but their physicians estimated a frequency of 14% (173 patients). Heart failure patients were more than three times as likely to have their angina underestimated, and patients who reported a single bout of angina per month were about 70% less likely than those who reported daily or weekly attacks.

Years in practice and the number of angina patients in the case load didn’t seem to make a difference. Patient demographics, atypical symptoms, and comorbidities besides heart failure didn’t either. “Some physicians were much better at recognizing the frequency of patients’ angina,” said lead investigator Suzanne Arnold, MD, a cardiologist at Saint Luke’s Mid America Heart Institute in Kansas City, Mo., and her associates.

“Evaluation of angina is subject to limitations inherent in history taking, including pre-existing biases and time constraints on the part of physicians and patients. ... Under-recognition of angina by physicians may result in under treatment with revascularization or medications that could improve patients’ quality of life,” and it wastes healthcare dollars, they said.

The team concluded that angina needs to be assessed directly from patients with a standardized survey like the Seattle Angina Questionnaire (SAQ). “We still routinely depend solely on an unstructured interview instead of directly asking patients using standardized assessments,” the investigators noted. “A more systematic approach is needed for eliciting a history and assessing angina in patients with coronary artery disease to appropriately guide further testing and treatment. ... The use of a validated, patient-centered tool for eliciting patients’ angina, such as the SAQ, should be tested in routine clinical care to see if it improves angina recognition, treatment, and outcomes,” the study team said (Circ Cardiovasc Qual Outcomes. 2016 AUG 16;doi: 10.1161/CIRCOUTCOMES.116.002781).

Patients in the study were, on average, 69 years old, and the majority were white men. About 40% reported previous myocardial infarctions, and more than half were stented. Well over three quarters were on beta-blockers for angina.

The senior investigator, John Spertus, MD, holds a copyright on the SAQ used in the study. Gilead Sciences funded the work. Investigators reported ties to Gilead, Abbvie, Genentech, Glumetrics, Maquet, Sanofi, AstraZeneca, Edwards Life Sciences, Roche, St. Jude Medical, Regeneron, Lilly, and ZS Pharma.

[email protected]

Angina is underrecognized by cardiologists in clinic visits, compared with assessments made by the patients themselves, suggesting that a standard screening tool be used to improve accuracy.

Researchers conducted a survey of 1,257 patients and their 155 doctors at 25 cardiology outpatient practices in 19 states. All patients had documented coronary artery disease and completed the Seattle Angina Questionnaire (SAQ) before their office visits to assess angina symptoms and frequency. Right after they left, their cardiologists estimated and recorded their idea of how often their patients had heart pain and what their symptoms were.

Patient and physician estimates didn’t match: 411 patients (33%) reported at least one bout of angina in the previous month, but their physicians estimated a frequency of 14% (173 patients). Heart failure patients were more than three times as likely to have their angina underestimated, and patients who reported a single bout of angina per month were about 70% less likely than those who reported daily or weekly attacks.

Years in practice and the number of angina patients in the case load didn’t seem to make a difference. Patient demographics, atypical symptoms, and comorbidities besides heart failure didn’t either. “Some physicians were much better at recognizing the frequency of patients’ angina,” said lead investigator Suzanne Arnold, MD, a cardiologist at Saint Luke’s Mid America Heart Institute in Kansas City, Mo., and her associates.

“Evaluation of angina is subject to limitations inherent in history taking, including pre-existing biases and time constraints on the part of physicians and patients. ... Under-recognition of angina by physicians may result in under treatment with revascularization or medications that could improve patients’ quality of life,” and it wastes healthcare dollars, they said.

The team concluded that angina needs to be assessed directly from patients with a standardized survey like the Seattle Angina Questionnaire (SAQ). “We still routinely depend solely on an unstructured interview instead of directly asking patients using standardized assessments,” the investigators noted. “A more systematic approach is needed for eliciting a history and assessing angina in patients with coronary artery disease to appropriately guide further testing and treatment. ... The use of a validated, patient-centered tool for eliciting patients’ angina, such as the SAQ, should be tested in routine clinical care to see if it improves angina recognition, treatment, and outcomes,” the study team said (Circ Cardiovasc Qual Outcomes. 2016 AUG 16;doi: 10.1161/CIRCOUTCOMES.116.002781).

Patients in the study were, on average, 69 years old, and the majority were white men. About 40% reported previous myocardial infarctions, and more than half were stented. Well over three quarters were on beta-blockers for angina.

The senior investigator, John Spertus, MD, holds a copyright on the SAQ used in the study. Gilead Sciences funded the work. Investigators reported ties to Gilead, Abbvie, Genentech, Glumetrics, Maquet, Sanofi, AstraZeneca, Edwards Life Sciences, Roche, St. Jude Medical, Regeneron, Lilly, and ZS Pharma.

[email protected]

Angina is underrecognized by cardiologists in clinic visits, compared with assessments made by the patients themselves, suggesting that a standard screening tool be used to improve accuracy.

Researchers conducted a survey of 1,257 patients and their 155 doctors at 25 cardiology outpatient practices in 19 states. All patients had documented coronary artery disease and completed the Seattle Angina Questionnaire (SAQ) before their office visits to assess angina symptoms and frequency. Right after they left, their cardiologists estimated and recorded their idea of how often their patients had heart pain and what their symptoms were.

Patient and physician estimates didn’t match: 411 patients (33%) reported at least one bout of angina in the previous month, but their physicians estimated a frequency of 14% (173 patients). Heart failure patients were more than three times as likely to have their angina underestimated, and patients who reported a single bout of angina per month were about 70% less likely than those who reported daily or weekly attacks.

Years in practice and the number of angina patients in the case load didn’t seem to make a difference. Patient demographics, atypical symptoms, and comorbidities besides heart failure didn’t either. “Some physicians were much better at recognizing the frequency of patients’ angina,” said lead investigator Suzanne Arnold, MD, a cardiologist at Saint Luke’s Mid America Heart Institute in Kansas City, Mo., and her associates.

“Evaluation of angina is subject to limitations inherent in history taking, including pre-existing biases and time constraints on the part of physicians and patients. ... Under-recognition of angina by physicians may result in under treatment with revascularization or medications that could improve patients’ quality of life,” and it wastes healthcare dollars, they said.

The team concluded that angina needs to be assessed directly from patients with a standardized survey like the Seattle Angina Questionnaire (SAQ). “We still routinely depend solely on an unstructured interview instead of directly asking patients using standardized assessments,” the investigators noted. “A more systematic approach is needed for eliciting a history and assessing angina in patients with coronary artery disease to appropriately guide further testing and treatment. ... The use of a validated, patient-centered tool for eliciting patients’ angina, such as the SAQ, should be tested in routine clinical care to see if it improves angina recognition, treatment, and outcomes,” the study team said (Circ Cardiovasc Qual Outcomes. 2016 AUG 16;doi: 10.1161/CIRCOUTCOMES.116.002781).

Patients in the study were, on average, 69 years old, and the majority were white men. About 40% reported previous myocardial infarctions, and more than half were stented. Well over three quarters were on beta-blockers for angina.

The senior investigator, John Spertus, MD, holds a copyright on the SAQ used in the study. Gilead Sciences funded the work. Investigators reported ties to Gilead, Abbvie, Genentech, Glumetrics, Maquet, Sanofi, AstraZeneca, Edwards Life Sciences, Roche, St. Jude Medical, Regeneron, Lilly, and ZS Pharma.

[email protected]

The FBI is raising concerns that language in the Interstate Medical Licensure Compact violates federal regulations over criminal background checks. The government pushback could mean implementation delays of telemedicine legislation that 17 states have enacted.

In a letter to the Minnesota Bureau of Criminal Apprehension, an FBI attorney wrote that the state’s compact law does not meet federal rules that allow the sharing of information with states for purposes of criminal background checks. In addition, no federal statutory authority exists for the FBI to share criminal files with a “private” entity such as the interstate commission, wrote Christopher B. Chaney, an attorney in the FBI Office of the General Counsel in Clarksburg, W.Va. The FBI sent a letter expressing the same concerns to the Montana Department of Justice regarding Montana’s compact law.

The Minnesota Board of Medical Practice has requested that the FBI reverse its findings, writing in an Aug. 3 letter that the agency does not appear to fully understand how the compact works. The board is scheduled to begin issuing licenses via the compact in January 2017, said Ruth Martinez, the board’s executive director.

“We believe it’s an erroneous conclusion that they’ve drawn,” Ms. Martinez said in an interview. “We are very actively engaged in rule-writing and in preparing technology and so forth to be ready to issue licenses, and we feel very confident that this determination will be overturned.”

The Montana Board of Medical Examiners meanwhile is aware of the FBI’s letter and is closely monitoring the situation in Minnesota before taking action, said Ian Marquand, executive officer for the Montana Board of Medical Examiners.

“We are still digesting this and are anxious to see what happens with the Minnesota situation,” Mr. Marquand said in an interview. “That may provide the road map.”

The Interstate Medical Licensure Compact is aimed at making it easier for telemedicine physicians to gain licenses in multiple states. Under the model legislation, developed by the Federation of State Medical Boards (FSMB), physicians designate a member state as the state of principal licensure and select the other states in which they wish to be licensed. The state of principal licensure then verifies the physician’s eligibility and provides credential information to the interstate commission, which collects applicable fees and transmits the doctor’s information to the other states. Upon receipt in the additional states, the physician would be granted a license.

In July 2015, the U.S. Health Resources and Services Administration awarded the FSMB a grant to support establishment of the commission and aid with the compact’s infrastructure.

There is nothing unique about Minnesota’s compact law, Ms. Martinez said. The statute is based on the same model legislation that passed in 16 other states. She believes that Minnesota’s law is merely one of the first to be reviewed by the FBI. Both Minnesota and Montana officials had requested that their respective state departments of justice determine if the compact laws met public law standards pertaining to criminal history records.

Ms. Martinez said that she hopes that the board’s letter to the FBI will help explain how the compact process works and prevent further federal rejections in other jurisdictions. She notes for example that the FBI incorrectly characterizes the interstate commission as a “private” entity in its letter, when the commission is a corporate body and a joint agency of the member states. The FBI also misunderstands how the commission interacts with the individual state licensing boards and the process of licensure, according to the board’s reply letter. It is not the commission that will be using FBI data, but the member states that will be utilizing the information in the course of verification, writes Rick Masters, special counsel to the National Center for Interstate Compacts.

The Federation of State Medical Boards is closely watching the matter and supports the Minnesota Board of Medical Practice, said Lisa A. Robin FSMB’s chief advocacy officer.

“The FSMB, along with the Council of State Governments (CSG), agrees with and supports the Minnesota board’s position in this matter,” Ms. Robin said in an emailed statement. “The compact’s statutory language does not alter state-based responsibility for the administration of criminal background checks, nor does it seek to extend this responsibility beyond individual state medical boards.”

At press time, the FBI’s Mr. Chaney had not responded to a message seeking comment.

[email protected]

On Twitter @legal_med

The FBI is raising concerns that language in the Interstate Medical Licensure Compact violates federal regulations over criminal background checks. The government pushback could mean implementation delays of telemedicine legislation that 17 states have enacted.

In a letter to the Minnesota Bureau of Criminal Apprehension, an FBI attorney wrote that the state’s compact law does not meet federal rules that allow the sharing of information with states for purposes of criminal background checks. In addition, no federal statutory authority exists for the FBI to share criminal files with a “private” entity such as the interstate commission, wrote Christopher B. Chaney, an attorney in the FBI Office of the General Counsel in Clarksburg, W.Va. The FBI sent a letter expressing the same concerns to the Montana Department of Justice regarding Montana’s compact law.

The Minnesota Board of Medical Practice has requested that the FBI reverse its findings, writing in an Aug. 3 letter that the agency does not appear to fully understand how the compact works. The board is scheduled to begin issuing licenses via the compact in January 2017, said Ruth Martinez, the board’s executive director.

“We believe it’s an erroneous conclusion that they’ve drawn,” Ms. Martinez said in an interview. “We are very actively engaged in rule-writing and in preparing technology and so forth to be ready to issue licenses, and we feel very confident that this determination will be overturned.”

The Montana Board of Medical Examiners meanwhile is aware of the FBI’s letter and is closely monitoring the situation in Minnesota before taking action, said Ian Marquand, executive officer for the Montana Board of Medical Examiners.

“We are still digesting this and are anxious to see what happens with the Minnesota situation,” Mr. Marquand said in an interview. “That may provide the road map.”

The Interstate Medical Licensure Compact is aimed at making it easier for telemedicine physicians to gain licenses in multiple states. Under the model legislation, developed by the Federation of State Medical Boards (FSMB), physicians designate a member state as the state of principal licensure and select the other states in which they wish to be licensed. The state of principal licensure then verifies the physician’s eligibility and provides credential information to the interstate commission, which collects applicable fees and transmits the doctor’s information to the other states. Upon receipt in the additional states, the physician would be granted a license.

In July 2015, the U.S. Health Resources and Services Administration awarded the FSMB a grant to support establishment of the commission and aid with the compact’s infrastructure.

There is nothing unique about Minnesota’s compact law, Ms. Martinez said. The statute is based on the same model legislation that passed in 16 other states. She believes that Minnesota’s law is merely one of the first to be reviewed by the FBI. Both Minnesota and Montana officials had requested that their respective state departments of justice determine if the compact laws met public law standards pertaining to criminal history records.

Ms. Martinez said that she hopes that the board’s letter to the FBI will help explain how the compact process works and prevent further federal rejections in other jurisdictions. She notes for example that the FBI incorrectly characterizes the interstate commission as a “private” entity in its letter, when the commission is a corporate body and a joint agency of the member states. The FBI also misunderstands how the commission interacts with the individual state licensing boards and the process of licensure, according to the board’s reply letter. It is not the commission that will be using FBI data, but the member states that will be utilizing the information in the course of verification, writes Rick Masters, special counsel to the National Center for Interstate Compacts.

The Federation of State Medical Boards is closely watching the matter and supports the Minnesota Board of Medical Practice, said Lisa A. Robin FSMB’s chief advocacy officer.

“The FSMB, along with the Council of State Governments (CSG), agrees with and supports the Minnesota board’s position in this matter,” Ms. Robin said in an emailed statement. “The compact’s statutory language does not alter state-based responsibility for the administration of criminal background checks, nor does it seek to extend this responsibility beyond individual state medical boards.”

At press time, the FBI’s Mr. Chaney had not responded to a message seeking comment.

[email protected]

On Twitter @legal_med

The FBI is raising concerns that language in the Interstate Medical Licensure Compact violates federal regulations over criminal background checks. The government pushback could mean implementation delays of telemedicine legislation that 17 states have enacted.

In a letter to the Minnesota Bureau of Criminal Apprehension, an FBI attorney wrote that the state’s compact law does not meet federal rules that allow the sharing of information with states for purposes of criminal background checks. In addition, no federal statutory authority exists for the FBI to share criminal files with a “private” entity such as the interstate commission, wrote Christopher B. Chaney, an attorney in the FBI Office of the General Counsel in Clarksburg, W.Va. The FBI sent a letter expressing the same concerns to the Montana Department of Justice regarding Montana’s compact law.

The Minnesota Board of Medical Practice has requested that the FBI reverse its findings, writing in an Aug. 3 letter that the agency does not appear to fully understand how the compact works. The board is scheduled to begin issuing licenses via the compact in January 2017, said Ruth Martinez, the board’s executive director.

“We believe it’s an erroneous conclusion that they’ve drawn,” Ms. Martinez said in an interview. “We are very actively engaged in rule-writing and in preparing technology and so forth to be ready to issue licenses, and we feel very confident that this determination will be overturned.”

The Montana Board of Medical Examiners meanwhile is aware of the FBI’s letter and is closely monitoring the situation in Minnesota before taking action, said Ian Marquand, executive officer for the Montana Board of Medical Examiners.

“We are still digesting this and are anxious to see what happens with the Minnesota situation,” Mr. Marquand said in an interview. “That may provide the road map.”

The Interstate Medical Licensure Compact is aimed at making it easier for telemedicine physicians to gain licenses in multiple states. Under the model legislation, developed by the Federation of State Medical Boards (FSMB), physicians designate a member state as the state of principal licensure and select the other states in which they wish to be licensed. The state of principal licensure then verifies the physician’s eligibility and provides credential information to the interstate commission, which collects applicable fees and transmits the doctor’s information to the other states. Upon receipt in the additional states, the physician would be granted a license.

In July 2015, the U.S. Health Resources and Services Administration awarded the FSMB a grant to support establishment of the commission and aid with the compact’s infrastructure.

There is nothing unique about Minnesota’s compact law, Ms. Martinez said. The statute is based on the same model legislation that passed in 16 other states. She believes that Minnesota’s law is merely one of the first to be reviewed by the FBI. Both Minnesota and Montana officials had requested that their respective state departments of justice determine if the compact laws met public law standards pertaining to criminal history records.

Ms. Martinez said that she hopes that the board’s letter to the FBI will help explain how the compact process works and prevent further federal rejections in other jurisdictions. She notes for example that the FBI incorrectly characterizes the interstate commission as a “private” entity in its letter, when the commission is a corporate body and a joint agency of the member states. The FBI also misunderstands how the commission interacts with the individual state licensing boards and the process of licensure, according to the board’s reply letter. It is not the commission that will be using FBI data, but the member states that will be utilizing the information in the course of verification, writes Rick Masters, special counsel to the National Center for Interstate Compacts.

The Federation of State Medical Boards is closely watching the matter and supports the Minnesota Board of Medical Practice, said Lisa A. Robin FSMB’s chief advocacy officer.

“The FSMB, along with the Council of State Governments (CSG), agrees with and supports the Minnesota board’s position in this matter,” Ms. Robin said in an emailed statement. “The compact’s statutory language does not alter state-based responsibility for the administration of criminal background checks, nor does it seek to extend this responsibility beyond individual state medical boards.”

At press time, the FBI’s Mr. Chaney had not responded to a message seeking comment.

[email protected]

On Twitter @legal_med

The majority of physician practices are uncertain about joining or starting an accountable care organization (ACO), according to a survey.

Of nearly 400 hospital-owned and freestanding outpatient practices, 65% were unsure how to approach accountable care, a survey by Healthcare Information and Management Systems Society (HIMSS) Analytics found. About 13% of health providers said they expected to join an established ACO, while 14% planned to form an ACO, and 8% planned to create an ACO with a neighboring provider.

HIMSS Analytics director of research Brendan FitzGeraldand his team surveyed 436 health providers during June 23–July 12, 2016, regarding electronic health record (EHR) adoption, accountable care, and health information exchanges, among other subjects. The respondents included physicians, practice managers/administrators, physician assistants, nurse practitioners, and practice IT directors. Investigators also analyzed the HIMSS Analytics LOGIC database, which includes 47,084 hospital-owned practices and 57,909 freestanding practices.

Respondents also reported a high level of uncertainty around plans to join a health information exchange (HIE): 48% of health providers were unsure about whether to join an HIE, compared with 46% who were uncertain in 2015. Of respondents who plan to join an HIE, 10% plan to enter a hospital or health system HIE, 7% plan to enter a regional HIE, and 17% plan to join a state health information exchange.

As far as EHR adoption, nearly 78% of respondents representing a free standing outpatient facility (228 practices) reported having an EHR, a 30% increase since 2010. Data from the LOGIC database found 92% of hospital-owned outpatient facilities had a live and operational EHR. Of all survey respondents, 66% did not have plans to replace or upgrade their current outpatient solution, or purchase a new solution. Of health providers that planned to purchase a new EHR, 18% said they would be upgrading, 9% would be purchasing a new solution, and 7% would be replacing a their current EHR.

The survey shows that most doctors appear to be content with the EHR solutions they have adopted with no plans to change systems, said Mr. FitzGerald.

“The level of universal adoption is great, and it seems that physicians for the most part, are satisfied with the work they’ve done to implement and utilize these solutions the first time around,” he said in an interview. “While there may be some getting used to the process of using these particular solutions or even some functionality shortcomings, it seems likes physicians are moving forward with the solutions they have on hand.”

[email protected]

On Twitter @legal_med

The majority of physician practices are uncertain about joining or starting an accountable care organization (ACO), according to a survey.

Of nearly 400 hospital-owned and freestanding outpatient practices, 65% were unsure how to approach accountable care, a survey by Healthcare Information and Management Systems Society (HIMSS) Analytics found. About 13% of health providers said they expected to join an established ACO, while 14% planned to form an ACO, and 8% planned to create an ACO with a neighboring provider.

HIMSS Analytics director of research Brendan FitzGeraldand his team surveyed 436 health providers during June 23–July 12, 2016, regarding electronic health record (EHR) adoption, accountable care, and health information exchanges, among other subjects. The respondents included physicians, practice managers/administrators, physician assistants, nurse practitioners, and practice IT directors. Investigators also analyzed the HIMSS Analytics LOGIC database, which includes 47,084 hospital-owned practices and 57,909 freestanding practices.

Respondents also reported a high level of uncertainty around plans to join a health information exchange (HIE): 48% of health providers were unsure about whether to join an HIE, compared with 46% who were uncertain in 2015. Of respondents who plan to join an HIE, 10% plan to enter a hospital or health system HIE, 7% plan to enter a regional HIE, and 17% plan to join a state health information exchange.

As far as EHR adoption, nearly 78% of respondents representing a free standing outpatient facility (228 practices) reported having an EHR, a 30% increase since 2010. Data from the LOGIC database found 92% of hospital-owned outpatient facilities had a live and operational EHR. Of all survey respondents, 66% did not have plans to replace or upgrade their current outpatient solution, or purchase a new solution. Of health providers that planned to purchase a new EHR, 18% said they would be upgrading, 9% would be purchasing a new solution, and 7% would be replacing a their current EHR.

The survey shows that most doctors appear to be content with the EHR solutions they have adopted with no plans to change systems, said Mr. FitzGerald.

“The level of universal adoption is great, and it seems that physicians for the most part, are satisfied with the work they’ve done to implement and utilize these solutions the first time around,” he said in an interview. “While there may be some getting used to the process of using these particular solutions or even some functionality shortcomings, it seems likes physicians are moving forward with the solutions they have on hand.”

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On Twitter @legal_med

The majority of physician practices are uncertain about joining or starting an accountable care organization (ACO), according to a survey.

Of nearly 400 hospital-owned and freestanding outpatient practices, 65% were unsure how to approach accountable care, a survey by Healthcare Information and Management Systems Society (HIMSS) Analytics found. About 13% of health providers said they expected to join an established ACO, while 14% planned to form an ACO, and 8% planned to create an ACO with a neighboring provider.

HIMSS Analytics director of research Brendan FitzGeraldand his team surveyed 436 health providers during June 23–July 12, 2016, regarding electronic health record (EHR) adoption, accountable care, and health information exchanges, among other subjects. The respondents included physicians, practice managers/administrators, physician assistants, nurse practitioners, and practice IT directors. Investigators also analyzed the HIMSS Analytics LOGIC database, which includes 47,084 hospital-owned practices and 57,909 freestanding practices.

Respondents also reported a high level of uncertainty around plans to join a health information exchange (HIE): 48% of health providers were unsure about whether to join an HIE, compared with 46% who were uncertain in 2015. Of respondents who plan to join an HIE, 10% plan to enter a hospital or health system HIE, 7% plan to enter a regional HIE, and 17% plan to join a state health information exchange.

As far as EHR adoption, nearly 78% of respondents representing a free standing outpatient facility (228 practices) reported having an EHR, a 30% increase since 2010. Data from the LOGIC database found 92% of hospital-owned outpatient facilities had a live and operational EHR. Of all survey respondents, 66% did not have plans to replace or upgrade their current outpatient solution, or purchase a new solution. Of health providers that planned to purchase a new EHR, 18% said they would be upgrading, 9% would be purchasing a new solution, and 7% would be replacing a their current EHR.

The survey shows that most doctors appear to be content with the EHR solutions they have adopted with no plans to change systems, said Mr. FitzGerald.

“The level of universal adoption is great, and it seems that physicians for the most part, are satisfied with the work they’ve done to implement and utilize these solutions the first time around,” he said in an interview. “While there may be some getting used to the process of using these particular solutions or even some functionality shortcomings, it seems likes physicians are moving forward with the solutions they have on hand.”

[email protected]

On Twitter @legal_med

A model incorporating 17 easily obtainable preoperative variables may help clinicians estimate patients’ risk of developing pneumonia after undergoing coronary artery bypass graft surgery, according to a report published in Annals of Thoracic Surgery.

“This model may be used to inform clinician-patient decision making and to identify opportunities for mitigating a patient’s risk,” said Raymond J. Strobel, a medical student at the University of Michigan, Ann Arbor, and his associates.

American Heart Association

Postoperative pneumonia is the most common hospital-acquired infection following CABG, and it raises mortality risk fourfold and increases length of stay threefold. But reliable estimation of patient risk of post-CABG pneumonia has been difficult because of its low relative incidence – roughly 3% – and because most studies of the disorder are nearly a decade out of date.

To devise a predictive model using current data, Mr. Strobel and his associates assessed numerous potential risk factors and outcomes for 16,084 consecutive patients undergoing CABG at all 33 cardiac centers across Michigan during a 3-year period. They identified 531 cases of post-CABG pneumonia (3.3%) in this cohort.

The investigators performed a univariate analysis to test the associations between pneumonia and numerous factors related to patient demographics, medical history, comorbid diseases, laboratory values, cardiac anatomy, cardiac function, pulmonary function, the CABG procedure, and the institution where the procedure was performed. Variables that were found to be significantly associated with pneumonia (though usually with small absolute magnitudes) were then assessed in a multivariate analysis, which was further refined to create the final model.

The final model includes 17 factors that clearly raise the risk of post-CABG pneumonia. These include an elevated leukocyte count; a decreased hematocrit; older patient age; comorbidities such as peripheral vascular disease, diabetes, and liver disease; markers of pulmonary impairment such as cigarette smoking, the need for home oxygen therapy, and chronic lung disease; markers of cardiac dysfunction such as a recent history of arrhythmia and decreased ejection fraction; and emergency or urgent rather than elective operative status.

“This model performs well and demonstrates robustness across important clinical subgroups and centers,” the investigators said (Ann Thorac Surg. 2016 Jun 1; doi: 10.1016/j.athoracsur.2016.03.074).

In particular, this study identified preoperative leukocytosis to be a significant predictor of post-CABG pneumonia across several subgroups of patients. “We speculate that patients presenting with an elevated white blood cell count before surgery may be mounting an immune response against a pathogen and that the insult of CABG significantly increases their odds of postoperative pneumonia. ... It may be prudent to delay surgery until the source of leukocytosis is satisfactorily investigated, if not identified and treated, or the leukocytosis has otherwise resolved,” Mr. Strobel and his associates noted.

A model incorporating 17 easily obtainable preoperative variables may help clinicians estimate patients’ risk of developing pneumonia after undergoing coronary artery bypass graft surgery, according to a report published in Annals of Thoracic Surgery.

“This model may be used to inform clinician-patient decision making and to identify opportunities for mitigating a patient’s risk,” said Raymond J. Strobel, a medical student at the University of Michigan, Ann Arbor, and his associates.

American Heart Association

Postoperative pneumonia is the most common hospital-acquired infection following CABG, and it raises mortality risk fourfold and increases length of stay threefold. But reliable estimation of patient risk of post-CABG pneumonia has been difficult because of its low relative incidence – roughly 3% – and because most studies of the disorder are nearly a decade out of date.

To devise a predictive model using current data, Mr. Strobel and his associates assessed numerous potential risk factors and outcomes for 16,084 consecutive patients undergoing CABG at all 33 cardiac centers across Michigan during a 3-year period. They identified 531 cases of post-CABG pneumonia (3.3%) in this cohort.

The investigators performed a univariate analysis to test the associations between pneumonia and numerous factors related to patient demographics, medical history, comorbid diseases, laboratory values, cardiac anatomy, cardiac function, pulmonary function, the CABG procedure, and the institution where the procedure was performed. Variables that were found to be significantly associated with pneumonia (though usually with small absolute magnitudes) were then assessed in a multivariate analysis, which was further refined to create the final model.

The final model includes 17 factors that clearly raise the risk of post-CABG pneumonia. These include an elevated leukocyte count; a decreased hematocrit; older patient age; comorbidities such as peripheral vascular disease, diabetes, and liver disease; markers of pulmonary impairment such as cigarette smoking, the need for home oxygen therapy, and chronic lung disease; markers of cardiac dysfunction such as a recent history of arrhythmia and decreased ejection fraction; and emergency or urgent rather than elective operative status.

“This model performs well and demonstrates robustness across important clinical subgroups and centers,” the investigators said (Ann Thorac Surg. 2016 Jun 1; doi: 10.1016/j.athoracsur.2016.03.074).

In particular, this study identified preoperative leukocytosis to be a significant predictor of post-CABG pneumonia across several subgroups of patients. “We speculate that patients presenting with an elevated white blood cell count before surgery may be mounting an immune response against a pathogen and that the insult of CABG significantly increases their odds of postoperative pneumonia. ... It may be prudent to delay surgery until the source of leukocytosis is satisfactorily investigated, if not identified and treated, or the leukocytosis has otherwise resolved,” Mr. Strobel and his associates noted.

A model incorporating 17 easily obtainable preoperative variables may help clinicians estimate patients’ risk of developing pneumonia after undergoing coronary artery bypass graft surgery, according to a report published in Annals of Thoracic Surgery.

“This model may be used to inform clinician-patient decision making and to identify opportunities for mitigating a patient’s risk,” said Raymond J. Strobel, a medical student at the University of Michigan, Ann Arbor, and his associates.

American Heart Association

Postoperative pneumonia is the most common hospital-acquired infection following CABG, and it raises mortality risk fourfold and increases length of stay threefold. But reliable estimation of patient risk of post-CABG pneumonia has been difficult because of its low relative incidence – roughly 3% – and because most studies of the disorder are nearly a decade out of date.

To devise a predictive model using current data, Mr. Strobel and his associates assessed numerous potential risk factors and outcomes for 16,084 consecutive patients undergoing CABG at all 33 cardiac centers across Michigan during a 3-year period. They identified 531 cases of post-CABG pneumonia (3.3%) in this cohort.

The investigators performed a univariate analysis to test the associations between pneumonia and numerous factors related to patient demographics, medical history, comorbid diseases, laboratory values, cardiac anatomy, cardiac function, pulmonary function, the CABG procedure, and the institution where the procedure was performed. Variables that were found to be significantly associated with pneumonia (though usually with small absolute magnitudes) were then assessed in a multivariate analysis, which was further refined to create the final model.

The final model includes 17 factors that clearly raise the risk of post-CABG pneumonia. These include an elevated leukocyte count; a decreased hematocrit; older patient age; comorbidities such as peripheral vascular disease, diabetes, and liver disease; markers of pulmonary impairment such as cigarette smoking, the need for home oxygen therapy, and chronic lung disease; markers of cardiac dysfunction such as a recent history of arrhythmia and decreased ejection fraction; and emergency or urgent rather than elective operative status.

“This model performs well and demonstrates robustness across important clinical subgroups and centers,” the investigators said (Ann Thorac Surg. 2016 Jun 1; doi: 10.1016/j.athoracsur.2016.03.074).

In particular, this study identified preoperative leukocytosis to be a significant predictor of post-CABG pneumonia across several subgroups of patients. “We speculate that patients presenting with an elevated white blood cell count before surgery may be mounting an immune response against a pathogen and that the insult of CABG significantly increases their odds of postoperative pneumonia. ... It may be prudent to delay surgery until the source of leukocytosis is satisfactorily investigated, if not identified and treated, or the leukocytosis has otherwise resolved,” Mr. Strobel and his associates noted.

ORLANDO – Screening urinalysis should be a part of routine care for children and young adults with hemophilia, although the clinical significance of the finding is still unclear, investigators say.

Among 93 boys and young men with hemophilia A or B followed at a hemophilia treatment center, nearly half were found to have hematuria on routine screening, a possible indicator for future renal problems, said Kyle Davis, MD, and Amy Dunn, MD, from the division of hematology at Nationwide Children’s Hospital in Columbus, Ohio.

Neil Osterweil/Frontline Medical News

“It’s not routine for all centers to screen for hematuria, so there is likely a large number of patients that are underrecognized, who have hematuria but we don’t even know it,” Dr. Davis said in an interview at the World Federation of Hemophilia World Congress.

Hematuria is a recognized complication in patients with hemophilia A and B, second only to joint damage in frequency. In addition, adults with hemophilia have been shown to have a higher prevalence of renal disease than the general population, suggesting that hematuria might be a marker or harbinger of later renal disease, the authors proposed in a scientific poster.

The investigators conducted their study as part of a quality improvement program at their center aimed at increasing the frequency of urine screening in patients with hemophilia during annual comprehensive visits.

They looked at urinalysis results collected from all male patients older than 2 years with hemophilia A or B seen at their center from August 2011 through September 2015. They defined hematuria as the presence of three or more red blood cells on at least one urinalysis sample.

They also performed univariate logistic regression to evaluate the association of hematuria with patient age, race, hemophilia type and severity, treatment regimen, and history of inhibitory antibodies.

A total of 93 patients, 67 with hemophilia A and 26 with hemophilia B, were included. In all, 43 patients (47%) were identified as having hematuria, with a median of seven red cells. Hematuria was seen in 37 patients with hemophilia A (55%), and in 6 patients with hemophilia B (23%).

Characteristics associated with risk for hematuria included older age and hemophilia A.

Imaging studies available on 24 of the 93 patients showed renal calculi in 3 patients, minor pelviectasis in 1, and congenital dysplastic left kidney, ureterocele, and right hydroureter in 1 patient.

Dr. Davis and Dr. Dunn said that while screening urinalysis could be considered as a part of routine hemophilia, additional studies are needed to replicate the finding in other treatment centers and to determine whether urinalysis results can be predictive of future renal disease, and if so, whether interventions might help.

“For example, there is the potential that if you recognize hematuria in a patient and that patient is currently on an on-demand treatment process, should we switch to prophylaxis?” Dr Davis said.

Dr. Dunn noted that “certainly there are high-risk populations who should be screened, like our patients who have an active inhibitor or even a tolerized inhibitor. Our data suggest that we ought to be looking a bit more closely at those patients, and perhaps that will help us tease out the cause of this. Can we blame it all on hemophilia, or is there something else going on?”

The study was internally funded. Dr. Davis and Dr. Dunn reported no relevant disclosures.

ORLANDO – Screening urinalysis should be a part of routine care for children and young adults with hemophilia, although the clinical significance of the finding is still unclear, investigators say.

Among 93 boys and young men with hemophilia A or B followed at a hemophilia treatment center, nearly half were found to have hematuria on routine screening, a possible indicator for future renal problems, said Kyle Davis, MD, and Amy Dunn, MD, from the division of hematology at Nationwide Children’s Hospital in Columbus, Ohio.

Neil Osterweil/Frontline Medical News

“It’s not routine for all centers to screen for hematuria, so there is likely a large number of patients that are underrecognized, who have hematuria but we don’t even know it,” Dr. Davis said in an interview at the World Federation of Hemophilia World Congress.

Hematuria is a recognized complication in patients with hemophilia A and B, second only to joint damage in frequency. In addition, adults with hemophilia have been shown to have a higher prevalence of renal disease than the general population, suggesting that hematuria might be a marker or harbinger of later renal disease, the authors proposed in a scientific poster.

The investigators conducted their study as part of a quality improvement program at their center aimed at increasing the frequency of urine screening in patients with hemophilia during annual comprehensive visits.

They looked at urinalysis results collected from all male patients older than 2 years with hemophilia A or B seen at their center from August 2011 through September 2015. They defined hematuria as the presence of three or more red blood cells on at least one urinalysis sample.

They also performed univariate logistic regression to evaluate the association of hematuria with patient age, race, hemophilia type and severity, treatment regimen, and history of inhibitory antibodies.

A total of 93 patients, 67 with hemophilia A and 26 with hemophilia B, were included. In all, 43 patients (47%) were identified as having hematuria, with a median of seven red cells. Hematuria was seen in 37 patients with hemophilia A (55%), and in 6 patients with hemophilia B (23%).

Characteristics associated with risk for hematuria included older age and hemophilia A.

Imaging studies available on 24 of the 93 patients showed renal calculi in 3 patients, minor pelviectasis in 1, and congenital dysplastic left kidney, ureterocele, and right hydroureter in 1 patient.

Dr. Davis and Dr. Dunn said that while screening urinalysis could be considered as a part of routine hemophilia, additional studies are needed to replicate the finding in other treatment centers and to determine whether urinalysis results can be predictive of future renal disease, and if so, whether interventions might help.

“For example, there is the potential that if you recognize hematuria in a patient and that patient is currently on an on-demand treatment process, should we switch to prophylaxis?” Dr Davis said.

Dr. Dunn noted that “certainly there are high-risk populations who should be screened, like our patients who have an active inhibitor or even a tolerized inhibitor. Our data suggest that we ought to be looking a bit more closely at those patients, and perhaps that will help us tease out the cause of this. Can we blame it all on hemophilia, or is there something else going on?”

The study was internally funded. Dr. Davis and Dr. Dunn reported no relevant disclosures.

ORLANDO – Screening urinalysis should be a part of routine care for children and young adults with hemophilia, although the clinical significance of the finding is still unclear, investigators say.

Among 93 boys and young men with hemophilia A or B followed at a hemophilia treatment center, nearly half were found to have hematuria on routine screening, a possible indicator for future renal problems, said Kyle Davis, MD, and Amy Dunn, MD, from the division of hematology at Nationwide Children’s Hospital in Columbus, Ohio.

Neil Osterweil/Frontline Medical News

“It’s not routine for all centers to screen for hematuria, so there is likely a large number of patients that are underrecognized, who have hematuria but we don’t even know it,” Dr. Davis said in an interview at the World Federation of Hemophilia World Congress.

Hematuria is a recognized complication in patients with hemophilia A and B, second only to joint damage in frequency. In addition, adults with hemophilia have been shown to have a higher prevalence of renal disease than the general population, suggesting that hematuria might be a marker or harbinger of later renal disease, the authors proposed in a scientific poster.

The investigators conducted their study as part of a quality improvement program at their center aimed at increasing the frequency of urine screening in patients with hemophilia during annual comprehensive visits.

They looked at urinalysis results collected from all male patients older than 2 years with hemophilia A or B seen at their center from August 2011 through September 2015. They defined hematuria as the presence of three or more red blood cells on at least one urinalysis sample.

They also performed univariate logistic regression to evaluate the association of hematuria with patient age, race, hemophilia type and severity, treatment regimen, and history of inhibitory antibodies.

A total of 93 patients, 67 with hemophilia A and 26 with hemophilia B, were included. In all, 43 patients (47%) were identified as having hematuria, with a median of seven red cells. Hematuria was seen in 37 patients with hemophilia A (55%), and in 6 patients with hemophilia B (23%).

Characteristics associated with risk for hematuria included older age and hemophilia A.

Imaging studies available on 24 of the 93 patients showed renal calculi in 3 patients, minor pelviectasis in 1, and congenital dysplastic left kidney, ureterocele, and right hydroureter in 1 patient.

Dr. Davis and Dr. Dunn said that while screening urinalysis could be considered as a part of routine hemophilia, additional studies are needed to replicate the finding in other treatment centers and to determine whether urinalysis results can be predictive of future renal disease, and if so, whether interventions might help.

“For example, there is the potential that if you recognize hematuria in a patient and that patient is currently on an on-demand treatment process, should we switch to prophylaxis?” Dr Davis said.

Dr. Dunn noted that “certainly there are high-risk populations who should be screened, like our patients who have an active inhibitor or even a tolerized inhibitor. Our data suggest that we ought to be looking a bit more closely at those patients, and perhaps that will help us tease out the cause of this. Can we blame it all on hemophilia, or is there something else going on?”

The study was internally funded. Dr. Davis and Dr. Dunn reported no relevant disclosures.