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Pediatric Academic Societies (PAS): Annual Meeting
Cystic fibrosis–related diabetes requires different approach
SAN DIEGO – Cystic fibrosis–related diabetes is a unique disease, and it requires a different mindset on the part of the treating physician.
“The risk of cardiovascular death drives a lot of the recommendations for management of our patients with type 1 and type 2 diabetes, but this doesn’t apply in cystic fibrosis. Patients with cystic fibrosis–related diabetes do not appear to get macrovascular complications. These patients have other, more important concerns – namely, survival. They die from their CF lung disease. Diabetes is important, but we have to remember that in CF, lung function and nutrition come first. It’s our job to work around that,” Dr. Antoinette Moran asserted at the annual meeting of the Pediatric Academic Societies.
Diabetes is the most common comorbidity associated with CF. And it spells big trouble. It’s associated with pancreatic insufficiency, liver dysfunction, requirement for corticosteroids, and prognostically with undernutrition, worse pulmonary function, and early death, noted Dr. Moran, professor of pediatrics and chief of the division of pediatric endocrinology and diabetes at the University of Minnesota, Minneapolis.
The prevalence of cystic fibrosis–related diabetes (CFRD) is age related. It’s rare in children, but the prevalence climbs to about 15% in adolescents, 40% in 20- to 39-year-olds, and 55% after age 40.
“In fact, more than 80% of CF patients with the most severe mutations have diabetes by the time they’re 40,” according to Dr. Moran, who was lead author of CFRD management guidelines released last year by the International Society for Pediatric and Adolescent Diabetes (Pediatr. Diabetes 2014 Sep;15 Suppl 20:65-76).
CFRD is not an autoimmune disease. Ketones are rare. Glycosylated hemoglobin levels are spuriously low. And the definitive treatment for CFRD is insulin.
“Remember, you’re not just treating hyperglycemia, you’re treating insulin deficiency. Insulin deficiency is really the hallmark of this disease. It is progressive and eventually severe, but not complete – unlike in type 1 diabetes,” she observed. “Treatment of patients in their well state is similar to treating type 1 diabetes in the honeymoon phase. However, during acute illness patients become extremely insulin resistant. It’s a black hole that you can pour insulin into, and sometimes you can’t get them to budge. Then a couple of months later they’re insulin sensitive again.”
Multiple studies have demonstrated that diabetes has a negative impact upon survival in patients with CF. Both hyperglycemia and insulin insufficiency have negative impacts upon the CF lung disease.
Insulin is a potent anabolic hormone that’s necessary for maintenance of body weight and lean body mass, and insulin insufficiency leads to a catabolic state which accelerates pulmonary decline in CF. Studies show that nutritional status and pulmonary function start to decline in CF patients several years before they’re diagnosed with diabetes. Thus, by the time CFRD is diagnosed, patients have already experienced several years of insulin insufficiency, with adverse consequences.
Moreover, when blood glucose levels exceed 144 mg/dL, glucose appears in the airways of CF patients. That’s not good. It probably promotes pulmonary infection. Anecdotal evidence suggests hyperglycemia makes sputum thicker and more difficult to clear as well as boosting bacterial growth. And continuous glucose monitoring studies conducted in patients with CFRD indicate they spend roughly half of each day with a blood glucose in excess of 144 mg/dL.
Aggressive screening and early initiation of insulin therapy help reverse chronic weight loss and reduce mortality in patients with CFRD. The various guidelines recommend annual screening for diabetes in CF patients starting by age 10.
“I personally believe it should begin much earlier than that,” Dr. Moran said, citing a study led by her Minnesota colleague Dr. Katie L. Ode that showed that abnormal glucose tolerance was already present in 41% of children with CF at ages 6-9, and that those children had a high rate of early-onset CFRD (Pediatr. Diabetes 2010 Nov;11:487-92).
The oral glucose tolerance test, performed when the patient is clinically stable, is the screening tool of choice for CFRD.
“It’s not that it’s such a great test – we all know it has problems – but the other tests perform poorly in CF. And a diagnosis based upon an oral glucose tolerance test correlates with prognosis and future outcomes, so you get meaningful data when you do it,” she explained.
Evidence-based guidelines for CFRD put forth jointly by the American Diabetes Association, Cystic Fibrosis Foundation, and Lawson Wilkins Pediatric Endocrinology Society (Diabetes Care 2010;33:2697-2708) emphasize that, unlike in patients without CF, the diagnosis of CFRD can be made while a patient is hospitalized with an acute illness. The criterion is fasting or postprandial hyperglycemia persisting for more than 48 hours after hospitalization.
“Why are we calling this diabetes? These patients have repeated bouts of acute illness. The CF patient you’re seeing today in the hospital may very well be back in 5 months, and again 2 months after that. It’s a frequent event in these patients, and when their diabetes persists for longer than 48 hours it tends to persist for weeks before their need for insulin goes away until the next time they get sick. But most of these patients spend a substantial amount of time each year hyperglycemic. And most importantly, if you use as your date of diagnosis diabetes that’s present at the time of an acute illness, it correlates with microvascular complications and with mortality. So it establishes a meaningful start point for future risk,” Dr. Moran said.
She reported financial relationships with Novo Nordisk and Vertex.
SAN DIEGO – Cystic fibrosis–related diabetes is a unique disease, and it requires a different mindset on the part of the treating physician.
“The risk of cardiovascular death drives a lot of the recommendations for management of our patients with type 1 and type 2 diabetes, but this doesn’t apply in cystic fibrosis. Patients with cystic fibrosis–related diabetes do not appear to get macrovascular complications. These patients have other, more important concerns – namely, survival. They die from their CF lung disease. Diabetes is important, but we have to remember that in CF, lung function and nutrition come first. It’s our job to work around that,” Dr. Antoinette Moran asserted at the annual meeting of the Pediatric Academic Societies.
Diabetes is the most common comorbidity associated with CF. And it spells big trouble. It’s associated with pancreatic insufficiency, liver dysfunction, requirement for corticosteroids, and prognostically with undernutrition, worse pulmonary function, and early death, noted Dr. Moran, professor of pediatrics and chief of the division of pediatric endocrinology and diabetes at the University of Minnesota, Minneapolis.
The prevalence of cystic fibrosis–related diabetes (CFRD) is age related. It’s rare in children, but the prevalence climbs to about 15% in adolescents, 40% in 20- to 39-year-olds, and 55% after age 40.
“In fact, more than 80% of CF patients with the most severe mutations have diabetes by the time they’re 40,” according to Dr. Moran, who was lead author of CFRD management guidelines released last year by the International Society for Pediatric and Adolescent Diabetes (Pediatr. Diabetes 2014 Sep;15 Suppl 20:65-76).
CFRD is not an autoimmune disease. Ketones are rare. Glycosylated hemoglobin levels are spuriously low. And the definitive treatment for CFRD is insulin.
“Remember, you’re not just treating hyperglycemia, you’re treating insulin deficiency. Insulin deficiency is really the hallmark of this disease. It is progressive and eventually severe, but not complete – unlike in type 1 diabetes,” she observed. “Treatment of patients in their well state is similar to treating type 1 diabetes in the honeymoon phase. However, during acute illness patients become extremely insulin resistant. It’s a black hole that you can pour insulin into, and sometimes you can’t get them to budge. Then a couple of months later they’re insulin sensitive again.”
Multiple studies have demonstrated that diabetes has a negative impact upon survival in patients with CF. Both hyperglycemia and insulin insufficiency have negative impacts upon the CF lung disease.
Insulin is a potent anabolic hormone that’s necessary for maintenance of body weight and lean body mass, and insulin insufficiency leads to a catabolic state which accelerates pulmonary decline in CF. Studies show that nutritional status and pulmonary function start to decline in CF patients several years before they’re diagnosed with diabetes. Thus, by the time CFRD is diagnosed, patients have already experienced several years of insulin insufficiency, with adverse consequences.
Moreover, when blood glucose levels exceed 144 mg/dL, glucose appears in the airways of CF patients. That’s not good. It probably promotes pulmonary infection. Anecdotal evidence suggests hyperglycemia makes sputum thicker and more difficult to clear as well as boosting bacterial growth. And continuous glucose monitoring studies conducted in patients with CFRD indicate they spend roughly half of each day with a blood glucose in excess of 144 mg/dL.
Aggressive screening and early initiation of insulin therapy help reverse chronic weight loss and reduce mortality in patients with CFRD. The various guidelines recommend annual screening for diabetes in CF patients starting by age 10.
“I personally believe it should begin much earlier than that,” Dr. Moran said, citing a study led by her Minnesota colleague Dr. Katie L. Ode that showed that abnormal glucose tolerance was already present in 41% of children with CF at ages 6-9, and that those children had a high rate of early-onset CFRD (Pediatr. Diabetes 2010 Nov;11:487-92).
The oral glucose tolerance test, performed when the patient is clinically stable, is the screening tool of choice for CFRD.
“It’s not that it’s such a great test – we all know it has problems – but the other tests perform poorly in CF. And a diagnosis based upon an oral glucose tolerance test correlates with prognosis and future outcomes, so you get meaningful data when you do it,” she explained.
Evidence-based guidelines for CFRD put forth jointly by the American Diabetes Association, Cystic Fibrosis Foundation, and Lawson Wilkins Pediatric Endocrinology Society (Diabetes Care 2010;33:2697-2708) emphasize that, unlike in patients without CF, the diagnosis of CFRD can be made while a patient is hospitalized with an acute illness. The criterion is fasting or postprandial hyperglycemia persisting for more than 48 hours after hospitalization.
“Why are we calling this diabetes? These patients have repeated bouts of acute illness. The CF patient you’re seeing today in the hospital may very well be back in 5 months, and again 2 months after that. It’s a frequent event in these patients, and when their diabetes persists for longer than 48 hours it tends to persist for weeks before their need for insulin goes away until the next time they get sick. But most of these patients spend a substantial amount of time each year hyperglycemic. And most importantly, if you use as your date of diagnosis diabetes that’s present at the time of an acute illness, it correlates with microvascular complications and with mortality. So it establishes a meaningful start point for future risk,” Dr. Moran said.
She reported financial relationships with Novo Nordisk and Vertex.
SAN DIEGO – Cystic fibrosis–related diabetes is a unique disease, and it requires a different mindset on the part of the treating physician.
“The risk of cardiovascular death drives a lot of the recommendations for management of our patients with type 1 and type 2 diabetes, but this doesn’t apply in cystic fibrosis. Patients with cystic fibrosis–related diabetes do not appear to get macrovascular complications. These patients have other, more important concerns – namely, survival. They die from their CF lung disease. Diabetes is important, but we have to remember that in CF, lung function and nutrition come first. It’s our job to work around that,” Dr. Antoinette Moran asserted at the annual meeting of the Pediatric Academic Societies.
Diabetes is the most common comorbidity associated with CF. And it spells big trouble. It’s associated with pancreatic insufficiency, liver dysfunction, requirement for corticosteroids, and prognostically with undernutrition, worse pulmonary function, and early death, noted Dr. Moran, professor of pediatrics and chief of the division of pediatric endocrinology and diabetes at the University of Minnesota, Minneapolis.
The prevalence of cystic fibrosis–related diabetes (CFRD) is age related. It’s rare in children, but the prevalence climbs to about 15% in adolescents, 40% in 20- to 39-year-olds, and 55% after age 40.
“In fact, more than 80% of CF patients with the most severe mutations have diabetes by the time they’re 40,” according to Dr. Moran, who was lead author of CFRD management guidelines released last year by the International Society for Pediatric and Adolescent Diabetes (Pediatr. Diabetes 2014 Sep;15 Suppl 20:65-76).
CFRD is not an autoimmune disease. Ketones are rare. Glycosylated hemoglobin levels are spuriously low. And the definitive treatment for CFRD is insulin.
“Remember, you’re not just treating hyperglycemia, you’re treating insulin deficiency. Insulin deficiency is really the hallmark of this disease. It is progressive and eventually severe, but not complete – unlike in type 1 diabetes,” she observed. “Treatment of patients in their well state is similar to treating type 1 diabetes in the honeymoon phase. However, during acute illness patients become extremely insulin resistant. It’s a black hole that you can pour insulin into, and sometimes you can’t get them to budge. Then a couple of months later they’re insulin sensitive again.”
Multiple studies have demonstrated that diabetes has a negative impact upon survival in patients with CF. Both hyperglycemia and insulin insufficiency have negative impacts upon the CF lung disease.
Insulin is a potent anabolic hormone that’s necessary for maintenance of body weight and lean body mass, and insulin insufficiency leads to a catabolic state which accelerates pulmonary decline in CF. Studies show that nutritional status and pulmonary function start to decline in CF patients several years before they’re diagnosed with diabetes. Thus, by the time CFRD is diagnosed, patients have already experienced several years of insulin insufficiency, with adverse consequences.
Moreover, when blood glucose levels exceed 144 mg/dL, glucose appears in the airways of CF patients. That’s not good. It probably promotes pulmonary infection. Anecdotal evidence suggests hyperglycemia makes sputum thicker and more difficult to clear as well as boosting bacterial growth. And continuous glucose monitoring studies conducted in patients with CFRD indicate they spend roughly half of each day with a blood glucose in excess of 144 mg/dL.
Aggressive screening and early initiation of insulin therapy help reverse chronic weight loss and reduce mortality in patients with CFRD. The various guidelines recommend annual screening for diabetes in CF patients starting by age 10.
“I personally believe it should begin much earlier than that,” Dr. Moran said, citing a study led by her Minnesota colleague Dr. Katie L. Ode that showed that abnormal glucose tolerance was already present in 41% of children with CF at ages 6-9, and that those children had a high rate of early-onset CFRD (Pediatr. Diabetes 2010 Nov;11:487-92).
The oral glucose tolerance test, performed when the patient is clinically stable, is the screening tool of choice for CFRD.
“It’s not that it’s such a great test – we all know it has problems – but the other tests perform poorly in CF. And a diagnosis based upon an oral glucose tolerance test correlates with prognosis and future outcomes, so you get meaningful data when you do it,” she explained.
Evidence-based guidelines for CFRD put forth jointly by the American Diabetes Association, Cystic Fibrosis Foundation, and Lawson Wilkins Pediatric Endocrinology Society (Diabetes Care 2010;33:2697-2708) emphasize that, unlike in patients without CF, the diagnosis of CFRD can be made while a patient is hospitalized with an acute illness. The criterion is fasting or postprandial hyperglycemia persisting for more than 48 hours after hospitalization.
“Why are we calling this diabetes? These patients have repeated bouts of acute illness. The CF patient you’re seeing today in the hospital may very well be back in 5 months, and again 2 months after that. It’s a frequent event in these patients, and when their diabetes persists for longer than 48 hours it tends to persist for weeks before their need for insulin goes away until the next time they get sick. But most of these patients spend a substantial amount of time each year hyperglycemic. And most importantly, if you use as your date of diagnosis diabetes that’s present at the time of an acute illness, it correlates with microvascular complications and with mortality. So it establishes a meaningful start point for future risk,” Dr. Moran said.
She reported financial relationships with Novo Nordisk and Vertex.
EXPERT ANALYSIS FROM THE PAS ANNUAL MEETING
How to code for cystic fibrosis–related diabetes
SAN DIEGO – A question that arises all the time for physicians who find themselves providing care for a patient with cystic fibrosis–related diabetes is, How do I code for it?
No specific code exists for cystic fibrosis–related diabetes (CFRD), even though it is a unique illness and the most common comorbid condition among patients with CF.
“People use a lot of different codes. I use the type 1 diabetes code, and my personal opinion is that there are good reasons for doing so,” Dr. Antoinette Moran said at the annual meeting of the Pediatric Academic Societies.
“For one thing, the patients perform similar tasks as those with type 1 diabetes. They’re taking the same amount of your time and your diabetes educator’s time. But here’s the most important reason: It seems like all around the country, insurance companies are getting more and more restrictive for people who don’t carry a diagnosis of type 1 diabetes. These CFRD patients need to test their blood sugars at least 4 times a day, sometimes 10 times a day. These are patients who do really, really well on insulin pump therapy. We don’t want to be the ones limiting their options just based on what is admittedly an arbitrary code,” explained Dr. Moran, professor of pediatrics and chief of the division of pediatric endocrinology and diabetes at the University of Minnesota – Minneapolis.
She reported financial relationships with Novo Nordisk and Vertex.
SAN DIEGO – A question that arises all the time for physicians who find themselves providing care for a patient with cystic fibrosis–related diabetes is, How do I code for it?
No specific code exists for cystic fibrosis–related diabetes (CFRD), even though it is a unique illness and the most common comorbid condition among patients with CF.
“People use a lot of different codes. I use the type 1 diabetes code, and my personal opinion is that there are good reasons for doing so,” Dr. Antoinette Moran said at the annual meeting of the Pediatric Academic Societies.
“For one thing, the patients perform similar tasks as those with type 1 diabetes. They’re taking the same amount of your time and your diabetes educator’s time. But here’s the most important reason: It seems like all around the country, insurance companies are getting more and more restrictive for people who don’t carry a diagnosis of type 1 diabetes. These CFRD patients need to test their blood sugars at least 4 times a day, sometimes 10 times a day. These are patients who do really, really well on insulin pump therapy. We don’t want to be the ones limiting their options just based on what is admittedly an arbitrary code,” explained Dr. Moran, professor of pediatrics and chief of the division of pediatric endocrinology and diabetes at the University of Minnesota – Minneapolis.
She reported financial relationships with Novo Nordisk and Vertex.
SAN DIEGO – A question that arises all the time for physicians who find themselves providing care for a patient with cystic fibrosis–related diabetes is, How do I code for it?
No specific code exists for cystic fibrosis–related diabetes (CFRD), even though it is a unique illness and the most common comorbid condition among patients with CF.
“People use a lot of different codes. I use the type 1 diabetes code, and my personal opinion is that there are good reasons for doing so,” Dr. Antoinette Moran said at the annual meeting of the Pediatric Academic Societies.
“For one thing, the patients perform similar tasks as those with type 1 diabetes. They’re taking the same amount of your time and your diabetes educator’s time. But here’s the most important reason: It seems like all around the country, insurance companies are getting more and more restrictive for people who don’t carry a diagnosis of type 1 diabetes. These CFRD patients need to test their blood sugars at least 4 times a day, sometimes 10 times a day. These are patients who do really, really well on insulin pump therapy. We don’t want to be the ones limiting their options just based on what is admittedly an arbitrary code,” explained Dr. Moran, professor of pediatrics and chief of the division of pediatric endocrinology and diabetes at the University of Minnesota – Minneapolis.
She reported financial relationships with Novo Nordisk and Vertex.
EXPERT OPINION FROM THE PAS ANNUAL MEETING
PAS: Communication style influences HPV vaccination
SAN DIEGO – More adolescents received the HPV vaccine when the vaccine was discussed in the context of other vaccines, and when the providers said they expected that the vaccine would be administered at the visit, results from a multisite study suggest.
Patients were more likely to get the HPV vaccine when it was discussed in context with other due vaccines (94% vs. 71%; P< .01) and when it was offered in the context of expectant provision, compared with all other communication types (100% vs. 76%; P< .01), researchers led by Dr. Paul M. Darden wrote in a poster abstract presented at the annual meeting of the Pediatric Academic Societies.
In a study conducted at six medical practices and two practice-based research networks, Dr. Darden, chief of the section of general and community pediatrics at the University of Oklahoma, and his associates set out to describe the types of recommendations for adolescent vaccines that nurses and clinicians give, how they vary with the type of vaccine, and whether the type of recommendation is associated with adolescent receipt of HPV vaccine.
To accomplish this, well visits where vaccines were due in patients aged 11-17 years were audiotaped and transcribed. Nurse and clinician texts were coded by validated coders. Clinician recommendations for Tdap, MCV4 and HPV were coded separately into one of five communication categories: none, passive (today you are due for ...), active (I really recommend ...), collaborative (today would you like to receive ...), and expectant provision (today you will get ...).
The researchers analyzed results from 106 patient visits (a range of 15-20 per practice), with 58 due for MCV4, 49 due for Tdap, and 101 due for HPV vaccine. Slightly more than half of the adolescents (53%) were 11 or 12 years of age, while the remainder ranged in age from 13 to 17 years. Nearly two-thirds (64%) were male, 38% were black, 28% were white, 27% were Hispanic, and the rest were from other ethnicities. A nurse assessment was audiotaped in 63 of the visits.
If the nurse mentioned that the patient was due for HPV vaccine, the patient was more likely to be vaccinated with HPV vaccine than if the nurse either did not address or only generally addressed the patient’s vaccination status (100% vs. 72%; P<i/>= .05). No communication for HPV was less common than for MCV and Tdap vaccines (6%, 14%, and 16%, respectively; P<i/>= .03.), while a collaborative recommendation (today would you like to receive …) was more common with the HPV vaccine (36% vs. 9% for MCV and 6% for Tdap; P< .01)
“The CDC recommends clinicians use a strong recommendation with patients for HPV vaccine delivery,” the researchers wrote. “Our research reflects that adolescents are more likely to receive vaccinations after any type of recommendation, but some appear to be more effective than others.” The results “can help inform the organization of pediatric vaccine delivery practices and the training of clinicians. Further research is needed in effective communication to identify the best way to discuss and deliver vaccines to adolescent patients.”
The study was funded by a grant through the Department of Health & Human Services, Health Resources and Services Administration, Maternal and Child Health Research Program. The researchers reported having no relevant financial conflicts.
On Twitter @dougbrunk
SAN DIEGO – More adolescents received the HPV vaccine when the vaccine was discussed in the context of other vaccines, and when the providers said they expected that the vaccine would be administered at the visit, results from a multisite study suggest.
Patients were more likely to get the HPV vaccine when it was discussed in context with other due vaccines (94% vs. 71%; P< .01) and when it was offered in the context of expectant provision, compared with all other communication types (100% vs. 76%; P< .01), researchers led by Dr. Paul M. Darden wrote in a poster abstract presented at the annual meeting of the Pediatric Academic Societies.
In a study conducted at six medical practices and two practice-based research networks, Dr. Darden, chief of the section of general and community pediatrics at the University of Oklahoma, and his associates set out to describe the types of recommendations for adolescent vaccines that nurses and clinicians give, how they vary with the type of vaccine, and whether the type of recommendation is associated with adolescent receipt of HPV vaccine.
To accomplish this, well visits where vaccines were due in patients aged 11-17 years were audiotaped and transcribed. Nurse and clinician texts were coded by validated coders. Clinician recommendations for Tdap, MCV4 and HPV were coded separately into one of five communication categories: none, passive (today you are due for ...), active (I really recommend ...), collaborative (today would you like to receive ...), and expectant provision (today you will get ...).
The researchers analyzed results from 106 patient visits (a range of 15-20 per practice), with 58 due for MCV4, 49 due for Tdap, and 101 due for HPV vaccine. Slightly more than half of the adolescents (53%) were 11 or 12 years of age, while the remainder ranged in age from 13 to 17 years. Nearly two-thirds (64%) were male, 38% were black, 28% were white, 27% were Hispanic, and the rest were from other ethnicities. A nurse assessment was audiotaped in 63 of the visits.
If the nurse mentioned that the patient was due for HPV vaccine, the patient was more likely to be vaccinated with HPV vaccine than if the nurse either did not address or only generally addressed the patient’s vaccination status (100% vs. 72%; P<i/>= .05). No communication for HPV was less common than for MCV and Tdap vaccines (6%, 14%, and 16%, respectively; P<i/>= .03.), while a collaborative recommendation (today would you like to receive …) was more common with the HPV vaccine (36% vs. 9% for MCV and 6% for Tdap; P< .01)
“The CDC recommends clinicians use a strong recommendation with patients for HPV vaccine delivery,” the researchers wrote. “Our research reflects that adolescents are more likely to receive vaccinations after any type of recommendation, but some appear to be more effective than others.” The results “can help inform the organization of pediatric vaccine delivery practices and the training of clinicians. Further research is needed in effective communication to identify the best way to discuss and deliver vaccines to adolescent patients.”
The study was funded by a grant through the Department of Health & Human Services, Health Resources and Services Administration, Maternal and Child Health Research Program. The researchers reported having no relevant financial conflicts.
On Twitter @dougbrunk
SAN DIEGO – More adolescents received the HPV vaccine when the vaccine was discussed in the context of other vaccines, and when the providers said they expected that the vaccine would be administered at the visit, results from a multisite study suggest.
Patients were more likely to get the HPV vaccine when it was discussed in context with other due vaccines (94% vs. 71%; P< .01) and when it was offered in the context of expectant provision, compared with all other communication types (100% vs. 76%; P< .01), researchers led by Dr. Paul M. Darden wrote in a poster abstract presented at the annual meeting of the Pediatric Academic Societies.
In a study conducted at six medical practices and two practice-based research networks, Dr. Darden, chief of the section of general and community pediatrics at the University of Oklahoma, and his associates set out to describe the types of recommendations for adolescent vaccines that nurses and clinicians give, how they vary with the type of vaccine, and whether the type of recommendation is associated with adolescent receipt of HPV vaccine.
To accomplish this, well visits where vaccines were due in patients aged 11-17 years were audiotaped and transcribed. Nurse and clinician texts were coded by validated coders. Clinician recommendations for Tdap, MCV4 and HPV were coded separately into one of five communication categories: none, passive (today you are due for ...), active (I really recommend ...), collaborative (today would you like to receive ...), and expectant provision (today you will get ...).
The researchers analyzed results from 106 patient visits (a range of 15-20 per practice), with 58 due for MCV4, 49 due for Tdap, and 101 due for HPV vaccine. Slightly more than half of the adolescents (53%) were 11 or 12 years of age, while the remainder ranged in age from 13 to 17 years. Nearly two-thirds (64%) were male, 38% were black, 28% were white, 27% were Hispanic, and the rest were from other ethnicities. A nurse assessment was audiotaped in 63 of the visits.
If the nurse mentioned that the patient was due for HPV vaccine, the patient was more likely to be vaccinated with HPV vaccine than if the nurse either did not address or only generally addressed the patient’s vaccination status (100% vs. 72%; P<i/>= .05). No communication for HPV was less common than for MCV and Tdap vaccines (6%, 14%, and 16%, respectively; P<i/>= .03.), while a collaborative recommendation (today would you like to receive …) was more common with the HPV vaccine (36% vs. 9% for MCV and 6% for Tdap; P< .01)
“The CDC recommends clinicians use a strong recommendation with patients for HPV vaccine delivery,” the researchers wrote. “Our research reflects that adolescents are more likely to receive vaccinations after any type of recommendation, but some appear to be more effective than others.” The results “can help inform the organization of pediatric vaccine delivery practices and the training of clinicians. Further research is needed in effective communication to identify the best way to discuss and deliver vaccines to adolescent patients.”
The study was funded by a grant through the Department of Health & Human Services, Health Resources and Services Administration, Maternal and Child Health Research Program. The researchers reported having no relevant financial conflicts.
On Twitter @dougbrunk
AT THE PAS ANNUAL MEETING
Key clinical point: Expectant provision was the most successful communication method for assuring HPV vaccination.
Major finding: Patients were more likely to get the HPV vaccine when it was discussed in context with other due vaccines (94% vs. 71%; P< .01) and when it was offered in the context of expectant provision, compared with all other communication types (100% vs. 76%; P< .01).
Data source: A study of 106 adolescent patient visits to six medical practices and two practice-based research networks (a range 15 to 20 per practice), with 58 due MCV4, 49 due Tdap, and 101 due for HPV vaccine.
Disclosures: The study was funded by a grant through the Department of Health & Human Services, Health Resources and Services Administration, Maternal and Child Health Research Program. The researchers reported having no relevant financial conflicts.
PAS: Getting a grip on glucokinase MODY
SAN DIEGO – The two main things to understand about maturity-onset diabetes of the young due to mutations in the glucokinase gene are that this form of diabetes is far more common than you probably realize, and – unique in the world of diabetes – no treatment is warranted, according to Dr. Siri Atma W. Greeley, a pediatric endocrinologist at the University of Chicago.
He cited what he called “a great study” by investigators at the University of Exeter (England), who showed that very, very few patients with glucokinase maturity-onset diabetes of the young (GCK MODY) develop micro- or macrovascular complications. Despite a median 48.6 years of follow-up of 99 patients with GCK MODY, also known as MODY 2, the prevalence and severity of retinopathy, nephropathy, peripheral neuropathy, cardiovascular disease, and peripheral vascular disease weren’t significantly different from controls (JAMA 2014;311:279-86).
“Just remember – these patients do not get diabetes-related complications. And we think that if they do, it might be because they later go on to develop type 2 diabetes; for instance, if they become obese and have a genetic predisposition in addition to having their GCK mutation,” Dr. Greeley said at the annual meeting of the Pediatric Academic Societies.
There’s another reason to spare patients with GCK MODY from lifelong diabetes therapy, besides the facts that treatment is costly, has side effects, and does nothing to minimize their risk of vascular complications because their risk isn’t increased: Namely, pharmacotherapy doesn’t alter glycemic control in these patients. The Exeter group has shown that HbA1c in patients with GCK MODY isn’t affected by treatment with insulin or oral hypoglycemic agents (Diabetologia 2014;57:54-6). That’s because the GCK gene acts as a blood glucose sensor for the pancreas, and a mutation causes the gene to reset blood glucose at a slightly higher than normal level. Treatment is ineffective because the body will relentlessly strive to maintain blood glucose at the reset level, he explained.
Typically, however, patients with GCK MODY are treated – inappropriately – with insulin or oral hypoglycemic agents because they have been misdiagnosed as having type 2 or less commonly type 1 diabetes. Indeed, roughly half of patients with GCK MODY have been on drug therapy for more than 3 months at the time they enroll in the U.S. Monogenic Diabetes Registry maintained by Dr. Greeley and coworkers at the University of Chicago. Some are actually on an insulin pump.
“There’s a lot of unnecessary treatment going on with these patients,” he said.
The only time treatment of GCK MODY is appropriate, the endocrinologist added, is in some affected women during pregnancy in order to control fetal growth.
How common is GCK MODY in pregnancy? The Exeter group has estimated the population prevalence at 1.2 cases per 1,000 pregnancies, or 0.1%, based on genetic testing of participants in the Atlantic Diabetes in Pregnancy Study (Diabetes Care 2014;37:1230-6). However, among more than 61,000 unrelated individuals who have participated in various large-scale gene sequencing projects under the umbrella of the Exome Aggregation Consortium, GCK mutation rates were higher, ranging from 2.71 cases per 1,000 non-Finnish Europeans to 4.93 per 1,000 among Latinos and 5.74 per 1,000 Africans.
More than 90% of all cases of MODY with a known cause are due to mutations in one of four genes: GCK, hepatocyte nuclear factor homeobox 1-alpha (HNF1A), HNF1 homeobox 1B, or HNF4 alpha. Investigators in the U.S. multicenter SEARCH for Diabetes in Youth Study performed gene-sequencing studies in 586 study participants and found the prevalence of mutations in GCK, HNF1A, or HNF4 alpha was 1.2% among the pediatric diabetes population (J. Clin. Endocrinol. Metab. 2013;98:4055-62). That finding has clear implications for clinical practice: “All of you, if you’re seeing any number of diabetes patients, should have at least a handful of cases of MODY,” Dr. Greeley observed.
The hallmark of GCK MODY is mild fasting hyperglycemia present from birth, with a stable HbA1c below 7.8% throughout life. But Dr. Greeley emphasized that there is no set of clinical features that make the diagnosis of GCK MODY or other forms of MODY with 100% certainty. The only way to firmly establish the diagnosis is through genetic testing, which in Dr. Greeley’s view is vastly underutilized. He was coinvestigator in a study that demonstrated that genetic testing for causative mutations in the big-four genes is cost effective in selected circumstances. And at least one major insurer, he added, is starting to come around to that point of view.
Dr. Greeley’s research is funded by the National Institutes of Health, the American Diabetes Association, and the Kovler Family Foundation. He reported having no financial conflicts.
SAN DIEGO – The two main things to understand about maturity-onset diabetes of the young due to mutations in the glucokinase gene are that this form of diabetes is far more common than you probably realize, and – unique in the world of diabetes – no treatment is warranted, according to Dr. Siri Atma W. Greeley, a pediatric endocrinologist at the University of Chicago.
He cited what he called “a great study” by investigators at the University of Exeter (England), who showed that very, very few patients with glucokinase maturity-onset diabetes of the young (GCK MODY) develop micro- or macrovascular complications. Despite a median 48.6 years of follow-up of 99 patients with GCK MODY, also known as MODY 2, the prevalence and severity of retinopathy, nephropathy, peripheral neuropathy, cardiovascular disease, and peripheral vascular disease weren’t significantly different from controls (JAMA 2014;311:279-86).
“Just remember – these patients do not get diabetes-related complications. And we think that if they do, it might be because they later go on to develop type 2 diabetes; for instance, if they become obese and have a genetic predisposition in addition to having their GCK mutation,” Dr. Greeley said at the annual meeting of the Pediatric Academic Societies.
There’s another reason to spare patients with GCK MODY from lifelong diabetes therapy, besides the facts that treatment is costly, has side effects, and does nothing to minimize their risk of vascular complications because their risk isn’t increased: Namely, pharmacotherapy doesn’t alter glycemic control in these patients. The Exeter group has shown that HbA1c in patients with GCK MODY isn’t affected by treatment with insulin or oral hypoglycemic agents (Diabetologia 2014;57:54-6). That’s because the GCK gene acts as a blood glucose sensor for the pancreas, and a mutation causes the gene to reset blood glucose at a slightly higher than normal level. Treatment is ineffective because the body will relentlessly strive to maintain blood glucose at the reset level, he explained.
Typically, however, patients with GCK MODY are treated – inappropriately – with insulin or oral hypoglycemic agents because they have been misdiagnosed as having type 2 or less commonly type 1 diabetes. Indeed, roughly half of patients with GCK MODY have been on drug therapy for more than 3 months at the time they enroll in the U.S. Monogenic Diabetes Registry maintained by Dr. Greeley and coworkers at the University of Chicago. Some are actually on an insulin pump.
“There’s a lot of unnecessary treatment going on with these patients,” he said.
The only time treatment of GCK MODY is appropriate, the endocrinologist added, is in some affected women during pregnancy in order to control fetal growth.
How common is GCK MODY in pregnancy? The Exeter group has estimated the population prevalence at 1.2 cases per 1,000 pregnancies, or 0.1%, based on genetic testing of participants in the Atlantic Diabetes in Pregnancy Study (Diabetes Care 2014;37:1230-6). However, among more than 61,000 unrelated individuals who have participated in various large-scale gene sequencing projects under the umbrella of the Exome Aggregation Consortium, GCK mutation rates were higher, ranging from 2.71 cases per 1,000 non-Finnish Europeans to 4.93 per 1,000 among Latinos and 5.74 per 1,000 Africans.
More than 90% of all cases of MODY with a known cause are due to mutations in one of four genes: GCK, hepatocyte nuclear factor homeobox 1-alpha (HNF1A), HNF1 homeobox 1B, or HNF4 alpha. Investigators in the U.S. multicenter SEARCH for Diabetes in Youth Study performed gene-sequencing studies in 586 study participants and found the prevalence of mutations in GCK, HNF1A, or HNF4 alpha was 1.2% among the pediatric diabetes population (J. Clin. Endocrinol. Metab. 2013;98:4055-62). That finding has clear implications for clinical practice: “All of you, if you’re seeing any number of diabetes patients, should have at least a handful of cases of MODY,” Dr. Greeley observed.
The hallmark of GCK MODY is mild fasting hyperglycemia present from birth, with a stable HbA1c below 7.8% throughout life. But Dr. Greeley emphasized that there is no set of clinical features that make the diagnosis of GCK MODY or other forms of MODY with 100% certainty. The only way to firmly establish the diagnosis is through genetic testing, which in Dr. Greeley’s view is vastly underutilized. He was coinvestigator in a study that demonstrated that genetic testing for causative mutations in the big-four genes is cost effective in selected circumstances. And at least one major insurer, he added, is starting to come around to that point of view.
Dr. Greeley’s research is funded by the National Institutes of Health, the American Diabetes Association, and the Kovler Family Foundation. He reported having no financial conflicts.
SAN DIEGO – The two main things to understand about maturity-onset diabetes of the young due to mutations in the glucokinase gene are that this form of diabetes is far more common than you probably realize, and – unique in the world of diabetes – no treatment is warranted, according to Dr. Siri Atma W. Greeley, a pediatric endocrinologist at the University of Chicago.
He cited what he called “a great study” by investigators at the University of Exeter (England), who showed that very, very few patients with glucokinase maturity-onset diabetes of the young (GCK MODY) develop micro- or macrovascular complications. Despite a median 48.6 years of follow-up of 99 patients with GCK MODY, also known as MODY 2, the prevalence and severity of retinopathy, nephropathy, peripheral neuropathy, cardiovascular disease, and peripheral vascular disease weren’t significantly different from controls (JAMA 2014;311:279-86).
“Just remember – these patients do not get diabetes-related complications. And we think that if they do, it might be because they later go on to develop type 2 diabetes; for instance, if they become obese and have a genetic predisposition in addition to having their GCK mutation,” Dr. Greeley said at the annual meeting of the Pediatric Academic Societies.
There’s another reason to spare patients with GCK MODY from lifelong diabetes therapy, besides the facts that treatment is costly, has side effects, and does nothing to minimize their risk of vascular complications because their risk isn’t increased: Namely, pharmacotherapy doesn’t alter glycemic control in these patients. The Exeter group has shown that HbA1c in patients with GCK MODY isn’t affected by treatment with insulin or oral hypoglycemic agents (Diabetologia 2014;57:54-6). That’s because the GCK gene acts as a blood glucose sensor for the pancreas, and a mutation causes the gene to reset blood glucose at a slightly higher than normal level. Treatment is ineffective because the body will relentlessly strive to maintain blood glucose at the reset level, he explained.
Typically, however, patients with GCK MODY are treated – inappropriately – with insulin or oral hypoglycemic agents because they have been misdiagnosed as having type 2 or less commonly type 1 diabetes. Indeed, roughly half of patients with GCK MODY have been on drug therapy for more than 3 months at the time they enroll in the U.S. Monogenic Diabetes Registry maintained by Dr. Greeley and coworkers at the University of Chicago. Some are actually on an insulin pump.
“There’s a lot of unnecessary treatment going on with these patients,” he said.
The only time treatment of GCK MODY is appropriate, the endocrinologist added, is in some affected women during pregnancy in order to control fetal growth.
How common is GCK MODY in pregnancy? The Exeter group has estimated the population prevalence at 1.2 cases per 1,000 pregnancies, or 0.1%, based on genetic testing of participants in the Atlantic Diabetes in Pregnancy Study (Diabetes Care 2014;37:1230-6). However, among more than 61,000 unrelated individuals who have participated in various large-scale gene sequencing projects under the umbrella of the Exome Aggregation Consortium, GCK mutation rates were higher, ranging from 2.71 cases per 1,000 non-Finnish Europeans to 4.93 per 1,000 among Latinos and 5.74 per 1,000 Africans.
More than 90% of all cases of MODY with a known cause are due to mutations in one of four genes: GCK, hepatocyte nuclear factor homeobox 1-alpha (HNF1A), HNF1 homeobox 1B, or HNF4 alpha. Investigators in the U.S. multicenter SEARCH for Diabetes in Youth Study performed gene-sequencing studies in 586 study participants and found the prevalence of mutations in GCK, HNF1A, or HNF4 alpha was 1.2% among the pediatric diabetes population (J. Clin. Endocrinol. Metab. 2013;98:4055-62). That finding has clear implications for clinical practice: “All of you, if you’re seeing any number of diabetes patients, should have at least a handful of cases of MODY,” Dr. Greeley observed.
The hallmark of GCK MODY is mild fasting hyperglycemia present from birth, with a stable HbA1c below 7.8% throughout life. But Dr. Greeley emphasized that there is no set of clinical features that make the diagnosis of GCK MODY or other forms of MODY with 100% certainty. The only way to firmly establish the diagnosis is through genetic testing, which in Dr. Greeley’s view is vastly underutilized. He was coinvestigator in a study that demonstrated that genetic testing for causative mutations in the big-four genes is cost effective in selected circumstances. And at least one major insurer, he added, is starting to come around to that point of view.
Dr. Greeley’s research is funded by the National Institutes of Health, the American Diabetes Association, and the Kovler Family Foundation. He reported having no financial conflicts.
EXPERT ANALYSIS FROM THE PAS ANNUAL MEETING
Study evaluates early-life determinants of adolescent adiponectin levels
SAN DIEGO – Adiponectin, a “healthy” hormone secreted from adipose tissue, was higher in adolescent females compared with males, and decreased as body weight increased, a longitudinal cohort analysis demonstrated.
“Low adiponectin levels are associated with metabolic risk, regardless of fat mass and sex,” lead study author Dr. Marcela Reyes said at the annual meeting of the Pediatric Academic Societies. “There is currently a gap in knowledge in factors that determine circulating adiponectin levels.”
In an effort to evaluate the role of infancy exposures (duration of breast feeding and weight-gain velocity) on adolescent adiponectin levels after taking into account gender and fat mass, Dr. Reyes and her associates studied a cohort of 584 normal–birth weight adolescents who were recruited at age 4 months for an iron deficiency preventive trial in Santiago, Chile from 1991 to 1996 and evaluated for cardiovascular risk 16 years later.
Dr. Reyes of the Institute of Nutrition and Food Technology at the University of Chile, Santiago, and her associates prospectively assessed breastfeeding from the age of 4 months and measured weight and height monthly. Adolescent outcomes included body mass index (BMI) z-scores, fat mass, and fasting serum adiponectin levels. The researchers used linear regression to model the effect of short breastfeeding (defined as breastfeeding for shorter than 180 days as the sole source of milk, as recommended by pediatricians) and weight gain in the first 6 months on adolescent adiponectin levels, after controlling for fat mass and gender.
The mean body weight at birth of the 584 adolescents was 3.5 kg, which increased to 8.0 kg at 6 months, with no change in the weight-for-age z-scores; 75% experienced a short exposure to breastfeeding. At age 16 years, their mean adiponectin level was 11.3 mcg/mL and differed by weight status and gender.
Specifically, the mean adiponectin levels among normal weight, overweight, and obese males were 11.06, 8.86, and 7.80 mcg/mL, respectively, while the mean adiponectin levels among normal weight, overweight, and obese females were 13.42, 12.12, and 9.04 mcg/mL, respectively. After the researchers controlled for gender and fat mass in adolescence, they found that shorter breastfeeding and change in weight-for-age z-score were associated with lower adolescent adiponectin levels (a 1.5 mcg/mL decrease in adiponectin levels for shorter breast feeding and a 0.7 mcg/mL decrease for every unit increase of weight-for-age z-score).
“Adiponectin levels are heterogeneous across sex and weight status,” Dr. Reyes concluded. “Earlier first bottle and higher weight gain during the first 6 months of age were associated with lower adiponectin levels in the adolescents.” She characterized the first 1,000 days of life as “a window of opportunity to try to prolong breastfeeding or to deal with rapid weight gain. This could help adolescents have healthier metabolic performance that may carry over into later life.”
The study was funded by the National Institutes of Health. Dr. Reyes reported having no relevant financial disclosures.
On Twitter @dougbrunk
SAN DIEGO – Adiponectin, a “healthy” hormone secreted from adipose tissue, was higher in adolescent females compared with males, and decreased as body weight increased, a longitudinal cohort analysis demonstrated.
“Low adiponectin levels are associated with metabolic risk, regardless of fat mass and sex,” lead study author Dr. Marcela Reyes said at the annual meeting of the Pediatric Academic Societies. “There is currently a gap in knowledge in factors that determine circulating adiponectin levels.”
In an effort to evaluate the role of infancy exposures (duration of breast feeding and weight-gain velocity) on adolescent adiponectin levels after taking into account gender and fat mass, Dr. Reyes and her associates studied a cohort of 584 normal–birth weight adolescents who were recruited at age 4 months for an iron deficiency preventive trial in Santiago, Chile from 1991 to 1996 and evaluated for cardiovascular risk 16 years later.
Dr. Reyes of the Institute of Nutrition and Food Technology at the University of Chile, Santiago, and her associates prospectively assessed breastfeeding from the age of 4 months and measured weight and height monthly. Adolescent outcomes included body mass index (BMI) z-scores, fat mass, and fasting serum adiponectin levels. The researchers used linear regression to model the effect of short breastfeeding (defined as breastfeeding for shorter than 180 days as the sole source of milk, as recommended by pediatricians) and weight gain in the first 6 months on adolescent adiponectin levels, after controlling for fat mass and gender.
The mean body weight at birth of the 584 adolescents was 3.5 kg, which increased to 8.0 kg at 6 months, with no change in the weight-for-age z-scores; 75% experienced a short exposure to breastfeeding. At age 16 years, their mean adiponectin level was 11.3 mcg/mL and differed by weight status and gender.
Specifically, the mean adiponectin levels among normal weight, overweight, and obese males were 11.06, 8.86, and 7.80 mcg/mL, respectively, while the mean adiponectin levels among normal weight, overweight, and obese females were 13.42, 12.12, and 9.04 mcg/mL, respectively. After the researchers controlled for gender and fat mass in adolescence, they found that shorter breastfeeding and change in weight-for-age z-score were associated with lower adolescent adiponectin levels (a 1.5 mcg/mL decrease in adiponectin levels for shorter breast feeding and a 0.7 mcg/mL decrease for every unit increase of weight-for-age z-score).
“Adiponectin levels are heterogeneous across sex and weight status,” Dr. Reyes concluded. “Earlier first bottle and higher weight gain during the first 6 months of age were associated with lower adiponectin levels in the adolescents.” She characterized the first 1,000 days of life as “a window of opportunity to try to prolong breastfeeding or to deal with rapid weight gain. This could help adolescents have healthier metabolic performance that may carry over into later life.”
The study was funded by the National Institutes of Health. Dr. Reyes reported having no relevant financial disclosures.
On Twitter @dougbrunk
SAN DIEGO – Adiponectin, a “healthy” hormone secreted from adipose tissue, was higher in adolescent females compared with males, and decreased as body weight increased, a longitudinal cohort analysis demonstrated.
“Low adiponectin levels are associated with metabolic risk, regardless of fat mass and sex,” lead study author Dr. Marcela Reyes said at the annual meeting of the Pediatric Academic Societies. “There is currently a gap in knowledge in factors that determine circulating adiponectin levels.”
In an effort to evaluate the role of infancy exposures (duration of breast feeding and weight-gain velocity) on adolescent adiponectin levels after taking into account gender and fat mass, Dr. Reyes and her associates studied a cohort of 584 normal–birth weight adolescents who were recruited at age 4 months for an iron deficiency preventive trial in Santiago, Chile from 1991 to 1996 and evaluated for cardiovascular risk 16 years later.
Dr. Reyes of the Institute of Nutrition and Food Technology at the University of Chile, Santiago, and her associates prospectively assessed breastfeeding from the age of 4 months and measured weight and height monthly. Adolescent outcomes included body mass index (BMI) z-scores, fat mass, and fasting serum adiponectin levels. The researchers used linear regression to model the effect of short breastfeeding (defined as breastfeeding for shorter than 180 days as the sole source of milk, as recommended by pediatricians) and weight gain in the first 6 months on adolescent adiponectin levels, after controlling for fat mass and gender.
The mean body weight at birth of the 584 adolescents was 3.5 kg, which increased to 8.0 kg at 6 months, with no change in the weight-for-age z-scores; 75% experienced a short exposure to breastfeeding. At age 16 years, their mean adiponectin level was 11.3 mcg/mL and differed by weight status and gender.
Specifically, the mean adiponectin levels among normal weight, overweight, and obese males were 11.06, 8.86, and 7.80 mcg/mL, respectively, while the mean adiponectin levels among normal weight, overweight, and obese females were 13.42, 12.12, and 9.04 mcg/mL, respectively. After the researchers controlled for gender and fat mass in adolescence, they found that shorter breastfeeding and change in weight-for-age z-score were associated with lower adolescent adiponectin levels (a 1.5 mcg/mL decrease in adiponectin levels for shorter breast feeding and a 0.7 mcg/mL decrease for every unit increase of weight-for-age z-score).
“Adiponectin levels are heterogeneous across sex and weight status,” Dr. Reyes concluded. “Earlier first bottle and higher weight gain during the first 6 months of age were associated with lower adiponectin levels in the adolescents.” She characterized the first 1,000 days of life as “a window of opportunity to try to prolong breastfeeding or to deal with rapid weight gain. This could help adolescents have healthier metabolic performance that may carry over into later life.”
The study was funded by the National Institutes of Health. Dr. Reyes reported having no relevant financial disclosures.
On Twitter @dougbrunk
AT THE PAS ANNUAL MEETING
Key clinical point: Earlier first bottle and higher weight gain in the first 6 months of life were associated with lower adiponectin levels in adolescents.
Major finding: After controlling for gender and fat mass in adolescence, shorter breastfeeding and change in weight-for-age z-score were associated with lower adolescent adiponectin levels (a 1.5 mcg/mL decrease in adiponectin levels for shorter breast feeding and a 0.7 mcg/mL decrease for every unit increase of weight-for-age z-score).
Data source: A cohort of 584 normal–birth weight adolescents who were recruited at age 4 months for an iron deficiency preventive trial in Santiago, Chile from 1991 to 1996 and evaluated for cardiovascular risk 16 years later.
Disclosures:The study was funded by the National Institutes of Health. Dr. Reyes reported having no relevant financial disclosures.
PAS: Genetic testing for MODY deemed increasingly cost effective
SAN DIEGO – Routine genetic testing for maturity-onset diabetes of the young has become compellingly cost effective in selected populations of diabetic patients, Dr. Siri Atma W. Greeley asserted at the annual meeting of the Pediatric Academic Societies.
“We’re not quite at the point of saying test everyone with diabetes for monogenic causes, but as the cost of genetic testing goes down that could actually happen,” said Dr. Greeley, a pediatric endocrinologist at the University of Chicago.
Today, however, the genetic testing is greatly underutilized and the insurance industry remains balky about providing coverage. That’s starting to change, though, as Dr. Greeley and other MODY experts meet with insurers and explain the dollars-and-cents benefits. Encouragingly, Aetna has led the way forward by publishing its rules for coverage of MODY genetic testing in 2015.
Dr. Greeley was coauthor of a study that evaluated the cost-effectiveness of testing for mutations in three genes responsible for more than 90% of cases of MODY with a known cause. The study, led by his University of Chicago colleague Dr. Rochelle N. Naylor, involved a hypothetical cohort of 25- to 40-year-olds presumed to have type 2 diabetes. Various studies indicate that roughly 2% of such patients actually turn out to have MODY. The question asked by the researchers was, is it cost effective to find them?
With a 2% MODY prevalence, the answer turned out to be no. However, if the population undergoing genetic testing could be enriched through application of clinical criteria associated with increased risk of MODY, then testing does become cost effective even when it identifies a case only 6% of the time. Under that scenario, at a genetic testing cost of $2,580, the incremental cost-effectiveness ratio is $50,000 per additional quality-adjusted life year, which meets the definition of cost-effectiveness widely accepted by health policy makers.
The improvement in quality-adjusted life years is achieved in the case of MODY on the basis of reduced lifetime costs of treatment and complications because one relatively common type of MODY known as glucokinase MODY, or MODY 2, requires no treatment and has essentially no vascular complications, while other common forms of MODY generally respond well to low-dose sulfonylureas rather than more elaborate insulin regimens.
The analysis also concluded that routine testing in a population with a 2% prevalence of MODY would become cost effective if the price tag for testing decreased to $700, as seems highly plausible with further advances in sequencing. And if the MODY prevalence is 31%, a policy of routine genetic testing for MODY actually becomes cost saving rather than just cost effective (Diabetes Care 2014;37:202-9).
This cost-effectiveness analysis doesn’t take into account the added value of genetic testing in terms of family counseling. MODY is transmitted in autosomal dominant fashion, so first-degree relatives of an affected individual have a 50% chance of inheriting a MODY gene mutation, Dr. Greeley noted.
He assisted University of Chicago laboratory scientists in creating a commercially available panel that tests for more than 40 genes known to cause diabetes, including all of the genes known to cause the various types of MODY.
The American Diabetes Association, in its standards of care for 2015, lists a series of criteria that boost the likelihood of monogenic diabetes above the background 2% rate, including diabetes with negative autoantibodies and no signs of insulin resistance or obesity. Moreover, investigators at the University of Exeter (England) have developed an eight-question MODY probability calculator to guide genetic testing decisions, although this tool requires validation. The Exeter group also has shown that among women with gestational diabetes who meet the dual criteria of a body mass index below 25 kg/m2 plus a fasting blood glucose of 5.5 mmol/L or more, genetic testing will identify one case of glucokinase MODY for every 2.7 such women tested (Diabetes Care 2014;37:1230-6).
Dr. Greeley’s research is funded by the National Institutes of Health, the American Diabetes Association, and the Kovler Family Foundation. He reported having no financial conflicts and emphasized that he has no financial ties to the University of Chicago’s genetic testing lab.
SAN DIEGO – Routine genetic testing for maturity-onset diabetes of the young has become compellingly cost effective in selected populations of diabetic patients, Dr. Siri Atma W. Greeley asserted at the annual meeting of the Pediatric Academic Societies.
“We’re not quite at the point of saying test everyone with diabetes for monogenic causes, but as the cost of genetic testing goes down that could actually happen,” said Dr. Greeley, a pediatric endocrinologist at the University of Chicago.
Today, however, the genetic testing is greatly underutilized and the insurance industry remains balky about providing coverage. That’s starting to change, though, as Dr. Greeley and other MODY experts meet with insurers and explain the dollars-and-cents benefits. Encouragingly, Aetna has led the way forward by publishing its rules for coverage of MODY genetic testing in 2015.
Dr. Greeley was coauthor of a study that evaluated the cost-effectiveness of testing for mutations in three genes responsible for more than 90% of cases of MODY with a known cause. The study, led by his University of Chicago colleague Dr. Rochelle N. Naylor, involved a hypothetical cohort of 25- to 40-year-olds presumed to have type 2 diabetes. Various studies indicate that roughly 2% of such patients actually turn out to have MODY. The question asked by the researchers was, is it cost effective to find them?
With a 2% MODY prevalence, the answer turned out to be no. However, if the population undergoing genetic testing could be enriched through application of clinical criteria associated with increased risk of MODY, then testing does become cost effective even when it identifies a case only 6% of the time. Under that scenario, at a genetic testing cost of $2,580, the incremental cost-effectiveness ratio is $50,000 per additional quality-adjusted life year, which meets the definition of cost-effectiveness widely accepted by health policy makers.
The improvement in quality-adjusted life years is achieved in the case of MODY on the basis of reduced lifetime costs of treatment and complications because one relatively common type of MODY known as glucokinase MODY, or MODY 2, requires no treatment and has essentially no vascular complications, while other common forms of MODY generally respond well to low-dose sulfonylureas rather than more elaborate insulin regimens.
The analysis also concluded that routine testing in a population with a 2% prevalence of MODY would become cost effective if the price tag for testing decreased to $700, as seems highly plausible with further advances in sequencing. And if the MODY prevalence is 31%, a policy of routine genetic testing for MODY actually becomes cost saving rather than just cost effective (Diabetes Care 2014;37:202-9).
This cost-effectiveness analysis doesn’t take into account the added value of genetic testing in terms of family counseling. MODY is transmitted in autosomal dominant fashion, so first-degree relatives of an affected individual have a 50% chance of inheriting a MODY gene mutation, Dr. Greeley noted.
He assisted University of Chicago laboratory scientists in creating a commercially available panel that tests for more than 40 genes known to cause diabetes, including all of the genes known to cause the various types of MODY.
The American Diabetes Association, in its standards of care for 2015, lists a series of criteria that boost the likelihood of monogenic diabetes above the background 2% rate, including diabetes with negative autoantibodies and no signs of insulin resistance or obesity. Moreover, investigators at the University of Exeter (England) have developed an eight-question MODY probability calculator to guide genetic testing decisions, although this tool requires validation. The Exeter group also has shown that among women with gestational diabetes who meet the dual criteria of a body mass index below 25 kg/m2 plus a fasting blood glucose of 5.5 mmol/L or more, genetic testing will identify one case of glucokinase MODY for every 2.7 such women tested (Diabetes Care 2014;37:1230-6).
Dr. Greeley’s research is funded by the National Institutes of Health, the American Diabetes Association, and the Kovler Family Foundation. He reported having no financial conflicts and emphasized that he has no financial ties to the University of Chicago’s genetic testing lab.
SAN DIEGO – Routine genetic testing for maturity-onset diabetes of the young has become compellingly cost effective in selected populations of diabetic patients, Dr. Siri Atma W. Greeley asserted at the annual meeting of the Pediatric Academic Societies.
“We’re not quite at the point of saying test everyone with diabetes for monogenic causes, but as the cost of genetic testing goes down that could actually happen,” said Dr. Greeley, a pediatric endocrinologist at the University of Chicago.
Today, however, the genetic testing is greatly underutilized and the insurance industry remains balky about providing coverage. That’s starting to change, though, as Dr. Greeley and other MODY experts meet with insurers and explain the dollars-and-cents benefits. Encouragingly, Aetna has led the way forward by publishing its rules for coverage of MODY genetic testing in 2015.
Dr. Greeley was coauthor of a study that evaluated the cost-effectiveness of testing for mutations in three genes responsible for more than 90% of cases of MODY with a known cause. The study, led by his University of Chicago colleague Dr. Rochelle N. Naylor, involved a hypothetical cohort of 25- to 40-year-olds presumed to have type 2 diabetes. Various studies indicate that roughly 2% of such patients actually turn out to have MODY. The question asked by the researchers was, is it cost effective to find them?
With a 2% MODY prevalence, the answer turned out to be no. However, if the population undergoing genetic testing could be enriched through application of clinical criteria associated with increased risk of MODY, then testing does become cost effective even when it identifies a case only 6% of the time. Under that scenario, at a genetic testing cost of $2,580, the incremental cost-effectiveness ratio is $50,000 per additional quality-adjusted life year, which meets the definition of cost-effectiveness widely accepted by health policy makers.
The improvement in quality-adjusted life years is achieved in the case of MODY on the basis of reduced lifetime costs of treatment and complications because one relatively common type of MODY known as glucokinase MODY, or MODY 2, requires no treatment and has essentially no vascular complications, while other common forms of MODY generally respond well to low-dose sulfonylureas rather than more elaborate insulin regimens.
The analysis also concluded that routine testing in a population with a 2% prevalence of MODY would become cost effective if the price tag for testing decreased to $700, as seems highly plausible with further advances in sequencing. And if the MODY prevalence is 31%, a policy of routine genetic testing for MODY actually becomes cost saving rather than just cost effective (Diabetes Care 2014;37:202-9).
This cost-effectiveness analysis doesn’t take into account the added value of genetic testing in terms of family counseling. MODY is transmitted in autosomal dominant fashion, so first-degree relatives of an affected individual have a 50% chance of inheriting a MODY gene mutation, Dr. Greeley noted.
He assisted University of Chicago laboratory scientists in creating a commercially available panel that tests for more than 40 genes known to cause diabetes, including all of the genes known to cause the various types of MODY.
The American Diabetes Association, in its standards of care for 2015, lists a series of criteria that boost the likelihood of monogenic diabetes above the background 2% rate, including diabetes with negative autoantibodies and no signs of insulin resistance or obesity. Moreover, investigators at the University of Exeter (England) have developed an eight-question MODY probability calculator to guide genetic testing decisions, although this tool requires validation. The Exeter group also has shown that among women with gestational diabetes who meet the dual criteria of a body mass index below 25 kg/m2 plus a fasting blood glucose of 5.5 mmol/L or more, genetic testing will identify one case of glucokinase MODY for every 2.7 such women tested (Diabetes Care 2014;37:1230-6).
Dr. Greeley’s research is funded by the National Institutes of Health, the American Diabetes Association, and the Kovler Family Foundation. He reported having no financial conflicts and emphasized that he has no financial ties to the University of Chicago’s genetic testing lab.
EXPERT ANALYSIS FROM THE PAS ANNUAL MEETING
PAS: Bronchiolitis clinical pathway reduces length of stay, costs, readmissions
SAN DIEGO– Adoption of and strict adherence to a clinical pathway for diagnosis and treatment of bronchiolitis, especially in pediatric patients, can alleviate costs for both patients and hospitals in the ED and inpatient settings, and allow for shorter lengths of stay, according to a retrospective cohort study.
“This is an important topic because bronchiolitis is the leading cause of infant hospitalization in the U.S., and the cost of bronchiolitis hospitalization has been increasing,” Dr. Mersine A. Bryan of Seattle Children’s Hospital said at the annual meeting of the Pediatric Academic Societies.
“The care for bronchiolitis is supportive, meaning that testing and medical treatments are generally unnecessary, and can add to costs without improving outcomes. Because of that, bronchiolitis is a good candidate for clinical pathways and clinical practice guidelines,” Dr. Bryan said.
She and her coinvestigators looked at 282 children aged 0-24 months who presented at Seattle Children’s Hospital’s emergency department or inpatient setting with bronchiolitis between December 2009 and July 2012. A total of 18 process-of-care quality measures were instituted – 12 designed for inpatient care, 6 for emergency departments – with a primary objective of mitigating length-of-stay, costs, inpatient admission, and readmission. Pathways were meant to guide clinicians with “evidence-based recommendations and flows based on patient assessments and clinical findings.” Adherence to these pathways was scored by medical record review on a scale of 0-100 for each of the 18 categories. Low adherence was classified as a score below 86, midlevel adherence as a score between 86 and 93, and high adherence as anything above 94.
Mean adherence scores were: ED 78.2 (standard deviation [SD] 18.3, n = 279), inpatient 94.7 (SD 6.6, n = 231).No difference was noted in care of patients based on patient gender and medical complexity, but higher adherence was noted for younger patients.
Higher adherence led to shorter length of stay in both inpatient and emergency departments: 2.7 days vs. 3.7 days (P < .05), and 191 minutes vs. 264 minutes (P < .01), respectively. Mean patient costs saw greater reductions in departments with high adherence; a difference of $3,045 was noted in high-adherence inpatient departments, compared to a difference of $1,564 in inpatient departments with lower adherence to the pathway (P < .05). Similarly, emergency departments with high adherence saw average costs per patient drop by $183, compared to $95 for emergency departments with lower adherence scores (P < .05). Admittance odds and 7-day readmissions to emergency departments also were lower when adherence to pathways was higher.
Dr. Bryan cautioned that because this was a single-center study and the results may be difficult to generalize across institutions, adding that she and her coinvestigators were limited by the amount of information they could cull from available electronic medical records.
Dr. Bryan did not report any relevant financial disclosures.
SAN DIEGO– Adoption of and strict adherence to a clinical pathway for diagnosis and treatment of bronchiolitis, especially in pediatric patients, can alleviate costs for both patients and hospitals in the ED and inpatient settings, and allow for shorter lengths of stay, according to a retrospective cohort study.
“This is an important topic because bronchiolitis is the leading cause of infant hospitalization in the U.S., and the cost of bronchiolitis hospitalization has been increasing,” Dr. Mersine A. Bryan of Seattle Children’s Hospital said at the annual meeting of the Pediatric Academic Societies.
“The care for bronchiolitis is supportive, meaning that testing and medical treatments are generally unnecessary, and can add to costs without improving outcomes. Because of that, bronchiolitis is a good candidate for clinical pathways and clinical practice guidelines,” Dr. Bryan said.
She and her coinvestigators looked at 282 children aged 0-24 months who presented at Seattle Children’s Hospital’s emergency department or inpatient setting with bronchiolitis between December 2009 and July 2012. A total of 18 process-of-care quality measures were instituted – 12 designed for inpatient care, 6 for emergency departments – with a primary objective of mitigating length-of-stay, costs, inpatient admission, and readmission. Pathways were meant to guide clinicians with “evidence-based recommendations and flows based on patient assessments and clinical findings.” Adherence to these pathways was scored by medical record review on a scale of 0-100 for each of the 18 categories. Low adherence was classified as a score below 86, midlevel adherence as a score between 86 and 93, and high adherence as anything above 94.
Mean adherence scores were: ED 78.2 (standard deviation [SD] 18.3, n = 279), inpatient 94.7 (SD 6.6, n = 231).No difference was noted in care of patients based on patient gender and medical complexity, but higher adherence was noted for younger patients.
Higher adherence led to shorter length of stay in both inpatient and emergency departments: 2.7 days vs. 3.7 days (P < .05), and 191 minutes vs. 264 minutes (P < .01), respectively. Mean patient costs saw greater reductions in departments with high adherence; a difference of $3,045 was noted in high-adherence inpatient departments, compared to a difference of $1,564 in inpatient departments with lower adherence to the pathway (P < .05). Similarly, emergency departments with high adherence saw average costs per patient drop by $183, compared to $95 for emergency departments with lower adherence scores (P < .05). Admittance odds and 7-day readmissions to emergency departments also were lower when adherence to pathways was higher.
Dr. Bryan cautioned that because this was a single-center study and the results may be difficult to generalize across institutions, adding that she and her coinvestigators were limited by the amount of information they could cull from available electronic medical records.
Dr. Bryan did not report any relevant financial disclosures.
SAN DIEGO– Adoption of and strict adherence to a clinical pathway for diagnosis and treatment of bronchiolitis, especially in pediatric patients, can alleviate costs for both patients and hospitals in the ED and inpatient settings, and allow for shorter lengths of stay, according to a retrospective cohort study.
“This is an important topic because bronchiolitis is the leading cause of infant hospitalization in the U.S., and the cost of bronchiolitis hospitalization has been increasing,” Dr. Mersine A. Bryan of Seattle Children’s Hospital said at the annual meeting of the Pediatric Academic Societies.
“The care for bronchiolitis is supportive, meaning that testing and medical treatments are generally unnecessary, and can add to costs without improving outcomes. Because of that, bronchiolitis is a good candidate for clinical pathways and clinical practice guidelines,” Dr. Bryan said.
She and her coinvestigators looked at 282 children aged 0-24 months who presented at Seattle Children’s Hospital’s emergency department or inpatient setting with bronchiolitis between December 2009 and July 2012. A total of 18 process-of-care quality measures were instituted – 12 designed for inpatient care, 6 for emergency departments – with a primary objective of mitigating length-of-stay, costs, inpatient admission, and readmission. Pathways were meant to guide clinicians with “evidence-based recommendations and flows based on patient assessments and clinical findings.” Adherence to these pathways was scored by medical record review on a scale of 0-100 for each of the 18 categories. Low adherence was classified as a score below 86, midlevel adherence as a score between 86 and 93, and high adherence as anything above 94.
Mean adherence scores were: ED 78.2 (standard deviation [SD] 18.3, n = 279), inpatient 94.7 (SD 6.6, n = 231).No difference was noted in care of patients based on patient gender and medical complexity, but higher adherence was noted for younger patients.
Higher adherence led to shorter length of stay in both inpatient and emergency departments: 2.7 days vs. 3.7 days (P < .05), and 191 minutes vs. 264 minutes (P < .01), respectively. Mean patient costs saw greater reductions in departments with high adherence; a difference of $3,045 was noted in high-adherence inpatient departments, compared to a difference of $1,564 in inpatient departments with lower adherence to the pathway (P < .05). Similarly, emergency departments with high adherence saw average costs per patient drop by $183, compared to $95 for emergency departments with lower adherence scores (P < .05). Admittance odds and 7-day readmissions to emergency departments also were lower when adherence to pathways was higher.
Dr. Bryan cautioned that because this was a single-center study and the results may be difficult to generalize across institutions, adding that she and her coinvestigators were limited by the amount of information they could cull from available electronic medical records.
Dr. Bryan did not report any relevant financial disclosures.
AT THE PAS ANNUAL MEETING
Key clinical point: High adherence to a bronchiolitis clinical pathway can lead to shorter lengths of stay and lower costs for patients in the ED and inpatient settings without increasing readmission rates or compromising standard of care.
Major finding: ED and inpatient LOS decreased significantly in cohorts with high adherence to clinical pathway: 191 vs. 264 minutes for ED and 2.7 vs. 3.7 days for inpatient; average costs per patient decreased by $183 vs. $95 for ED and $3,045 vs. $1,564 for inpatient.
Data source: Retrospective cohort study of 282 patients ages 0-24 months at Seattle Children’s Hospital ED and/or inpatient setting from Dec. 2009, to July 2012.
Disclosures:Dr. Bryan did not report any relevant disclosures.
PAS: Swallow test may raise respiratory infection risk in infants
SAN DIEGO– There is no clear clinical benefit to diagnosing and treating infants with abnormal swallowing, according to the results of a video fluoroscopic swallow study (VFSS), and in certain cases, the study could be associated with an increased risk of developing acute respiratory infections (ARI) in these populations.
In a retrospective cohort study, Dr. Eric R. Coon of the University of Utah, Salt Lake City, and his colleagues examined data on all infants aged 12 months or younger who underwent VFSS from 2010 to 2012 at Primary Children’s Hospital in Salt Lake City.
“Providers implicitly believe that infant swallowing abnormalities lead to future respiratory illness,” Dr. Coon said at the annual meeting of the Pediatric Academic Societies. “However, data for that link is limited to descriptive case series, and studies relying on subjective definitions of aspiration that don’t include radiographic confirmation [and] interventions for swallowing abnormalities have not been shown to improve important clinical outcomes.”
The investigators looked at all inpatient, outpatient, and emergency department ARI cases in the Intermountain Healthcare system, a network of 22 hospital centers servicing five states, over the same time period in patients who experienced ARI between their first VFSS and age 3 years. ARI was defined as either bronchiolitis, asthma, pneumonia, or aspiration pneumonia, and was identified via IDC-9 codes.
Out of 576 infants, 199 (34%) exhibited oropharyngeal aspiration, 79 (14%) showed penetration, and 298 (52%)were classified as “normal.” Of the 199 with aspiration, 38 (19%) had thin aspiration and cough, 11 (6%) had thick aspiration and cough, 93 (47%) had thin aspiration and were silent, and 57 (28%) had thick aspiration and were silent.
Those deemed “thick aspiration, silent,” however, averaged 581 days to ARI, the shortest of any cohort, and a mean of 2.39 ARIs per subject. “Thin aspiration, cough” subjects had 638 mean days to ARI and a mean of 1.63 ARIs; “thick aspiration, cough” subjects had a mean of 750 days to ARI and 0.55 mean number of ARIs; and “thin aspiration, silent” had an average of 669 days to ARI and a mean of 1.69 ARIs (P < .05).
Those in the normal, or control, cohort averaged 715 days to ARI and 1.36 ARIs, while those with just penetration averaged 681 days to ARIs and 1.53 ARIs per subject (P < .05).
Cox regression models were used to calculate data time to first ARI, and Poisson regression was used for data on total number of ARIs experienced. Taking into account subject’s age at initial test, presence of complex chronic conditions in each subject, result of VFSS and type of aspiration intervention, silent aspiration with thickened feed yielded a Cox hazard ratio of 1.30 and a Poisson hazard ratio of 1.47, higher than all the others.
“The clinical importance of [VFSS]-detected abnormalities remains unclear, making them high-risk for overdiagnosis,” concluded Dr. Coon, adding that “patients may not experience net benefit, but may in fact be harmed.”
Dr. Coon did not report any relevant financial disclosures.
SAN DIEGO– There is no clear clinical benefit to diagnosing and treating infants with abnormal swallowing, according to the results of a video fluoroscopic swallow study (VFSS), and in certain cases, the study could be associated with an increased risk of developing acute respiratory infections (ARI) in these populations.
In a retrospective cohort study, Dr. Eric R. Coon of the University of Utah, Salt Lake City, and his colleagues examined data on all infants aged 12 months or younger who underwent VFSS from 2010 to 2012 at Primary Children’s Hospital in Salt Lake City.
“Providers implicitly believe that infant swallowing abnormalities lead to future respiratory illness,” Dr. Coon said at the annual meeting of the Pediatric Academic Societies. “However, data for that link is limited to descriptive case series, and studies relying on subjective definitions of aspiration that don’t include radiographic confirmation [and] interventions for swallowing abnormalities have not been shown to improve important clinical outcomes.”
The investigators looked at all inpatient, outpatient, and emergency department ARI cases in the Intermountain Healthcare system, a network of 22 hospital centers servicing five states, over the same time period in patients who experienced ARI between their first VFSS and age 3 years. ARI was defined as either bronchiolitis, asthma, pneumonia, or aspiration pneumonia, and was identified via IDC-9 codes.
Out of 576 infants, 199 (34%) exhibited oropharyngeal aspiration, 79 (14%) showed penetration, and 298 (52%)were classified as “normal.” Of the 199 with aspiration, 38 (19%) had thin aspiration and cough, 11 (6%) had thick aspiration and cough, 93 (47%) had thin aspiration and were silent, and 57 (28%) had thick aspiration and were silent.
Those deemed “thick aspiration, silent,” however, averaged 581 days to ARI, the shortest of any cohort, and a mean of 2.39 ARIs per subject. “Thin aspiration, cough” subjects had 638 mean days to ARI and a mean of 1.63 ARIs; “thick aspiration, cough” subjects had a mean of 750 days to ARI and 0.55 mean number of ARIs; and “thin aspiration, silent” had an average of 669 days to ARI and a mean of 1.69 ARIs (P < .05).
Those in the normal, or control, cohort averaged 715 days to ARI and 1.36 ARIs, while those with just penetration averaged 681 days to ARIs and 1.53 ARIs per subject (P < .05).
Cox regression models were used to calculate data time to first ARI, and Poisson regression was used for data on total number of ARIs experienced. Taking into account subject’s age at initial test, presence of complex chronic conditions in each subject, result of VFSS and type of aspiration intervention, silent aspiration with thickened feed yielded a Cox hazard ratio of 1.30 and a Poisson hazard ratio of 1.47, higher than all the others.
“The clinical importance of [VFSS]-detected abnormalities remains unclear, making them high-risk for overdiagnosis,” concluded Dr. Coon, adding that “patients may not experience net benefit, but may in fact be harmed.”
Dr. Coon did not report any relevant financial disclosures.
SAN DIEGO– There is no clear clinical benefit to diagnosing and treating infants with abnormal swallowing, according to the results of a video fluoroscopic swallow study (VFSS), and in certain cases, the study could be associated with an increased risk of developing acute respiratory infections (ARI) in these populations.
In a retrospective cohort study, Dr. Eric R. Coon of the University of Utah, Salt Lake City, and his colleagues examined data on all infants aged 12 months or younger who underwent VFSS from 2010 to 2012 at Primary Children’s Hospital in Salt Lake City.
“Providers implicitly believe that infant swallowing abnormalities lead to future respiratory illness,” Dr. Coon said at the annual meeting of the Pediatric Academic Societies. “However, data for that link is limited to descriptive case series, and studies relying on subjective definitions of aspiration that don’t include radiographic confirmation [and] interventions for swallowing abnormalities have not been shown to improve important clinical outcomes.”
The investigators looked at all inpatient, outpatient, and emergency department ARI cases in the Intermountain Healthcare system, a network of 22 hospital centers servicing five states, over the same time period in patients who experienced ARI between their first VFSS and age 3 years. ARI was defined as either bronchiolitis, asthma, pneumonia, or aspiration pneumonia, and was identified via IDC-9 codes.
Out of 576 infants, 199 (34%) exhibited oropharyngeal aspiration, 79 (14%) showed penetration, and 298 (52%)were classified as “normal.” Of the 199 with aspiration, 38 (19%) had thin aspiration and cough, 11 (6%) had thick aspiration and cough, 93 (47%) had thin aspiration and were silent, and 57 (28%) had thick aspiration and were silent.
Those deemed “thick aspiration, silent,” however, averaged 581 days to ARI, the shortest of any cohort, and a mean of 2.39 ARIs per subject. “Thin aspiration, cough” subjects had 638 mean days to ARI and a mean of 1.63 ARIs; “thick aspiration, cough” subjects had a mean of 750 days to ARI and 0.55 mean number of ARIs; and “thin aspiration, silent” had an average of 669 days to ARI and a mean of 1.69 ARIs (P < .05).
Those in the normal, or control, cohort averaged 715 days to ARI and 1.36 ARIs, while those with just penetration averaged 681 days to ARIs and 1.53 ARIs per subject (P < .05).
Cox regression models were used to calculate data time to first ARI, and Poisson regression was used for data on total number of ARIs experienced. Taking into account subject’s age at initial test, presence of complex chronic conditions in each subject, result of VFSS and type of aspiration intervention, silent aspiration with thickened feed yielded a Cox hazard ratio of 1.30 and a Poisson hazard ratio of 1.47, higher than all the others.
“The clinical importance of [VFSS]-detected abnormalities remains unclear, making them high-risk for overdiagnosis,” concluded Dr. Coon, adding that “patients may not experience net benefit, but may in fact be harmed.”
Dr. Coon did not report any relevant financial disclosures.
AT THE PAS ANNUAL MEETING
Key clinical point: Infants with swallowing abnormalities who are tested with video fluoroscopic swallow study are not at any less of a risk to develop an acute respiratory infection, and at least one type of swallowing abnormality poses an increased risk for an ARI.
Major finding: Thirty-four percent of infants demonstrated oropharyngeal aspiration; silent aspiration of thick feeds had the lowest mean days to ARI (581) and highest mean number of ARIs (2.39).
Data source: Retrospective cohort study of 576 infants (age <12 months) during 2010-2012.
Disclosures: Dr. Coon did not report any relevant disclosures.
PAS: Children’s hospitals take disproportionate financial losses from Medicaid
SAN DIEGO – Freestanding children’s hospitals take a far larger financial hit in serving Medicaid pediatric inpatients than do hospitals of other types, Dr. Jeffrey D. Colvin reported at the annual meeting of the Pediatric Academic Societies.
“Increasing Medicaid reimbursement for hospitals serving large volumes of pediatric inpatients covered by Medicaid should be considered,” asserted Dr. Colvin of Children’s Mercy Hospital in Kansas City, Mo.
He presented a cross-sectional study of the Kids’ Inpatient Database (KID) sponsored by the Agency for Healthcare Research and Quality. The analysis encompassed 843,725 discharges from 1,485 U.S. hospitals. The KID database contains total charges for every discharge. The purpose of the study was to determine the median inpatient net revenue from Medicaid by hospital type.
Hospitals of all types experienced a net financial loss for inpatient care of Medicaid-insured pediatric patients, but the size of the losses varied enormously. Freestanding children’s hospitals had a median annual loss of $9.7 million, compared with $1.8 million per year for children’s hospitals located within a general hospital, $204,100 for non-children’s teaching hospitals, and a median loss of just $28,300 per year for non-children’s non-teaching hospitals.
The rate of uninsured pediatric discharges at children’s hospitals was very low: 1.5% at the freestanding ones and 3.5% at those located within a general hospital.
“For all children’s hospitals, the reduction of uninsured patients under the Affordable Care Act is unlikely to offset the continuing losses from Medicaid,” Dr. Colvin observed.
The children’s hospitals provided a disproportionate amount of Medicaid-insured pediatric inpatient care. Freestanding children’s hospitals accounted for 0.8% of hospitals in the KID database, yet they were responsible for 6% of the discharges. And children’s hospitals within a general hospital composed 3.1% of all hospitals while handling 14% of all Medicaid discharges. In contrast, non-children’s non-teaching hospitals made up 75% of the hospital universe, but were responsible for 41.7% of discharges.
Forty-three percent of Medicaid discharges from freestanding children’s hospitals involved children with what is classified as a complex chronic condition. This was the case for 31% of discharges from children’s hospitals within a general hospital, 16.6% of Medicaid pediatric discharges from non-children’s teaching hospitals, and 8.8% of discharges from non-children’s non-teaching hospitals.
Dr. Colvin predicted that the financial burden on children’s hospitals is likely to worsen, given that under the Affordable Care Act, the Disproportionate Share Hospital Payments program that is part of Medicaid is scheduled to be greatly reduced if not eliminated.
The relationship between hospital charges and costs is convoluted. No single source exists for determining hospital-specific Medicaid revenue-to-cost ratios. Dr. Colvin and coinvestigators determined each hospital’s net Medicaid revenue by first figuring the hospital’s total cost, derived by multiplying total Medicaid inpatient charges by the Agency for Healthcare Research and Quality’s hospital-specific ratio of costs-to-charges. Total costs were then multiplied by the hospital’s ratio of revenue-to-costs as determined from the American Hospital Association and Centers for Medicare & Medicaid Services data. This figure, representing the hospital’s gross revenue from Medicaid, was subtracted from the costs to arrive at net revenue.
“This is really important information to give to policy makers, who seem to think that things will sort of level out under the Affordable Care Act,” said Dr. Megan M. Tschudy of Johns Hopkins University, Baltimore. Dr. Tschudy was session cochair.
Dr. Colvin concurred. “I would very much hope that this information has some kind of policy impact,” he said.
Dr. Colvin reported having no financial conflicts regarding this study, which was conducted without commercial support.
SAN DIEGO – Freestanding children’s hospitals take a far larger financial hit in serving Medicaid pediatric inpatients than do hospitals of other types, Dr. Jeffrey D. Colvin reported at the annual meeting of the Pediatric Academic Societies.
“Increasing Medicaid reimbursement for hospitals serving large volumes of pediatric inpatients covered by Medicaid should be considered,” asserted Dr. Colvin of Children’s Mercy Hospital in Kansas City, Mo.
He presented a cross-sectional study of the Kids’ Inpatient Database (KID) sponsored by the Agency for Healthcare Research and Quality. The analysis encompassed 843,725 discharges from 1,485 U.S. hospitals. The KID database contains total charges for every discharge. The purpose of the study was to determine the median inpatient net revenue from Medicaid by hospital type.
Hospitals of all types experienced a net financial loss for inpatient care of Medicaid-insured pediatric patients, but the size of the losses varied enormously. Freestanding children’s hospitals had a median annual loss of $9.7 million, compared with $1.8 million per year for children’s hospitals located within a general hospital, $204,100 for non-children’s teaching hospitals, and a median loss of just $28,300 per year for non-children’s non-teaching hospitals.
The rate of uninsured pediatric discharges at children’s hospitals was very low: 1.5% at the freestanding ones and 3.5% at those located within a general hospital.
“For all children’s hospitals, the reduction of uninsured patients under the Affordable Care Act is unlikely to offset the continuing losses from Medicaid,” Dr. Colvin observed.
The children’s hospitals provided a disproportionate amount of Medicaid-insured pediatric inpatient care. Freestanding children’s hospitals accounted for 0.8% of hospitals in the KID database, yet they were responsible for 6% of the discharges. And children’s hospitals within a general hospital composed 3.1% of all hospitals while handling 14% of all Medicaid discharges. In contrast, non-children’s non-teaching hospitals made up 75% of the hospital universe, but were responsible for 41.7% of discharges.
Forty-three percent of Medicaid discharges from freestanding children’s hospitals involved children with what is classified as a complex chronic condition. This was the case for 31% of discharges from children’s hospitals within a general hospital, 16.6% of Medicaid pediatric discharges from non-children’s teaching hospitals, and 8.8% of discharges from non-children’s non-teaching hospitals.
Dr. Colvin predicted that the financial burden on children’s hospitals is likely to worsen, given that under the Affordable Care Act, the Disproportionate Share Hospital Payments program that is part of Medicaid is scheduled to be greatly reduced if not eliminated.
The relationship between hospital charges and costs is convoluted. No single source exists for determining hospital-specific Medicaid revenue-to-cost ratios. Dr. Colvin and coinvestigators determined each hospital’s net Medicaid revenue by first figuring the hospital’s total cost, derived by multiplying total Medicaid inpatient charges by the Agency for Healthcare Research and Quality’s hospital-specific ratio of costs-to-charges. Total costs were then multiplied by the hospital’s ratio of revenue-to-costs as determined from the American Hospital Association and Centers for Medicare & Medicaid Services data. This figure, representing the hospital’s gross revenue from Medicaid, was subtracted from the costs to arrive at net revenue.
“This is really important information to give to policy makers, who seem to think that things will sort of level out under the Affordable Care Act,” said Dr. Megan M. Tschudy of Johns Hopkins University, Baltimore. Dr. Tschudy was session cochair.
Dr. Colvin concurred. “I would very much hope that this information has some kind of policy impact,” he said.
Dr. Colvin reported having no financial conflicts regarding this study, which was conducted without commercial support.
SAN DIEGO – Freestanding children’s hospitals take a far larger financial hit in serving Medicaid pediatric inpatients than do hospitals of other types, Dr. Jeffrey D. Colvin reported at the annual meeting of the Pediatric Academic Societies.
“Increasing Medicaid reimbursement for hospitals serving large volumes of pediatric inpatients covered by Medicaid should be considered,” asserted Dr. Colvin of Children’s Mercy Hospital in Kansas City, Mo.
He presented a cross-sectional study of the Kids’ Inpatient Database (KID) sponsored by the Agency for Healthcare Research and Quality. The analysis encompassed 843,725 discharges from 1,485 U.S. hospitals. The KID database contains total charges for every discharge. The purpose of the study was to determine the median inpatient net revenue from Medicaid by hospital type.
Hospitals of all types experienced a net financial loss for inpatient care of Medicaid-insured pediatric patients, but the size of the losses varied enormously. Freestanding children’s hospitals had a median annual loss of $9.7 million, compared with $1.8 million per year for children’s hospitals located within a general hospital, $204,100 for non-children’s teaching hospitals, and a median loss of just $28,300 per year for non-children’s non-teaching hospitals.
The rate of uninsured pediatric discharges at children’s hospitals was very low: 1.5% at the freestanding ones and 3.5% at those located within a general hospital.
“For all children’s hospitals, the reduction of uninsured patients under the Affordable Care Act is unlikely to offset the continuing losses from Medicaid,” Dr. Colvin observed.
The children’s hospitals provided a disproportionate amount of Medicaid-insured pediatric inpatient care. Freestanding children’s hospitals accounted for 0.8% of hospitals in the KID database, yet they were responsible for 6% of the discharges. And children’s hospitals within a general hospital composed 3.1% of all hospitals while handling 14% of all Medicaid discharges. In contrast, non-children’s non-teaching hospitals made up 75% of the hospital universe, but were responsible for 41.7% of discharges.
Forty-three percent of Medicaid discharges from freestanding children’s hospitals involved children with what is classified as a complex chronic condition. This was the case for 31% of discharges from children’s hospitals within a general hospital, 16.6% of Medicaid pediatric discharges from non-children’s teaching hospitals, and 8.8% of discharges from non-children’s non-teaching hospitals.
Dr. Colvin predicted that the financial burden on children’s hospitals is likely to worsen, given that under the Affordable Care Act, the Disproportionate Share Hospital Payments program that is part of Medicaid is scheduled to be greatly reduced if not eliminated.
The relationship between hospital charges and costs is convoluted. No single source exists for determining hospital-specific Medicaid revenue-to-cost ratios. Dr. Colvin and coinvestigators determined each hospital’s net Medicaid revenue by first figuring the hospital’s total cost, derived by multiplying total Medicaid inpatient charges by the Agency for Healthcare Research and Quality’s hospital-specific ratio of costs-to-charges. Total costs were then multiplied by the hospital’s ratio of revenue-to-costs as determined from the American Hospital Association and Centers for Medicare & Medicaid Services data. This figure, representing the hospital’s gross revenue from Medicaid, was subtracted from the costs to arrive at net revenue.
“This is really important information to give to policy makers, who seem to think that things will sort of level out under the Affordable Care Act,” said Dr. Megan M. Tschudy of Johns Hopkins University, Baltimore. Dr. Tschudy was session cochair.
Dr. Colvin concurred. “I would very much hope that this information has some kind of policy impact,” he said.
Dr. Colvin reported having no financial conflicts regarding this study, which was conducted without commercial support.
AT THE PAS ANNUAL MEETING
Key clinical point: Hospitals of all types experienced a net financial loss for inpatient care of Medicaid-insured pediatric patients, but the size of the losses varied enormously, with freestanding children’s hospitals taking the biggest hit.
Major finding: Freestanding children’s hospitals experience a median annual net financial loss for inpatient care of Medicaid-insured patients of $9.7 million, compared with a $28,300 loss for Medicaid pediatric inpatient care at non-teaching non-children’s hospitals.
Data source: A cross-sectional study of 843,725 discharges from 1,485 U.S. hospitals.
Disclosures: The presenter reported having no conflicts of interest. The study was done without commercial support.
PAS: Program curbs excess antibiotic prescribing in NICU
SAN DIEGO – Neonatal intensive care units are famously spendthrift when it comes to antibiotic utilization, but a well-executed antibiotic stewardship strategy can safely reduce unnecessary prescribing – as demonstrated at the 90-bed, level-IIIC neonatal intensive care unit (NICU) at Parkland Memorial Hospital, Dallas.
Results of the Surveillance and Correction of Unnecessary Antibiotic Therapy (SCOUT) study showed that total antibiotic days of therapy (DOT) in the Parkland NICU dropped by 27% following implementation of an antibiotic stewardship program featuring hard stops built into the electronic medical record, Dr. Joseph B. Cantey reported at the annual meeting of the Pediatric Academic Societies.
This overall reduction in antibiotic utilization was accomplished through improvements in the three specific categories of NICU antibiotic use targeted for intervention in the SCOUT study: treatment courses of more than 48 hours for “rule-out sepsis” and treatment lasting longer than 5 days for pneumonia or “culture-negative sepsis.”
The proportion of antibiotic treatment courses for rule-out sepsis that were discontinued by 48 hours when cultures were sterile tripled from 32% to 95% between a 9-month baseline period and a second 9-month period after implementation of the antibiotic stewardship program. The proportion of courses of antibiotics for pneumonia that were limited to 5 days doubled from 36% to 72%. Similarly, there was a doubling in the proportion of treatment courses for “culture-negative sepsis” limited to 5 days, with the rate going from 31% to 62%, said Dr. Cantey, a pediatrics fellow in training at the University of Texas Southwestern Medical Center, Dallas.
During the 9-month baseline surveillance period, in which there were 1,607 patients in the NICU, the total antibiotic use was 343 DOT per 1,000 patient-days. During period two with the intervention in place, there were 895 NICU patients, and 251 DOT per 1,000 patient-days. The DOT, a commonly used measure in the field of infectious diseases, is determined by multiplying the number of doses by the dosing interval. DOTs in patients on multiple antibiotics are additive, he explained.
During the baseline observation period, 94% of all antibiotic use in the NICU was empiric therapy for suspected infection. More specifically, 63% of all antibiotic use was for rule-out sepsis. And while many of the courses of antibiotics given for this reason that exceeded the 48-hour limit during the baseline period did so by only one or two doses, those extra doses added up to 41 DOT per 1,000 patient-years, making this a worthy target for intervention. Together with treatment of pneumonia or “culture-negative sepsis” for longer than 5 days, these three high-yield targets accounted for 87% of all antibiotic use in the NICU during the baseline period, Dr. Cantey said.
The infants occupying the NICU during the two 9-month study periods were virtually identical in terms of their characteristics and reasons for admission.
Antibiotics are the most commonly prescribed medications in NICUs. Their use has been associated with adverse NICU outcomes, including increased risks of necrotizing enterocolitis, late-onset sepsis, and death in infants with birth weights below 1,500 g, as well as an increase in multidrug-resistant organisms, he noted.
In SCOUT, the composite outcome of necrotizing enterocolitis, late-onset sepsis, or death didn’t differ between the two study periods: 17.1% at baseline and 15.8% during the intervention period. Similarly, the incidence of colonization with multidrug-resistant organisms was 1.4% during the baseline period and not significantly different at 1% after implementation of the antibiotic stewardship program. Larger multicenter studies with pooled data will be required to determine whether antibiotic stewardship in NICUs affects neonatal outcomes, Dr. Cantey said.
He added that he and his coinvestigators are now trying to identify additional NICU scenarios in which antibiotics can safely be withheld. One likely candidate: asymptomatic preterm infants exposed to premature rupture of membranes. The investigators also hope to utilize the ongoing prospective surveillance element of Parkland’s NICU antibiotic stewardship program to identify the safe minimum treatment duration for common conditions such as urinary tract infections, sepsis, and necrotizing enterocolitis.
Audience members were effusive in their praise of the SCOUT study and the Parkland program. They wanted to hear more details about how the physician behavior change was accomplished. Dr. Cantey said that the three intervention targets were approved by the NICU medical director and the plan was disseminated to all the neonatologists, nurse practitioners, fellows, and residents. It was important to be able to assure everyone that outcomes would be prospectively monitored closely to ensure safety. The toughest task, he added, was to create the hard stops in the electronic medical record so that, for example, treatment for rule-out sepsis would automatically stop at 48 hours: skilled information technologists were essential.
The SCOUT study was supported by a Gerber Novice Researcher Award from the Gerber Foundation. Dr. Cantey reported having no financial conflicts.
SAN DIEGO – Neonatal intensive care units are famously spendthrift when it comes to antibiotic utilization, but a well-executed antibiotic stewardship strategy can safely reduce unnecessary prescribing – as demonstrated at the 90-bed, level-IIIC neonatal intensive care unit (NICU) at Parkland Memorial Hospital, Dallas.
Results of the Surveillance and Correction of Unnecessary Antibiotic Therapy (SCOUT) study showed that total antibiotic days of therapy (DOT) in the Parkland NICU dropped by 27% following implementation of an antibiotic stewardship program featuring hard stops built into the electronic medical record, Dr. Joseph B. Cantey reported at the annual meeting of the Pediatric Academic Societies.
This overall reduction in antibiotic utilization was accomplished through improvements in the three specific categories of NICU antibiotic use targeted for intervention in the SCOUT study: treatment courses of more than 48 hours for “rule-out sepsis” and treatment lasting longer than 5 days for pneumonia or “culture-negative sepsis.”
The proportion of antibiotic treatment courses for rule-out sepsis that were discontinued by 48 hours when cultures were sterile tripled from 32% to 95% between a 9-month baseline period and a second 9-month period after implementation of the antibiotic stewardship program. The proportion of courses of antibiotics for pneumonia that were limited to 5 days doubled from 36% to 72%. Similarly, there was a doubling in the proportion of treatment courses for “culture-negative sepsis” limited to 5 days, with the rate going from 31% to 62%, said Dr. Cantey, a pediatrics fellow in training at the University of Texas Southwestern Medical Center, Dallas.
During the 9-month baseline surveillance period, in which there were 1,607 patients in the NICU, the total antibiotic use was 343 DOT per 1,000 patient-days. During period two with the intervention in place, there were 895 NICU patients, and 251 DOT per 1,000 patient-days. The DOT, a commonly used measure in the field of infectious diseases, is determined by multiplying the number of doses by the dosing interval. DOTs in patients on multiple antibiotics are additive, he explained.
During the baseline observation period, 94% of all antibiotic use in the NICU was empiric therapy for suspected infection. More specifically, 63% of all antibiotic use was for rule-out sepsis. And while many of the courses of antibiotics given for this reason that exceeded the 48-hour limit during the baseline period did so by only one or two doses, those extra doses added up to 41 DOT per 1,000 patient-years, making this a worthy target for intervention. Together with treatment of pneumonia or “culture-negative sepsis” for longer than 5 days, these three high-yield targets accounted for 87% of all antibiotic use in the NICU during the baseline period, Dr. Cantey said.
The infants occupying the NICU during the two 9-month study periods were virtually identical in terms of their characteristics and reasons for admission.
Antibiotics are the most commonly prescribed medications in NICUs. Their use has been associated with adverse NICU outcomes, including increased risks of necrotizing enterocolitis, late-onset sepsis, and death in infants with birth weights below 1,500 g, as well as an increase in multidrug-resistant organisms, he noted.
In SCOUT, the composite outcome of necrotizing enterocolitis, late-onset sepsis, or death didn’t differ between the two study periods: 17.1% at baseline and 15.8% during the intervention period. Similarly, the incidence of colonization with multidrug-resistant organisms was 1.4% during the baseline period and not significantly different at 1% after implementation of the antibiotic stewardship program. Larger multicenter studies with pooled data will be required to determine whether antibiotic stewardship in NICUs affects neonatal outcomes, Dr. Cantey said.
He added that he and his coinvestigators are now trying to identify additional NICU scenarios in which antibiotics can safely be withheld. One likely candidate: asymptomatic preterm infants exposed to premature rupture of membranes. The investigators also hope to utilize the ongoing prospective surveillance element of Parkland’s NICU antibiotic stewardship program to identify the safe minimum treatment duration for common conditions such as urinary tract infections, sepsis, and necrotizing enterocolitis.
Audience members were effusive in their praise of the SCOUT study and the Parkland program. They wanted to hear more details about how the physician behavior change was accomplished. Dr. Cantey said that the three intervention targets were approved by the NICU medical director and the plan was disseminated to all the neonatologists, nurse practitioners, fellows, and residents. It was important to be able to assure everyone that outcomes would be prospectively monitored closely to ensure safety. The toughest task, he added, was to create the hard stops in the electronic medical record so that, for example, treatment for rule-out sepsis would automatically stop at 48 hours: skilled information technologists were essential.
The SCOUT study was supported by a Gerber Novice Researcher Award from the Gerber Foundation. Dr. Cantey reported having no financial conflicts.
SAN DIEGO – Neonatal intensive care units are famously spendthrift when it comes to antibiotic utilization, but a well-executed antibiotic stewardship strategy can safely reduce unnecessary prescribing – as demonstrated at the 90-bed, level-IIIC neonatal intensive care unit (NICU) at Parkland Memorial Hospital, Dallas.
Results of the Surveillance and Correction of Unnecessary Antibiotic Therapy (SCOUT) study showed that total antibiotic days of therapy (DOT) in the Parkland NICU dropped by 27% following implementation of an antibiotic stewardship program featuring hard stops built into the electronic medical record, Dr. Joseph B. Cantey reported at the annual meeting of the Pediatric Academic Societies.
This overall reduction in antibiotic utilization was accomplished through improvements in the three specific categories of NICU antibiotic use targeted for intervention in the SCOUT study: treatment courses of more than 48 hours for “rule-out sepsis” and treatment lasting longer than 5 days for pneumonia or “culture-negative sepsis.”
The proportion of antibiotic treatment courses for rule-out sepsis that were discontinued by 48 hours when cultures were sterile tripled from 32% to 95% between a 9-month baseline period and a second 9-month period after implementation of the antibiotic stewardship program. The proportion of courses of antibiotics for pneumonia that were limited to 5 days doubled from 36% to 72%. Similarly, there was a doubling in the proportion of treatment courses for “culture-negative sepsis” limited to 5 days, with the rate going from 31% to 62%, said Dr. Cantey, a pediatrics fellow in training at the University of Texas Southwestern Medical Center, Dallas.
During the 9-month baseline surveillance period, in which there were 1,607 patients in the NICU, the total antibiotic use was 343 DOT per 1,000 patient-days. During period two with the intervention in place, there were 895 NICU patients, and 251 DOT per 1,000 patient-days. The DOT, a commonly used measure in the field of infectious diseases, is determined by multiplying the number of doses by the dosing interval. DOTs in patients on multiple antibiotics are additive, he explained.
During the baseline observation period, 94% of all antibiotic use in the NICU was empiric therapy for suspected infection. More specifically, 63% of all antibiotic use was for rule-out sepsis. And while many of the courses of antibiotics given for this reason that exceeded the 48-hour limit during the baseline period did so by only one or two doses, those extra doses added up to 41 DOT per 1,000 patient-years, making this a worthy target for intervention. Together with treatment of pneumonia or “culture-negative sepsis” for longer than 5 days, these three high-yield targets accounted for 87% of all antibiotic use in the NICU during the baseline period, Dr. Cantey said.
The infants occupying the NICU during the two 9-month study periods were virtually identical in terms of their characteristics and reasons for admission.
Antibiotics are the most commonly prescribed medications in NICUs. Their use has been associated with adverse NICU outcomes, including increased risks of necrotizing enterocolitis, late-onset sepsis, and death in infants with birth weights below 1,500 g, as well as an increase in multidrug-resistant organisms, he noted.
In SCOUT, the composite outcome of necrotizing enterocolitis, late-onset sepsis, or death didn’t differ between the two study periods: 17.1% at baseline and 15.8% during the intervention period. Similarly, the incidence of colonization with multidrug-resistant organisms was 1.4% during the baseline period and not significantly different at 1% after implementation of the antibiotic stewardship program. Larger multicenter studies with pooled data will be required to determine whether antibiotic stewardship in NICUs affects neonatal outcomes, Dr. Cantey said.
He added that he and his coinvestigators are now trying to identify additional NICU scenarios in which antibiotics can safely be withheld. One likely candidate: asymptomatic preterm infants exposed to premature rupture of membranes. The investigators also hope to utilize the ongoing prospective surveillance element of Parkland’s NICU antibiotic stewardship program to identify the safe minimum treatment duration for common conditions such as urinary tract infections, sepsis, and necrotizing enterocolitis.
Audience members were effusive in their praise of the SCOUT study and the Parkland program. They wanted to hear more details about how the physician behavior change was accomplished. Dr. Cantey said that the three intervention targets were approved by the NICU medical director and the plan was disseminated to all the neonatologists, nurse practitioners, fellows, and residents. It was important to be able to assure everyone that outcomes would be prospectively monitored closely to ensure safety. The toughest task, he added, was to create the hard stops in the electronic medical record so that, for example, treatment for rule-out sepsis would automatically stop at 48 hours: skilled information technologists were essential.
The SCOUT study was supported by a Gerber Novice Researcher Award from the Gerber Foundation. Dr. Cantey reported having no financial conflicts.
AT THE PAS ANNUAL MEETING
Key clinical point: Total antibiotic utilization in a level-IIIC neonatal intensive care unit was safely reduced by 27% through a formal antibiotic stewardship program.
Major finding: The rate of discontinuation of courses of antibiotics given for “rule-out sepsis” by 48 hours tripled from 32% at baseline to 95% post intervention.
Data source: This prospective study carried out in a 90-bed NICU involved an initial 9-month baseline observation period and a second 9-month period starting after implementation of the stewardship program.
Disclosures: The study was supported by a Gerber Novice Researcher Award from the Gerber Foundation. The presenter reported having no relevant financial disclosures.
