Past decompensation in alcohol-associated hepatitis may be linked with worse survival following liver transplantation, but it’s not all bad news, according to a retrospective study.

Traditionally, patients with alcoholic liver disease were asked to be alcohol free for 6 months before consideration for a liver transplantation. In recent years, there’s been a loosening of that policy, with physicians considering “early” liver transplantation (early LT) instead of waiting 6 months. “It became obvious that a lot of patients do resume alcohol use after transplant, and most of them don’t appear to suffer too much in the way of adverse consequences,” said Paul Martin, MD, chief of hepatology at the University of Miami, who was not involved in the current research.

In 2011, a study confirmed that suspicion, finding that 6-month survival was 77% among carefully selected patients with alcohol-associated hepatitis for whom the 6-month sobriety requirement was waived; 6-month survival in those who did not receive a transplant was 22%. The selection criteria included the presence of supportive family members, the absence of severe coexisting conditions, and a commitment to abstaining from alcohol.

Sebastian Kaulitzki/Science Photo Library

However, authors of the current study, published in the American Journal of Gastroenterology sought nuance: The appropriateness of prior decompensation as exclusion criteria in published studies is unknown, so the researchers compared outcomes of patients with prior versus first-time liver decompensation in alcohol-associated hepatitis.
 

Not all bad news

The study included 241 patients from six sites who consecutively received early LT between 2007 and 2020. Among these, 210 were identified as having a first-time liver decompensation event and 31 as having had a prior history of liver decompensation, defined as being diagnosed with ascites, hepatic encephalopathy, variceal bleeding, or jaundice.

There was no significant difference in median age, Model for End-Stage Liver Disease (MELD) scores, or post–liver transplant follow-up time between those with first-time liver decompensation or a prior history. The unadjusted 1-year survival rate was 93% in the first decompensation group (95% confidence interval, 89%-96%) and 86% in the prior decompensation group (95% CI, 66%-94%). The unadjusted 3-year survival rates were 85% (95% CI, 79%-90%) and 78% (95% CI, 57%-89%), respectively.

Importantly, the researchers found an association between prior decompensation and higher adjusted post–liver transplantation mortality (adjusted hazard ratio, 2.72; 95% CI, 1.61-4.59) and harmful alcohol use (aHR, 1.77; 95% CI, 1.07-2.92).

However, the researchers noted that these patients, who had MELD scores of 39 and previous decompensation, were at exceptionally high risk of short-term mortality, but still had 1- and 3-year survival rates above 85% and 75%, respectively, with early LT. “While longer follow-up is desirable as graft failure related to alcohol is most apparent after 5-years post LT, these results suggest that prior decompensation alone should not be considered an absolute contraindication to early LT.”

Limitations of the study included its retrospective data and small sample size for patients with prior decompensation.

“These findings validate the value of the ‘first decompensation’ criteria in published experiences regarding early LT for [alcoholic hepatitis],” the investigators concluded. “Further larger and prospective studies with longer-term follow-up will be needed to assess ways to optimally select patients in this cohort who may benefit most from early LT, and ways to manage patients at highest risk for worse outcomes post LT.”
 

A note of caution for early LT

About half of all liver mortality is attributable to alcoholic-associated liver disease. Corticosteroids can improve short-term survival, but there are no medications proven to increase long-term survival. That leaves liver transplant as the sole alternative for patients who don’t respond to corticosteroids.

“Programs in North America have liberalized their acceptance criteria for patients with alcoholic liver disease, and that’s resulted in large numbers of patients being transplanted who have less than 6 months abstinence. And overall, the results seem good, but I think this paper strikes an appropriate note of caution. In essence, if a patient had at least one prior episode of liver failure related to alcoholic excess and had recovered from that, and continued to drink and got into trouble again, [and then] presented for consideration for liver transplantation, the fact that they resumed alcohol use after prior episodes of decompensation suggests that they may be less-than-ideal candidates [for liver transplantation],” said Dr. Martin.

He pointed out important caveats to the study, including its retrospective nature and its inclusion of a relatively small number of patients with a history of liver decompensation. But it reinforces what physicians generally know, which is that some patients with severe alcohol use disorder also have liver failure, and they tend to fare worse than others after a liver transplant.

Still, physicians also face a conundrum because there are increasing numbers of younger patients who won’t survive if they don’t get a liver transplant. “The challenge is picking out patients who are going to be good candidates from a purely medical point of view, but have a low likelihood of resuming alcohol use after transplantation [which could injure] the new liver,” said Dr. Martin. The new study has the potential to provide some additional guidance in patient selection.

The study authors disclosed no relevant conflicts of interest. Dr. Martin has no relevant financial disclosures.

Past decompensation in alcohol-associated hepatitis may be linked with worse survival following liver transplantation, but it’s not all bad news, according to a retrospective study.

Traditionally, patients with alcoholic liver disease were asked to be alcohol free for 6 months before consideration for a liver transplantation. In recent years, there’s been a loosening of that policy, with physicians considering “early” liver transplantation (early LT) instead of waiting 6 months. “It became obvious that a lot of patients do resume alcohol use after transplant, and most of them don’t appear to suffer too much in the way of adverse consequences,” said Paul Martin, MD, chief of hepatology at the University of Miami, who was not involved in the current research.

In 2011, a study confirmed that suspicion, finding that 6-month survival was 77% among carefully selected patients with alcohol-associated hepatitis for whom the 6-month sobriety requirement was waived; 6-month survival in those who did not receive a transplant was 22%. The selection criteria included the presence of supportive family members, the absence of severe coexisting conditions, and a commitment to abstaining from alcohol.

Sebastian Kaulitzki/Science Photo Library

However, authors of the current study, published in the American Journal of Gastroenterology sought nuance: The appropriateness of prior decompensation as exclusion criteria in published studies is unknown, so the researchers compared outcomes of patients with prior versus first-time liver decompensation in alcohol-associated hepatitis.
 

Not all bad news

The study included 241 patients from six sites who consecutively received early LT between 2007 and 2020. Among these, 210 were identified as having a first-time liver decompensation event and 31 as having had a prior history of liver decompensation, defined as being diagnosed with ascites, hepatic encephalopathy, variceal bleeding, or jaundice.

There was no significant difference in median age, Model for End-Stage Liver Disease (MELD) scores, or post–liver transplant follow-up time between those with first-time liver decompensation or a prior history. The unadjusted 1-year survival rate was 93% in the first decompensation group (95% confidence interval, 89%-96%) and 86% in the prior decompensation group (95% CI, 66%-94%). The unadjusted 3-year survival rates were 85% (95% CI, 79%-90%) and 78% (95% CI, 57%-89%), respectively.

Importantly, the researchers found an association between prior decompensation and higher adjusted post–liver transplantation mortality (adjusted hazard ratio, 2.72; 95% CI, 1.61-4.59) and harmful alcohol use (aHR, 1.77; 95% CI, 1.07-2.92).

However, the researchers noted that these patients, who had MELD scores of 39 and previous decompensation, were at exceptionally high risk of short-term mortality, but still had 1- and 3-year survival rates above 85% and 75%, respectively, with early LT. “While longer follow-up is desirable as graft failure related to alcohol is most apparent after 5-years post LT, these results suggest that prior decompensation alone should not be considered an absolute contraindication to early LT.”

Limitations of the study included its retrospective data and small sample size for patients with prior decompensation.

“These findings validate the value of the ‘first decompensation’ criteria in published experiences regarding early LT for [alcoholic hepatitis],” the investigators concluded. “Further larger and prospective studies with longer-term follow-up will be needed to assess ways to optimally select patients in this cohort who may benefit most from early LT, and ways to manage patients at highest risk for worse outcomes post LT.”
 

A note of caution for early LT

About half of all liver mortality is attributable to alcoholic-associated liver disease. Corticosteroids can improve short-term survival, but there are no medications proven to increase long-term survival. That leaves liver transplant as the sole alternative for patients who don’t respond to corticosteroids.

“Programs in North America have liberalized their acceptance criteria for patients with alcoholic liver disease, and that’s resulted in large numbers of patients being transplanted who have less than 6 months abstinence. And overall, the results seem good, but I think this paper strikes an appropriate note of caution. In essence, if a patient had at least one prior episode of liver failure related to alcoholic excess and had recovered from that, and continued to drink and got into trouble again, [and then] presented for consideration for liver transplantation, the fact that they resumed alcohol use after prior episodes of decompensation suggests that they may be less-than-ideal candidates [for liver transplantation],” said Dr. Martin.

He pointed out important caveats to the study, including its retrospective nature and its inclusion of a relatively small number of patients with a history of liver decompensation. But it reinforces what physicians generally know, which is that some patients with severe alcohol use disorder also have liver failure, and they tend to fare worse than others after a liver transplant.

Still, physicians also face a conundrum because there are increasing numbers of younger patients who won’t survive if they don’t get a liver transplant. “The challenge is picking out patients who are going to be good candidates from a purely medical point of view, but have a low likelihood of resuming alcohol use after transplantation [which could injure] the new liver,” said Dr. Martin. The new study has the potential to provide some additional guidance in patient selection.

The study authors disclosed no relevant conflicts of interest. Dr. Martin has no relevant financial disclosures.

Past decompensation in alcohol-associated hepatitis may be linked with worse survival following liver transplantation, but it’s not all bad news, according to a retrospective study.

Traditionally, patients with alcoholic liver disease were asked to be alcohol free for 6 months before consideration for a liver transplantation. In recent years, there’s been a loosening of that policy, with physicians considering “early” liver transplantation (early LT) instead of waiting 6 months. “It became obvious that a lot of patients do resume alcohol use after transplant, and most of them don’t appear to suffer too much in the way of adverse consequences,” said Paul Martin, MD, chief of hepatology at the University of Miami, who was not involved in the current research.

In 2011, a study confirmed that suspicion, finding that 6-month survival was 77% among carefully selected patients with alcohol-associated hepatitis for whom the 6-month sobriety requirement was waived; 6-month survival in those who did not receive a transplant was 22%. The selection criteria included the presence of supportive family members, the absence of severe coexisting conditions, and a commitment to abstaining from alcohol.

Sebastian Kaulitzki/Science Photo Library

However, authors of the current study, published in the American Journal of Gastroenterology sought nuance: The appropriateness of prior decompensation as exclusion criteria in published studies is unknown, so the researchers compared outcomes of patients with prior versus first-time liver decompensation in alcohol-associated hepatitis.
 

Not all bad news

The study included 241 patients from six sites who consecutively received early LT between 2007 and 2020. Among these, 210 were identified as having a first-time liver decompensation event and 31 as having had a prior history of liver decompensation, defined as being diagnosed with ascites, hepatic encephalopathy, variceal bleeding, or jaundice.

There was no significant difference in median age, Model for End-Stage Liver Disease (MELD) scores, or post–liver transplant follow-up time between those with first-time liver decompensation or a prior history. The unadjusted 1-year survival rate was 93% in the first decompensation group (95% confidence interval, 89%-96%) and 86% in the prior decompensation group (95% CI, 66%-94%). The unadjusted 3-year survival rates were 85% (95% CI, 79%-90%) and 78% (95% CI, 57%-89%), respectively.

Importantly, the researchers found an association between prior decompensation and higher adjusted post–liver transplantation mortality (adjusted hazard ratio, 2.72; 95% CI, 1.61-4.59) and harmful alcohol use (aHR, 1.77; 95% CI, 1.07-2.92).

However, the researchers noted that these patients, who had MELD scores of 39 and previous decompensation, were at exceptionally high risk of short-term mortality, but still had 1- and 3-year survival rates above 85% and 75%, respectively, with early LT. “While longer follow-up is desirable as graft failure related to alcohol is most apparent after 5-years post LT, these results suggest that prior decompensation alone should not be considered an absolute contraindication to early LT.”

Limitations of the study included its retrospective data and small sample size for patients with prior decompensation.

“These findings validate the value of the ‘first decompensation’ criteria in published experiences regarding early LT for [alcoholic hepatitis],” the investigators concluded. “Further larger and prospective studies with longer-term follow-up will be needed to assess ways to optimally select patients in this cohort who may benefit most from early LT, and ways to manage patients at highest risk for worse outcomes post LT.”
 

A note of caution for early LT

About half of all liver mortality is attributable to alcoholic-associated liver disease. Corticosteroids can improve short-term survival, but there are no medications proven to increase long-term survival. That leaves liver transplant as the sole alternative for patients who don’t respond to corticosteroids.

“Programs in North America have liberalized their acceptance criteria for patients with alcoholic liver disease, and that’s resulted in large numbers of patients being transplanted who have less than 6 months abstinence. And overall, the results seem good, but I think this paper strikes an appropriate note of caution. In essence, if a patient had at least one prior episode of liver failure related to alcoholic excess and had recovered from that, and continued to drink and got into trouble again, [and then] presented for consideration for liver transplantation, the fact that they resumed alcohol use after prior episodes of decompensation suggests that they may be less-than-ideal candidates [for liver transplantation],” said Dr. Martin.

He pointed out important caveats to the study, including its retrospective nature and its inclusion of a relatively small number of patients with a history of liver decompensation. But it reinforces what physicians generally know, which is that some patients with severe alcohol use disorder also have liver failure, and they tend to fare worse than others after a liver transplant.

Still, physicians also face a conundrum because there are increasing numbers of younger patients who won’t survive if they don’t get a liver transplant. “The challenge is picking out patients who are going to be good candidates from a purely medical point of view, but have a low likelihood of resuming alcohol use after transplantation [which could injure] the new liver,” said Dr. Martin. The new study has the potential to provide some additional guidance in patient selection.

The study authors disclosed no relevant conflicts of interest. Dr. Martin has no relevant financial disclosures.

Those of us who treat patients with type 2 diabetes (T2D) daily have long recognized a disturbing irony: diabetes is a disease whose management requires consistency in approach and constancy in delivery, but it is most prevalent among those whose lives often allow little to no time for either. 

In our clinic, many patients with diabetes are struggling, in some way, to incorporate diabetes management into their daily lives. They are juggling multiple jobs and family responsibilities; they are working jobs with inconsistent access to food or refrigeration (such as farming, service industry work, and others); and many—even those with insurance—are struggling to afford their insulin and non insulin medications, insulin administration supplies, and glucose testing equipment.

Studies show how stress deleteriously affects this disease. The body does not deal well with these frequent and persistent stressors; higher cortisol levels result in higher blood glucose levels, increased systemic inflammation, and other drivers of both diabetes and its complications; all have been extensively documented. 

What has been frustrating for our clinical community is knowing that since the early 2000s, new diabetes medications and technologies have been available that can make a difference in our patients’ lives, but for various reasons, they have not been well adopted, particularly among patients most likely to benefit from them. Consequently, we have not consistently seen meaningfully reduced glycated hemoglobin (A1c) levels or reduced rates of acute or chronic diabetes complications. Therapeutic inertia exists at the patient, systemic, and physician levels. 

Many of the new glucose-lowering medications can also improve cardiovascular and kidney disease outcomes with low risk for hypoglycemia and weight gain. Diabetes technologies like insulin pumps and continuous glucose monitors (CGM) have been demonstrated in clinical trials to improve A1c and reduce hypoglycemia risk. But the reality is that clinicians are seeing an increasing number of patients with high A1c, with hypoglycemia, with severe hyperglycemia, and with long-term diabetes complications. 

If these advancements are supposed to improve health outcomes, why are patient, community, and population health not improving? Why are some patients not receiving the care they need, while others get extra services that do not improve their health and may even harm them?

These advancements also create new questions for clinicians. At what point in the disease course should existing medications be ramped up, ramped down, or changed? Which patient characteristics or comorbidities allow or do not allow these changes?  When should we use technologies or when does their burden outweigh their potential benefits? What resources and support systems do our patients need to live well with their disease and how can these be procured?

Herein lies the problem: Diabetes is a dynamic disease that needs to be handled in a dynamic way, and that has not universally—or even frequently—occurred. Management must be a team endeavor, meaning that both patient and clinician must be proactive in diabetes management. It has been our experience, demonstrated in our work and in other studies, that success relies on a robust and comprehensive primary care system whose team members—physicians, advanced practice providers, nurses, pharmacists, certified diabetes care and education specialists, social workers, nurses, pharmacists, and dietitians—are all resilient and motivated to tackle one of the most complex, multifaceted, and multidimensional chronic health conditions in our practice.

Proactivity also includes consistent monitoring, learning from successes and failures, and public reporting. For the patient, proactive involvement generally means self-care multiple times a day.    

Let us now discuss the evidence that prompted our team’s proactive approach to caring for people living with diabetes.

Gauges and perspective

The prevalence of T2D in this country stands at 11.3% within the adult population. Between 2015 and 2020, death from diabetes increased by 27%.

For years, the research community has documented the wide range of socioeconomic factors that increase the risk for developing T2D and that, once developed, make it more difficult for patients to manage their disease and achieve optimal health outcomes that are possible with available medications and technologies. 

In 2019, Kazemian et al published work that examined the indicators of diabetes management progress (eg, A1c levels, cholesterol levels) of 1742 individuals, from 2005 to 2016. Just 23% to 25% of these patients achieved all goals, even though, during the study period, numerous medications were approved to manage disease better. Arguably, these should have improved the all-goal findings in the study. 

The first injectable glucagon-like peptide 1 receptor agonist (GLP-1 RA) was approved in 2005; between 2013 and 2016, the FDA also approved 4 sodium-glucose cotransporter 2 (SGLT2) inhibitors. Both medication classes can safely and effectively lower A1c with no weight gain and low risk for hypoglycemia. Over the past 4 years, a robust body of evidence has emerged to show that GLP-1 RAs and SGLT2 inhibitors not only lower A1c, but also reduce the likelihood of death from cardiovascular and kidney diseases. SGLT2 inhibitors are better at saving lives from hypertensive heart failure while the GLP-1 RAs are more protective from atherosclerotic cardiovascular events like myocardial infarction and stroke, as compared with placebo. Yet, these medications have not been, and continue not to be, regularly prescribed. In 1 study, the authors found that the rate of use for SGLT2 inhibitors was 3.8% in 2015 and 11.9% in 2019.

But there are several other reasons that patients do not receive these medicines.

Insurance

We conducted a retrospective cohort study of  382,574 adults between 58 and 66 years of age, insured by either a Medicare Advantage plan or commercial insurance, and compared treatment initiation of the 3 most common brand-name, second-line diabetes medications (as opposed to generic sulfonylureas), between 2016 and 2019. The rate of initiation was universally lower for Medicare Advantage members vs commercially insured individuals. 

While the rates of initiation of GLP-1 RAs, SGLT2 inhibitors, and dipeptidyl peptidase 4 (DPP-4) inhibitors increased between 2016 and 2019, rates were significantly higher among patients with commercial insurance. Specifically, GLP-1 RA initiation increased from 2.1% to 20.0% among commercial insurance beneficiaries and from 1.5% to 11.4% among Medicare Advantage beneficiaries. SGLT2 inhibitor initiation increased from 2.7% to 18.2% with commercial insurance and from 1.57% to 8.51% with Medicare Advantage. DPP-4 inhibitor initiation increased from 3.3% to 11.7% with commercial insurance and from 2.44% to 7.68% with Medicare Advantage. Within each calendar year, the odds of initiating one of these 3 medications with Medicare Advantage as compared with commercial insurance ranged from 0.28 to 0.70 for GLP-1 RAs; from 0.21 to 0.57 for SGLT2 inhibitors; and from 0.37 to 0.73 for DPP-4 inhibitors. 

We also looked at the initiation of these medications in individuals with cardiorenal comorbidities. In many cases, a drug was prescribed indiscriminately. A patient who would benefit from a GLP-1 RA because of cardiovascular, cerebrovascular, or kidney disease was less likely to be prescribed a GLP-1 RA than a medication like a DPP-4 inhibitor, which usually has the same formulary tier/class but does not have any of the cardiovascular or kidney benefits. Likewise, in those with heart failure or kidney disease, an SGLT2 inhibitor would have been the appropriate choice, but these patients were too often started on a DPP-4 inhibitor, which is not advised for those with heart failure and does provide kidney benefits. 

Last year, Tummalapalli et al, in their evaluation of 4135 US health plans, including commercial- or employer-based, Medicare, Medicaid, and other public health plans, identified multiple barriers to accessing SGLT2 inhibitor medications. While all plans included at least 1 SGLT2 inhibitor on their formularies, they restricted access in other ways. Prior authorizations were required by nearly half of Medicaid plans and nearly 40% of other public plans such as the Veterans Health Administration. Medicare and other public plans commonly imposed quantity limits on fills. Commercial plans frequently (up to 40%) required step therapy (use or failure of a generic diabetes medication) before approval. Copayments were also high in commercial plans, Medicare, and others. 

The need for prior authorizations dominates attempts to prescribe. Centene Corporation, for example, which manages plans for private and public payers, will not approve use of an SGLT2 inhibitor until the patient fails for 3 consecutive months on a prior treatment, has established cardiovascular disease or diabetic nephropathy, or has multiple cardiovascular risk factors. These comorbidities must be documented and verified, and the prior authorizations must be completed, often resulting in substantial administrative burden to clinicians. No wonder many, especially in primary care, may be wary of prescribing drugs that come with a paperwork trail and hours spent on documentation and insurance appeals, rather than on patient care.

The same can be said for prescribing a GLP-1 RA. United Healthcare’s Oxford Benefit Management requires that clinicians show a “history of suboptimal response, contraindication, or intolerance to metformin” before prescribing any of the 8 GLP-1 RAs. 

The average retail cost of 30 empagliflozin tablets, a once-daily medication, is $752. During the pandemic, 24% of the 5000 patients surveyed in an American Diabetes Association (ADA) poll used their stimulus check, relied on loans, or spent savings to pay for diabetes care. GLP-1 RA medications are even more expensive.  Depending on the patient’s pharmacy benefits, they may have to pay a substantial coinsurance out of pocket even after the annual deductible is met, creating financial barriers to starting and continuing recommended, evidence-based medications. Even if patients do get the recommended medications, they may be forced to ration other aspects of their lives, including other medications, food, and other necessities.

There are other important barriers to optimal utilization of evidence-based therapies, stemming from the fundamental social determinants of health: low income, low education level, and living in a socioeconomically deprived neighborhood.  

Social Determinants of Health

Diabetes prevalence is higher in patients experiencing socioeconomic and other structural barriers to health and health care. Fundamentally, 1 study showed that prevalence of diabetes was 1.4 times higher among people living on less than $15,000 a year, as opposed to those earning at least $50,000 a year. 

The risk of diabetes complications is also higher in individuals experiencing food or housing insecurity, those who have low income or education level, and residents in rural and socioeconomically deprived neighborhoods. Importantly, the same patient populations are also less likely to receive timely evidence-based care, contributing to and worsening health disparities. Despite their prevalence and importance, social determinants of health (SDoH) are not routinely recognized or discussed during clinical encounters, such that improving diabetes care and health outcomes is predicated on developing a system to screen for, recognize, and address the wide range of barriers faced by our patients. If a patient cannot afford a new medication or get to the clinic on a regular basis, lacks access to healthy food, or does not have time for diabetes self-management education or to focus on their health, then their well-being will suffer.

Many of these SDoH disproportionately affect racial and ethnic minority populations as the direct result of longstanding and deeply embedded systems, policies, and laws that underlie disparities in diabetes incidence, prevalence, management, and outcomes. As such, structural racism is increasingly recognized as a root cause of health disparities in diabetes and other chronic health conditions.

Proactive strategies

Since reactive care has not and cannot provide patients with the help they need and deserve, many in the diabetes care community have turned to proactive, team-based care. The Chronic Care Model, established in the 1990s, stresses decision-making support, strong team organization and delivery system design, and the wherewithal to monitor progress continually. Research has shown that the best results for patients stem from a multidisciplinary, data-driven, and proactive approach to identifying and meeting the totality of patient care needs. 

The ADA stresses the importance of comprehensive, team-based care for successful management of diabetes. This includes expanding the role of teams to implement evidence-based diabetes care, using electronic health record tools to support timely and guideline-recommended delivery of services, empowering and educating patients and caregivers, eliciting and addressing financial and psychosocial barriers to care, and identifying, developing, and engaging community resources to support better health and well-being.

Recognizing the centrality of team-based care to diabetes management, our team has developed and implemented an enhanced primary care diabetes (EPCD) model across the internal medicine and family medicine practices of Mayo Clinic, first in Rochester, Minnesota and then across multiple rural and small urban sites in southeast Minnesota. This model is centered around the primary care team nurse, who partners with clinicians to oversee, enforce, and coordinate the diabetes management of patients paneled to those clinicians. Nurses proactively identify patients, engage other members of the healthcare team (eg, pharmacists, social workers, certified diabetes care and education specialists) as needed, and maintain a continuous relationship with each patient to help them achieve and maintain their goals. This model was not only effective at improving glycemic control and other indicators of diabetes care quality, but also improved nursing and clinician satisfaction. 

It is important to recognize that comprehensive diabetes care comprises both medical and nonmedical interventions that address the totality of the patient’s care needs and the circumstances that hinder optimal health. Increasingly, robust data are emerging in support of nonmedical interventions that target SDoH, including structural racism as a root cause of racial and ethnic disparities in diabetes care and outcomes, with demonstrated evidence of improved health outcomes and narrowed health disparities.

It takes work, effort, and commitment to manage diabetes. But a team-based approach allows players on all sides to win. 

Those of us who treat patients with type 2 diabetes (T2D) daily have long recognized a disturbing irony: diabetes is a disease whose management requires consistency in approach and constancy in delivery, but it is most prevalent among those whose lives often allow little to no time for either. 

In our clinic, many patients with diabetes are struggling, in some way, to incorporate diabetes management into their daily lives. They are juggling multiple jobs and family responsibilities; they are working jobs with inconsistent access to food or refrigeration (such as farming, service industry work, and others); and many—even those with insurance—are struggling to afford their insulin and non insulin medications, insulin administration supplies, and glucose testing equipment.

Studies show how stress deleteriously affects this disease. The body does not deal well with these frequent and persistent stressors; higher cortisol levels result in higher blood glucose levels, increased systemic inflammation, and other drivers of both diabetes and its complications; all have been extensively documented. 

What has been frustrating for our clinical community is knowing that since the early 2000s, new diabetes medications and technologies have been available that can make a difference in our patients’ lives, but for various reasons, they have not been well adopted, particularly among patients most likely to benefit from them. Consequently, we have not consistently seen meaningfully reduced glycated hemoglobin (A1c) levels or reduced rates of acute or chronic diabetes complications. Therapeutic inertia exists at the patient, systemic, and physician levels. 

Many of the new glucose-lowering medications can also improve cardiovascular and kidney disease outcomes with low risk for hypoglycemia and weight gain. Diabetes technologies like insulin pumps and continuous glucose monitors (CGM) have been demonstrated in clinical trials to improve A1c and reduce hypoglycemia risk. But the reality is that clinicians are seeing an increasing number of patients with high A1c, with hypoglycemia, with severe hyperglycemia, and with long-term diabetes complications. 

If these advancements are supposed to improve health outcomes, why are patient, community, and population health not improving? Why are some patients not receiving the care they need, while others get extra services that do not improve their health and may even harm them?

These advancements also create new questions for clinicians. At what point in the disease course should existing medications be ramped up, ramped down, or changed? Which patient characteristics or comorbidities allow or do not allow these changes?  When should we use technologies or when does their burden outweigh their potential benefits? What resources and support systems do our patients need to live well with their disease and how can these be procured?

Herein lies the problem: Diabetes is a dynamic disease that needs to be handled in a dynamic way, and that has not universally—or even frequently—occurred. Management must be a team endeavor, meaning that both patient and clinician must be proactive in diabetes management. It has been our experience, demonstrated in our work and in other studies, that success relies on a robust and comprehensive primary care system whose team members—physicians, advanced practice providers, nurses, pharmacists, certified diabetes care and education specialists, social workers, nurses, pharmacists, and dietitians—are all resilient and motivated to tackle one of the most complex, multifaceted, and multidimensional chronic health conditions in our practice.

Proactivity also includes consistent monitoring, learning from successes and failures, and public reporting. For the patient, proactive involvement generally means self-care multiple times a day.    

Let us now discuss the evidence that prompted our team’s proactive approach to caring for people living with diabetes.

Gauges and perspective

The prevalence of T2D in this country stands at 11.3% within the adult population. Between 2015 and 2020, death from diabetes increased by 27%.

For years, the research community has documented the wide range of socioeconomic factors that increase the risk for developing T2D and that, once developed, make it more difficult for patients to manage their disease and achieve optimal health outcomes that are possible with available medications and technologies. 

In 2019, Kazemian et al published work that examined the indicators of diabetes management progress (eg, A1c levels, cholesterol levels) of 1742 individuals, from 2005 to 2016. Just 23% to 25% of these patients achieved all goals, even though, during the study period, numerous medications were approved to manage disease better. Arguably, these should have improved the all-goal findings in the study. 

The first injectable glucagon-like peptide 1 receptor agonist (GLP-1 RA) was approved in 2005; between 2013 and 2016, the FDA also approved 4 sodium-glucose cotransporter 2 (SGLT2) inhibitors. Both medication classes can safely and effectively lower A1c with no weight gain and low risk for hypoglycemia. Over the past 4 years, a robust body of evidence has emerged to show that GLP-1 RAs and SGLT2 inhibitors not only lower A1c, but also reduce the likelihood of death from cardiovascular and kidney diseases. SGLT2 inhibitors are better at saving lives from hypertensive heart failure while the GLP-1 RAs are more protective from atherosclerotic cardiovascular events like myocardial infarction and stroke, as compared with placebo. Yet, these medications have not been, and continue not to be, regularly prescribed. In 1 study, the authors found that the rate of use for SGLT2 inhibitors was 3.8% in 2015 and 11.9% in 2019.

But there are several other reasons that patients do not receive these medicines.

Insurance

We conducted a retrospective cohort study of  382,574 adults between 58 and 66 years of age, insured by either a Medicare Advantage plan or commercial insurance, and compared treatment initiation of the 3 most common brand-name, second-line diabetes medications (as opposed to generic sulfonylureas), between 2016 and 2019. The rate of initiation was universally lower for Medicare Advantage members vs commercially insured individuals. 

While the rates of initiation of GLP-1 RAs, SGLT2 inhibitors, and dipeptidyl peptidase 4 (DPP-4) inhibitors increased between 2016 and 2019, rates were significantly higher among patients with commercial insurance. Specifically, GLP-1 RA initiation increased from 2.1% to 20.0% among commercial insurance beneficiaries and from 1.5% to 11.4% among Medicare Advantage beneficiaries. SGLT2 inhibitor initiation increased from 2.7% to 18.2% with commercial insurance and from 1.57% to 8.51% with Medicare Advantage. DPP-4 inhibitor initiation increased from 3.3% to 11.7% with commercial insurance and from 2.44% to 7.68% with Medicare Advantage. Within each calendar year, the odds of initiating one of these 3 medications with Medicare Advantage as compared with commercial insurance ranged from 0.28 to 0.70 for GLP-1 RAs; from 0.21 to 0.57 for SGLT2 inhibitors; and from 0.37 to 0.73 for DPP-4 inhibitors. 

We also looked at the initiation of these medications in individuals with cardiorenal comorbidities. In many cases, a drug was prescribed indiscriminately. A patient who would benefit from a GLP-1 RA because of cardiovascular, cerebrovascular, or kidney disease was less likely to be prescribed a GLP-1 RA than a medication like a DPP-4 inhibitor, which usually has the same formulary tier/class but does not have any of the cardiovascular or kidney benefits. Likewise, in those with heart failure or kidney disease, an SGLT2 inhibitor would have been the appropriate choice, but these patients were too often started on a DPP-4 inhibitor, which is not advised for those with heart failure and does provide kidney benefits. 

Last year, Tummalapalli et al, in their evaluation of 4135 US health plans, including commercial- or employer-based, Medicare, Medicaid, and other public health plans, identified multiple barriers to accessing SGLT2 inhibitor medications. While all plans included at least 1 SGLT2 inhibitor on their formularies, they restricted access in other ways. Prior authorizations were required by nearly half of Medicaid plans and nearly 40% of other public plans such as the Veterans Health Administration. Medicare and other public plans commonly imposed quantity limits on fills. Commercial plans frequently (up to 40%) required step therapy (use or failure of a generic diabetes medication) before approval. Copayments were also high in commercial plans, Medicare, and others. 

The need for prior authorizations dominates attempts to prescribe. Centene Corporation, for example, which manages plans for private and public payers, will not approve use of an SGLT2 inhibitor until the patient fails for 3 consecutive months on a prior treatment, has established cardiovascular disease or diabetic nephropathy, or has multiple cardiovascular risk factors. These comorbidities must be documented and verified, and the prior authorizations must be completed, often resulting in substantial administrative burden to clinicians. No wonder many, especially in primary care, may be wary of prescribing drugs that come with a paperwork trail and hours spent on documentation and insurance appeals, rather than on patient care.

The same can be said for prescribing a GLP-1 RA. United Healthcare’s Oxford Benefit Management requires that clinicians show a “history of suboptimal response, contraindication, or intolerance to metformin” before prescribing any of the 8 GLP-1 RAs. 

The average retail cost of 30 empagliflozin tablets, a once-daily medication, is $752. During the pandemic, 24% of the 5000 patients surveyed in an American Diabetes Association (ADA) poll used their stimulus check, relied on loans, or spent savings to pay for diabetes care. GLP-1 RA medications are even more expensive.  Depending on the patient’s pharmacy benefits, they may have to pay a substantial coinsurance out of pocket even after the annual deductible is met, creating financial barriers to starting and continuing recommended, evidence-based medications. Even if patients do get the recommended medications, they may be forced to ration other aspects of their lives, including other medications, food, and other necessities.

There are other important barriers to optimal utilization of evidence-based therapies, stemming from the fundamental social determinants of health: low income, low education level, and living in a socioeconomically deprived neighborhood.  

Social Determinants of Health

Diabetes prevalence is higher in patients experiencing socioeconomic and other structural barriers to health and health care. Fundamentally, 1 study showed that prevalence of diabetes was 1.4 times higher among people living on less than $15,000 a year, as opposed to those earning at least $50,000 a year. 

The risk of diabetes complications is also higher in individuals experiencing food or housing insecurity, those who have low income or education level, and residents in rural and socioeconomically deprived neighborhoods. Importantly, the same patient populations are also less likely to receive timely evidence-based care, contributing to and worsening health disparities. Despite their prevalence and importance, social determinants of health (SDoH) are not routinely recognized or discussed during clinical encounters, such that improving diabetes care and health outcomes is predicated on developing a system to screen for, recognize, and address the wide range of barriers faced by our patients. If a patient cannot afford a new medication or get to the clinic on a regular basis, lacks access to healthy food, or does not have time for diabetes self-management education or to focus on their health, then their well-being will suffer.

Many of these SDoH disproportionately affect racial and ethnic minority populations as the direct result of longstanding and deeply embedded systems, policies, and laws that underlie disparities in diabetes incidence, prevalence, management, and outcomes. As such, structural racism is increasingly recognized as a root cause of health disparities in diabetes and other chronic health conditions.

Proactive strategies

Since reactive care has not and cannot provide patients with the help they need and deserve, many in the diabetes care community have turned to proactive, team-based care. The Chronic Care Model, established in the 1990s, stresses decision-making support, strong team organization and delivery system design, and the wherewithal to monitor progress continually. Research has shown that the best results for patients stem from a multidisciplinary, data-driven, and proactive approach to identifying and meeting the totality of patient care needs. 

The ADA stresses the importance of comprehensive, team-based care for successful management of diabetes. This includes expanding the role of teams to implement evidence-based diabetes care, using electronic health record tools to support timely and guideline-recommended delivery of services, empowering and educating patients and caregivers, eliciting and addressing financial and psychosocial barriers to care, and identifying, developing, and engaging community resources to support better health and well-being.

Recognizing the centrality of team-based care to diabetes management, our team has developed and implemented an enhanced primary care diabetes (EPCD) model across the internal medicine and family medicine practices of Mayo Clinic, first in Rochester, Minnesota and then across multiple rural and small urban sites in southeast Minnesota. This model is centered around the primary care team nurse, who partners with clinicians to oversee, enforce, and coordinate the diabetes management of patients paneled to those clinicians. Nurses proactively identify patients, engage other members of the healthcare team (eg, pharmacists, social workers, certified diabetes care and education specialists) as needed, and maintain a continuous relationship with each patient to help them achieve and maintain their goals. This model was not only effective at improving glycemic control and other indicators of diabetes care quality, but also improved nursing and clinician satisfaction. 

It is important to recognize that comprehensive diabetes care comprises both medical and nonmedical interventions that address the totality of the patient’s care needs and the circumstances that hinder optimal health. Increasingly, robust data are emerging in support of nonmedical interventions that target SDoH, including structural racism as a root cause of racial and ethnic disparities in diabetes care and outcomes, with demonstrated evidence of improved health outcomes and narrowed health disparities.

It takes work, effort, and commitment to manage diabetes. But a team-based approach allows players on all sides to win. 

Those of us who treat patients with type 2 diabetes (T2D) daily have long recognized a disturbing irony: diabetes is a disease whose management requires consistency in approach and constancy in delivery, but it is most prevalent among those whose lives often allow little to no time for either. 

In our clinic, many patients with diabetes are struggling, in some way, to incorporate diabetes management into their daily lives. They are juggling multiple jobs and family responsibilities; they are working jobs with inconsistent access to food or refrigeration (such as farming, service industry work, and others); and many—even those with insurance—are struggling to afford their insulin and non insulin medications, insulin administration supplies, and glucose testing equipment.

Studies show how stress deleteriously affects this disease. The body does not deal well with these frequent and persistent stressors; higher cortisol levels result in higher blood glucose levels, increased systemic inflammation, and other drivers of both diabetes and its complications; all have been extensively documented. 

What has been frustrating for our clinical community is knowing that since the early 2000s, new diabetes medications and technologies have been available that can make a difference in our patients’ lives, but for various reasons, they have not been well adopted, particularly among patients most likely to benefit from them. Consequently, we have not consistently seen meaningfully reduced glycated hemoglobin (A1c) levels or reduced rates of acute or chronic diabetes complications. Therapeutic inertia exists at the patient, systemic, and physician levels. 

Many of the new glucose-lowering medications can also improve cardiovascular and kidney disease outcomes with low risk for hypoglycemia and weight gain. Diabetes technologies like insulin pumps and continuous glucose monitors (CGM) have been demonstrated in clinical trials to improve A1c and reduce hypoglycemia risk. But the reality is that clinicians are seeing an increasing number of patients with high A1c, with hypoglycemia, with severe hyperglycemia, and with long-term diabetes complications. 

If these advancements are supposed to improve health outcomes, why are patient, community, and population health not improving? Why are some patients not receiving the care they need, while others get extra services that do not improve their health and may even harm them?

These advancements also create new questions for clinicians. At what point in the disease course should existing medications be ramped up, ramped down, or changed? Which patient characteristics or comorbidities allow or do not allow these changes?  When should we use technologies or when does their burden outweigh their potential benefits? What resources and support systems do our patients need to live well with their disease and how can these be procured?

Herein lies the problem: Diabetes is a dynamic disease that needs to be handled in a dynamic way, and that has not universally—or even frequently—occurred. Management must be a team endeavor, meaning that both patient and clinician must be proactive in diabetes management. It has been our experience, demonstrated in our work and in other studies, that success relies on a robust and comprehensive primary care system whose team members—physicians, advanced practice providers, nurses, pharmacists, certified diabetes care and education specialists, social workers, nurses, pharmacists, and dietitians—are all resilient and motivated to tackle one of the most complex, multifaceted, and multidimensional chronic health conditions in our practice.

Proactivity also includes consistent monitoring, learning from successes and failures, and public reporting. For the patient, proactive involvement generally means self-care multiple times a day.    

Let us now discuss the evidence that prompted our team’s proactive approach to caring for people living with diabetes.

Gauges and perspective

The prevalence of T2D in this country stands at 11.3% within the adult population. Between 2015 and 2020, death from diabetes increased by 27%.

For years, the research community has documented the wide range of socioeconomic factors that increase the risk for developing T2D and that, once developed, make it more difficult for patients to manage their disease and achieve optimal health outcomes that are possible with available medications and technologies. 

In 2019, Kazemian et al published work that examined the indicators of diabetes management progress (eg, A1c levels, cholesterol levels) of 1742 individuals, from 2005 to 2016. Just 23% to 25% of these patients achieved all goals, even though, during the study period, numerous medications were approved to manage disease better. Arguably, these should have improved the all-goal findings in the study. 

The first injectable glucagon-like peptide 1 receptor agonist (GLP-1 RA) was approved in 2005; between 2013 and 2016, the FDA also approved 4 sodium-glucose cotransporter 2 (SGLT2) inhibitors. Both medication classes can safely and effectively lower A1c with no weight gain and low risk for hypoglycemia. Over the past 4 years, a robust body of evidence has emerged to show that GLP-1 RAs and SGLT2 inhibitors not only lower A1c, but also reduce the likelihood of death from cardiovascular and kidney diseases. SGLT2 inhibitors are better at saving lives from hypertensive heart failure while the GLP-1 RAs are more protective from atherosclerotic cardiovascular events like myocardial infarction and stroke, as compared with placebo. Yet, these medications have not been, and continue not to be, regularly prescribed. In 1 study, the authors found that the rate of use for SGLT2 inhibitors was 3.8% in 2015 and 11.9% in 2019.

But there are several other reasons that patients do not receive these medicines.

Insurance

We conducted a retrospective cohort study of  382,574 adults between 58 and 66 years of age, insured by either a Medicare Advantage plan or commercial insurance, and compared treatment initiation of the 3 most common brand-name, second-line diabetes medications (as opposed to generic sulfonylureas), between 2016 and 2019. The rate of initiation was universally lower for Medicare Advantage members vs commercially insured individuals. 

While the rates of initiation of GLP-1 RAs, SGLT2 inhibitors, and dipeptidyl peptidase 4 (DPP-4) inhibitors increased between 2016 and 2019, rates were significantly higher among patients with commercial insurance. Specifically, GLP-1 RA initiation increased from 2.1% to 20.0% among commercial insurance beneficiaries and from 1.5% to 11.4% among Medicare Advantage beneficiaries. SGLT2 inhibitor initiation increased from 2.7% to 18.2% with commercial insurance and from 1.57% to 8.51% with Medicare Advantage. DPP-4 inhibitor initiation increased from 3.3% to 11.7% with commercial insurance and from 2.44% to 7.68% with Medicare Advantage. Within each calendar year, the odds of initiating one of these 3 medications with Medicare Advantage as compared with commercial insurance ranged from 0.28 to 0.70 for GLP-1 RAs; from 0.21 to 0.57 for SGLT2 inhibitors; and from 0.37 to 0.73 for DPP-4 inhibitors. 

We also looked at the initiation of these medications in individuals with cardiorenal comorbidities. In many cases, a drug was prescribed indiscriminately. A patient who would benefit from a GLP-1 RA because of cardiovascular, cerebrovascular, or kidney disease was less likely to be prescribed a GLP-1 RA than a medication like a DPP-4 inhibitor, which usually has the same formulary tier/class but does not have any of the cardiovascular or kidney benefits. Likewise, in those with heart failure or kidney disease, an SGLT2 inhibitor would have been the appropriate choice, but these patients were too often started on a DPP-4 inhibitor, which is not advised for those with heart failure and does provide kidney benefits. 

Last year, Tummalapalli et al, in their evaluation of 4135 US health plans, including commercial- or employer-based, Medicare, Medicaid, and other public health plans, identified multiple barriers to accessing SGLT2 inhibitor medications. While all plans included at least 1 SGLT2 inhibitor on their formularies, they restricted access in other ways. Prior authorizations were required by nearly half of Medicaid plans and nearly 40% of other public plans such as the Veterans Health Administration. Medicare and other public plans commonly imposed quantity limits on fills. Commercial plans frequently (up to 40%) required step therapy (use or failure of a generic diabetes medication) before approval. Copayments were also high in commercial plans, Medicare, and others. 

The need for prior authorizations dominates attempts to prescribe. Centene Corporation, for example, which manages plans for private and public payers, will not approve use of an SGLT2 inhibitor until the patient fails for 3 consecutive months on a prior treatment, has established cardiovascular disease or diabetic nephropathy, or has multiple cardiovascular risk factors. These comorbidities must be documented and verified, and the prior authorizations must be completed, often resulting in substantial administrative burden to clinicians. No wonder many, especially in primary care, may be wary of prescribing drugs that come with a paperwork trail and hours spent on documentation and insurance appeals, rather than on patient care.

The same can be said for prescribing a GLP-1 RA. United Healthcare’s Oxford Benefit Management requires that clinicians show a “history of suboptimal response, contraindication, or intolerance to metformin” before prescribing any of the 8 GLP-1 RAs. 

The average retail cost of 30 empagliflozin tablets, a once-daily medication, is $752. During the pandemic, 24% of the 5000 patients surveyed in an American Diabetes Association (ADA) poll used their stimulus check, relied on loans, or spent savings to pay for diabetes care. GLP-1 RA medications are even more expensive.  Depending on the patient’s pharmacy benefits, they may have to pay a substantial coinsurance out of pocket even after the annual deductible is met, creating financial barriers to starting and continuing recommended, evidence-based medications. Even if patients do get the recommended medications, they may be forced to ration other aspects of their lives, including other medications, food, and other necessities.

There are other important barriers to optimal utilization of evidence-based therapies, stemming from the fundamental social determinants of health: low income, low education level, and living in a socioeconomically deprived neighborhood.  

Social Determinants of Health

Diabetes prevalence is higher in patients experiencing socioeconomic and other structural barriers to health and health care. Fundamentally, 1 study showed that prevalence of diabetes was 1.4 times higher among people living on less than $15,000 a year, as opposed to those earning at least $50,000 a year. 

The risk of diabetes complications is also higher in individuals experiencing food or housing insecurity, those who have low income or education level, and residents in rural and socioeconomically deprived neighborhoods. Importantly, the same patient populations are also less likely to receive timely evidence-based care, contributing to and worsening health disparities. Despite their prevalence and importance, social determinants of health (SDoH) are not routinely recognized or discussed during clinical encounters, such that improving diabetes care and health outcomes is predicated on developing a system to screen for, recognize, and address the wide range of barriers faced by our patients. If a patient cannot afford a new medication or get to the clinic on a regular basis, lacks access to healthy food, or does not have time for diabetes self-management education or to focus on their health, then their well-being will suffer.

Many of these SDoH disproportionately affect racial and ethnic minority populations as the direct result of longstanding and deeply embedded systems, policies, and laws that underlie disparities in diabetes incidence, prevalence, management, and outcomes. As such, structural racism is increasingly recognized as a root cause of health disparities in diabetes and other chronic health conditions.

Proactive strategies

Since reactive care has not and cannot provide patients with the help they need and deserve, many in the diabetes care community have turned to proactive, team-based care. The Chronic Care Model, established in the 1990s, stresses decision-making support, strong team organization and delivery system design, and the wherewithal to monitor progress continually. Research has shown that the best results for patients stem from a multidisciplinary, data-driven, and proactive approach to identifying and meeting the totality of patient care needs. 

The ADA stresses the importance of comprehensive, team-based care for successful management of diabetes. This includes expanding the role of teams to implement evidence-based diabetes care, using electronic health record tools to support timely and guideline-recommended delivery of services, empowering and educating patients and caregivers, eliciting and addressing financial and psychosocial barriers to care, and identifying, developing, and engaging community resources to support better health and well-being.

Recognizing the centrality of team-based care to diabetes management, our team has developed and implemented an enhanced primary care diabetes (EPCD) model across the internal medicine and family medicine practices of Mayo Clinic, first in Rochester, Minnesota and then across multiple rural and small urban sites in southeast Minnesota. This model is centered around the primary care team nurse, who partners with clinicians to oversee, enforce, and coordinate the diabetes management of patients paneled to those clinicians. Nurses proactively identify patients, engage other members of the healthcare team (eg, pharmacists, social workers, certified diabetes care and education specialists) as needed, and maintain a continuous relationship with each patient to help them achieve and maintain their goals. This model was not only effective at improving glycemic control and other indicators of diabetes care quality, but also improved nursing and clinician satisfaction. 

It is important to recognize that comprehensive diabetes care comprises both medical and nonmedical interventions that address the totality of the patient’s care needs and the circumstances that hinder optimal health. Increasingly, robust data are emerging in support of nonmedical interventions that target SDoH, including structural racism as a root cause of racial and ethnic disparities in diabetes care and outcomes, with demonstrated evidence of improved health outcomes and narrowed health disparities.

It takes work, effort, and commitment to manage diabetes. But a team-based approach allows players on all sides to win. 

Many of our patients with refractory migraine do not respond to first-line acute or preventive treatments, and, almost by definition, first- and second-line treatments have failed in the majority of patients on calcitonin gene-related peptide (CGRP) antagonist medications. Three studies this month highlight the efficacy of CGRP monoclonal antibody (mAb) and small-molecule medications in this population specifically.

Most headache specialists are familiar with the "standard" or PREEMPT onabotulinumtoxinA (Botox) paradigm used preventively for migraine. This protocol uses 155 units of onabotulinumtoxinA over 31 sites in seven muscle groups. OnabotulinumtoxinA vials typically come in 100 or 200 units, and when preparing onabotulinumtoxinA for patients who are being injected most providers are forced to discard most or all of the remaining 45 units. Anecdotally, some providers do inject the entire 200-unit vial, and the additional injection sites are either given in another standard protocol or in a follow-the-pain manner.

The study by Zandieh and colleagues followed 175 patients with chronic migraine who first received three injections of 150 units of onabotulinumtoxinA, then three injections of 200 units of this agent. The additional 50 units were injected into the temporalis and occipitalis muscles — the standard sites were used, but additional units were injected into each of the sites. The majority of patients experienced primarily frontal pain; the injections were not given in specific areas where more pain was manifesting.

The average number of headache days per month decreased significantly when the onabotulinumtoxinA dose was increased; patients tolerated the medication over the 3-month period as well. In practice, many providers use the additional units of onabotulinumtoxinA. This study argues that there is a minimal risk, and probably a potential significant benefit, when using up to 200 units every 3 months. Providers should, however, be aware that in rare instances, some insurances will only cover a 155-unit injection, and the use of additional units may jeopardize reimbursement for those plans.

Many patients anecdotally will use cold or heat as a treatment for acute migraine pain; however, the topical use of temperature has not been well studied for this purpose. Cold stimulus has, importantly, been known to be a trigger of migraine as well as other headache disorders classified in the International Classification of Headache Disorders, third edition (ICHD-3), including external cold stimulus headache and "brain freeze" or internal cold stimulus headache. Hsu and colleagues produced a meta-analysis and systematic review on the use of cold for acute treatment of migraine.

Six studies were found to be eligible for this review. The cold stimulus could be placed anywhere on the head, and the studies could have considered its use for any migraine-associated symptom. This includes headache, eye pain, nausea, or vomiting. The interventions used cold somewhat differently, including as ice packing, cooling compression, soaking, and as a rinse. Both randomized and nonrandomized trials were included in the systematic review; however, only randomized controlled trials were used for the meta-analysis.

The primary outcome evaluated by the authors was pain intensity; secondary outcomes were duration of migraine pain as well as associated symptoms (eg, nausea, vomiting). The meta-analysis revealed that cold interventions reduce migraine pain by 3.21 points on an analog scale, and this was found to be effective within 30 minutes. At 1-2 hours after the intervention, the effect was not seen to be significant. At 24 hours, the effect of cold intervention was marginal. Cold was not seen to significantly reduce nausea or vomiting at 2 hours after intervention.

Although cold treatments are commonly used by patients, there appears to be benefit only early in the onset of a migraine attack. Headache specialists typically recommend early treatment with a migraine-specific acute medication; however, the medication may take minutes to hours before taking effect. Cold can be recommended to patients during that intervening period, and it may help until the time that their acute medications take effect.

Chronic refractory migraine remains one of the most debilitating neurologic disorders and is a challenge even for the best trained neurologist or headache specialist. There are few headache centers with inpatient headache units around the United States, and those that remain use treatments that most neurologists are not familiar with. Schwenk and colleagues retrospectively reviewed the data of a major academic headache center and revealed impressive outcomes in this very difficult-to-treat population.

This study reviewed the outcomes of 609 consecutive patients admitted to the Thomas Jefferson University inpatient headache unit from 2017 to 2021. These patients all received continuous lidocaine infusions that were titrated according to an internal protocol that balanced daily plasma lidocaine levels, tolerability, and pain relief. Hospital discharge occurred when patients were pain-free for 12-24 hours or had a minimal response after 5 days of treatment. All patients had at least eight severe headaches per month for at least 6 consecutive months and had tried one to seven preventive medications, with the result of either intolerance or ineffectiveness.

The primary outcome was change from baseline to discharge pain level. Patients were admitted with an average score of 7.0 of 10 on admission and were discharged at a score of 1.0 of 10. Secondary outcomes were average pain at post-discharge appointment vs baseline (5.5 vs 7.0), number of monthly headache days at post-discharge appointment (22.5 vs 26.8), and current and average pain levels at the post-discharge appointment, which were both significantly lower as well. The most common adverse effect was nausea; others noted were cardiovascular changes, hallucinations or nightmares, sedation, anxiety, and chest pain.

This is an important retrospective on the effectiveness of an inpatient lidocaine protocol for refractory chronic migraine. When considering this population, especially if multiple lines of preventive and acute medications are not effective, referral to an academic inpatient headache center should definitely be considered. This patient population does not respond effectively to most treatment modalities, and this is cause to give them hope.

Many of our patients with refractory migraine do not respond to first-line acute or preventive treatments, and, almost by definition, first- and second-line treatments have failed in the majority of patients on calcitonin gene-related peptide (CGRP) antagonist medications. Three studies this month highlight the efficacy of CGRP monoclonal antibody (mAb) and small-molecule medications in this population specifically.

Most headache specialists are familiar with the "standard" or PREEMPT onabotulinumtoxinA (Botox) paradigm used preventively for migraine. This protocol uses 155 units of onabotulinumtoxinA over 31 sites in seven muscle groups. OnabotulinumtoxinA vials typically come in 100 or 200 units, and when preparing onabotulinumtoxinA for patients who are being injected most providers are forced to discard most or all of the remaining 45 units. Anecdotally, some providers do inject the entire 200-unit vial, and the additional injection sites are either given in another standard protocol or in a follow-the-pain manner.

The study by Zandieh and colleagues followed 175 patients with chronic migraine who first received three injections of 150 units of onabotulinumtoxinA, then three injections of 200 units of this agent. The additional 50 units were injected into the temporalis and occipitalis muscles — the standard sites were used, but additional units were injected into each of the sites. The majority of patients experienced primarily frontal pain; the injections were not given in specific areas where more pain was manifesting.

The average number of headache days per month decreased significantly when the onabotulinumtoxinA dose was increased; patients tolerated the medication over the 3-month period as well. In practice, many providers use the additional units of onabotulinumtoxinA. This study argues that there is a minimal risk, and probably a potential significant benefit, when using up to 200 units every 3 months. Providers should, however, be aware that in rare instances, some insurances will only cover a 155-unit injection, and the use of additional units may jeopardize reimbursement for those plans.

Many patients anecdotally will use cold or heat as a treatment for acute migraine pain; however, the topical use of temperature has not been well studied for this purpose. Cold stimulus has, importantly, been known to be a trigger of migraine as well as other headache disorders classified in the International Classification of Headache Disorders, third edition (ICHD-3), including external cold stimulus headache and "brain freeze" or internal cold stimulus headache. Hsu and colleagues produced a meta-analysis and systematic review on the use of cold for acute treatment of migraine.

Six studies were found to be eligible for this review. The cold stimulus could be placed anywhere on the head, and the studies could have considered its use for any migraine-associated symptom. This includes headache, eye pain, nausea, or vomiting. The interventions used cold somewhat differently, including as ice packing, cooling compression, soaking, and as a rinse. Both randomized and nonrandomized trials were included in the systematic review; however, only randomized controlled trials were used for the meta-analysis.

The primary outcome evaluated by the authors was pain intensity; secondary outcomes were duration of migraine pain as well as associated symptoms (eg, nausea, vomiting). The meta-analysis revealed that cold interventions reduce migraine pain by 3.21 points on an analog scale, and this was found to be effective within 30 minutes. At 1-2 hours after the intervention, the effect was not seen to be significant. At 24 hours, the effect of cold intervention was marginal. Cold was not seen to significantly reduce nausea or vomiting at 2 hours after intervention.

Although cold treatments are commonly used by patients, there appears to be benefit only early in the onset of a migraine attack. Headache specialists typically recommend early treatment with a migraine-specific acute medication; however, the medication may take minutes to hours before taking effect. Cold can be recommended to patients during that intervening period, and it may help until the time that their acute medications take effect.

Chronic refractory migraine remains one of the most debilitating neurologic disorders and is a challenge even for the best trained neurologist or headache specialist. There are few headache centers with inpatient headache units around the United States, and those that remain use treatments that most neurologists are not familiar with. Schwenk and colleagues retrospectively reviewed the data of a major academic headache center and revealed impressive outcomes in this very difficult-to-treat population.

This study reviewed the outcomes of 609 consecutive patients admitted to the Thomas Jefferson University inpatient headache unit from 2017 to 2021. These patients all received continuous lidocaine infusions that were titrated according to an internal protocol that balanced daily plasma lidocaine levels, tolerability, and pain relief. Hospital discharge occurred when patients were pain-free for 12-24 hours or had a minimal response after 5 days of treatment. All patients had at least eight severe headaches per month for at least 6 consecutive months and had tried one to seven preventive medications, with the result of either intolerance or ineffectiveness.

The primary outcome was change from baseline to discharge pain level. Patients were admitted with an average score of 7.0 of 10 on admission and were discharged at a score of 1.0 of 10. Secondary outcomes were average pain at post-discharge appointment vs baseline (5.5 vs 7.0), number of monthly headache days at post-discharge appointment (22.5 vs 26.8), and current and average pain levels at the post-discharge appointment, which were both significantly lower as well. The most common adverse effect was nausea; others noted were cardiovascular changes, hallucinations or nightmares, sedation, anxiety, and chest pain.

This is an important retrospective on the effectiveness of an inpatient lidocaine protocol for refractory chronic migraine. When considering this population, especially if multiple lines of preventive and acute medications are not effective, referral to an academic inpatient headache center should definitely be considered. This patient population does not respond effectively to most treatment modalities, and this is cause to give them hope.

Many of our patients with refractory migraine do not respond to first-line acute or preventive treatments, and, almost by definition, first- and second-line treatments have failed in the majority of patients on calcitonin gene-related peptide (CGRP) antagonist medications. Three studies this month highlight the efficacy of CGRP monoclonal antibody (mAb) and small-molecule medications in this population specifically.

Most headache specialists are familiar with the "standard" or PREEMPT onabotulinumtoxinA (Botox) paradigm used preventively for migraine. This protocol uses 155 units of onabotulinumtoxinA over 31 sites in seven muscle groups. OnabotulinumtoxinA vials typically come in 100 or 200 units, and when preparing onabotulinumtoxinA for patients who are being injected most providers are forced to discard most or all of the remaining 45 units. Anecdotally, some providers do inject the entire 200-unit vial, and the additional injection sites are either given in another standard protocol or in a follow-the-pain manner.

The study by Zandieh and colleagues followed 175 patients with chronic migraine who first received three injections of 150 units of onabotulinumtoxinA, then three injections of 200 units of this agent. The additional 50 units were injected into the temporalis and occipitalis muscles — the standard sites were used, but additional units were injected into each of the sites. The majority of patients experienced primarily frontal pain; the injections were not given in specific areas where more pain was manifesting.

The average number of headache days per month decreased significantly when the onabotulinumtoxinA dose was increased; patients tolerated the medication over the 3-month period as well. In practice, many providers use the additional units of onabotulinumtoxinA. This study argues that there is a minimal risk, and probably a potential significant benefit, when using up to 200 units every 3 months. Providers should, however, be aware that in rare instances, some insurances will only cover a 155-unit injection, and the use of additional units may jeopardize reimbursement for those plans.

Many patients anecdotally will use cold or heat as a treatment for acute migraine pain; however, the topical use of temperature has not been well studied for this purpose. Cold stimulus has, importantly, been known to be a trigger of migraine as well as other headache disorders classified in the International Classification of Headache Disorders, third edition (ICHD-3), including external cold stimulus headache and "brain freeze" or internal cold stimulus headache. Hsu and colleagues produced a meta-analysis and systematic review on the use of cold for acute treatment of migraine.

Six studies were found to be eligible for this review. The cold stimulus could be placed anywhere on the head, and the studies could have considered its use for any migraine-associated symptom. This includes headache, eye pain, nausea, or vomiting. The interventions used cold somewhat differently, including as ice packing, cooling compression, soaking, and as a rinse. Both randomized and nonrandomized trials were included in the systematic review; however, only randomized controlled trials were used for the meta-analysis.

The primary outcome evaluated by the authors was pain intensity; secondary outcomes were duration of migraine pain as well as associated symptoms (eg, nausea, vomiting). The meta-analysis revealed that cold interventions reduce migraine pain by 3.21 points on an analog scale, and this was found to be effective within 30 minutes. At 1-2 hours after the intervention, the effect was not seen to be significant. At 24 hours, the effect of cold intervention was marginal. Cold was not seen to significantly reduce nausea or vomiting at 2 hours after intervention.

Although cold treatments are commonly used by patients, there appears to be benefit only early in the onset of a migraine attack. Headache specialists typically recommend early treatment with a migraine-specific acute medication; however, the medication may take minutes to hours before taking effect. Cold can be recommended to patients during that intervening period, and it may help until the time that their acute medications take effect.

Chronic refractory migraine remains one of the most debilitating neurologic disorders and is a challenge even for the best trained neurologist or headache specialist. There are few headache centers with inpatient headache units around the United States, and those that remain use treatments that most neurologists are not familiar with. Schwenk and colleagues retrospectively reviewed the data of a major academic headache center and revealed impressive outcomes in this very difficult-to-treat population.

This study reviewed the outcomes of 609 consecutive patients admitted to the Thomas Jefferson University inpatient headache unit from 2017 to 2021. These patients all received continuous lidocaine infusions that were titrated according to an internal protocol that balanced daily plasma lidocaine levels, tolerability, and pain relief. Hospital discharge occurred when patients were pain-free for 12-24 hours or had a minimal response after 5 days of treatment. All patients had at least eight severe headaches per month for at least 6 consecutive months and had tried one to seven preventive medications, with the result of either intolerance or ineffectiveness.

The primary outcome was change from baseline to discharge pain level. Patients were admitted with an average score of 7.0 of 10 on admission and were discharged at a score of 1.0 of 10. Secondary outcomes were average pain at post-discharge appointment vs baseline (5.5 vs 7.0), number of monthly headache days at post-discharge appointment (22.5 vs 26.8), and current and average pain levels at the post-discharge appointment, which were both significantly lower as well. The most common adverse effect was nausea; others noted were cardiovascular changes, hallucinations or nightmares, sedation, anxiety, and chest pain.

This is an important retrospective on the effectiveness of an inpatient lidocaine protocol for refractory chronic migraine. When considering this population, especially if multiple lines of preventive and acute medications are not effective, referral to an academic inpatient headache center should definitely be considered. This patient population does not respond effectively to most treatment modalities, and this is cause to give them hope.

How long should mothers breastfeed their babies?

The controversial question has cropped up again after the nation’s leading pediatrics group has issued new recommendations calling for women to breastfeed until their children turn 2, and possibly even longer.

The policy statement, Breastfeeding and the Use of Human Milk, was released on June 27 by the American Academy of Pediatrics. It calls out stigma, lack of support, and workplace barriers that make continued breastfeeding difficult for many mothers.

But the new policy statement isn’t going down smoothly with the Fed Is Best Foundation, a nonprofit group hoping to “debunk and sort out for the public” many of the proclamations in the AAP’s policies, said Christie del Castillo-Hegyi, MD, cofounder of the group and emergency physician at CHI St. Vincent, Little Rock, Ark.

The goal of Fed Is Best is to assist families and health care professionals with current research on the safe feeding of infants – whether with breast milk, formula, or a combination.

The AAP’s previous guidelines, issued in 2012, called for infants to be fed breast milk exclusively for their first 6 months. Continued breastfeeding was recommended while introducing complementary foods for a period of 1 year or longer, the policy stated. The updated policy extends the optimum time line for breastfeeding to up to 2 years, citing the health benefits for babies.
 

‘Tone deaf and one-sided’

The AAP policy is “tone deaf and one-sided to the 75% of the U.S. mothers who use formula either by necessity or choice,” Dr. del Castillo-Hegyi told this news organization.

She pointed to a long list of factors that could affect the health outcomes of infants with regard to breastfeeding versus formula-feeding. These include socioeconomic status, baseline maternal health and education, maternal genetics, and the effects of developing feeding complications from exclusive breastfeeding for infants whose mothers can’t produce enough milk. These issues can contribute to negative health outcomes and brain development in infants who go on to be formula fed, she said.

She also objected to the fact that the guidelines make little reference to a mother who needs to supplement breast milk with formula within 4 months – and even before that – to meet her infant’s nutritional requirements.

Mothers need to hear “that making sure their infant is adequately fed is the most important goal of any infant feeding recommendation,” Dr. del Castillo-Hegyi said. She noted that the AAP’s rigid guidelines may be impossible for many mothers to follow.

“The pressure to meet [the AAP’s] exceedingly high expectations is causing harm to mothers and babies,” she said, referring to earlier guidelines that contained similar suggestions.

If a mother’s milk is insufficient, babies are at risk for low growth rates, jaundice, and dehydration. Mothers also can be affected if they’re made to feel shame because they cannot provide adequate amounts of breast milk and must supplement their supply with formula.

The blanket nature of the AAPs recommendations is “irresponsible,” given the fact that only about one in four nursing people can produce sufficient breast milk to feed their baby, Dr. del Castillo-Hegyi said.

“Not only is there harm to the infant, who may suffer from developmental problems as a result of the malnutrition they experience, but it harms the mother who believes in the AAP to provide responsible guidelines that help them ensure the best nutrition to their infants,” she said.

Lori Feldman-Winter, MD, chair of the AAP Section on Breastfeeding, defended the updated guidance.

The policy aims “to clarify the evidence that breastfeeding matters and to use the best evidence to equip pediatricians with the ways they can support the mother’s choice,” Dr. Feldman-Winter said in an interview. “The bottom line is that most women can exclusively breastfeed according to our recommendation, but a growing number of women have conditions that make it difficult, such as obesity. Pediatricians are essential in recognizing suboptimal intake in the breastfed infant, and the policy delineates how to do this.”

Dr. Feldman-Winter added that the criticism of the policy “is not unexpected, given the many barriers in our society for women doing the work of mothering and trying to reach their personal breastfeeding goals. We know over 60% of mothers do not reach their intended goals. These barriers are even more apparent for the populations that are underserved and least likely to breastfeed.”

But Dr. del Castillo-Hegyi pushed back on the AAP’s claim that exclusive breastfeeding of infants up to 6 months of age confers significant benefits beyond combination breastfeeding and formula feeding. The policy “fails to address the fact that many mothers do not have the biological capacity to meet the recommendation and are simply unable to exclusively breastfeed their infants” for that length of time, she said.

While the differences of opinion might leave lactating mothers in limbo, another expert pointed out that “support” of mothers is critical.

Jessica Madden, MD, a pediatrician and lactation consultant in Cleveland, Ohio, said advocates should work to normalize extended breastfeeding in the general public.

“I think everyone should work to advocate together,” Dr. Madden said. “From the professional society standpoint, advocacy for extended breastfeeding should come from the Academy of Breastfeeding Medicine and the AAP’s Section on Breastfeeding Medicine.”

She said more emphasis should be focused on the roles that pediatricians and health care providers play, along with insurers and employers, to ensure that moms are confident and comfortable with whatever breastfeeding journey they take.

The AAP will be revisiting the recommendations again soon, Dr. Feldman-Winter said. The U.S. Preventive Services Task Force has completed a systematic review but has not set a date to release findings, she said.

Among the issues the USPSTF will address are whether interventions that support breastfeeding improve outcomes for children and mothers; how to improve the initiation, duration, intensity, and exclusivity of breastfeeding; and the identification of any potential harms of interventions that support breastfeeding.

“The research plan illustrates that breastfeeding is now an active area for research, and we will continue to update our recommendations according to the best evidence,” Dr. Feldman-Winter said.

Dr. del Castillo-Hegyi, Dr. Feldman-Winter, and Dr. Madden have disclosed no relevant financial relationships.

A version of this article first appeared on Medscape.com.

How long should mothers breastfeed their babies?

The controversial question has cropped up again after the nation’s leading pediatrics group has issued new recommendations calling for women to breastfeed until their children turn 2, and possibly even longer.

The policy statement, Breastfeeding and the Use of Human Milk, was released on June 27 by the American Academy of Pediatrics. It calls out stigma, lack of support, and workplace barriers that make continued breastfeeding difficult for many mothers.

But the new policy statement isn’t going down smoothly with the Fed Is Best Foundation, a nonprofit group hoping to “debunk and sort out for the public” many of the proclamations in the AAP’s policies, said Christie del Castillo-Hegyi, MD, cofounder of the group and emergency physician at CHI St. Vincent, Little Rock, Ark.

The goal of Fed Is Best is to assist families and health care professionals with current research on the safe feeding of infants – whether with breast milk, formula, or a combination.

The AAP’s previous guidelines, issued in 2012, called for infants to be fed breast milk exclusively for their first 6 months. Continued breastfeeding was recommended while introducing complementary foods for a period of 1 year or longer, the policy stated. The updated policy extends the optimum time line for breastfeeding to up to 2 years, citing the health benefits for babies.
 

‘Tone deaf and one-sided’

The AAP policy is “tone deaf and one-sided to the 75% of the U.S. mothers who use formula either by necessity or choice,” Dr. del Castillo-Hegyi told this news organization.

She pointed to a long list of factors that could affect the health outcomes of infants with regard to breastfeeding versus formula-feeding. These include socioeconomic status, baseline maternal health and education, maternal genetics, and the effects of developing feeding complications from exclusive breastfeeding for infants whose mothers can’t produce enough milk. These issues can contribute to negative health outcomes and brain development in infants who go on to be formula fed, she said.

She also objected to the fact that the guidelines make little reference to a mother who needs to supplement breast milk with formula within 4 months – and even before that – to meet her infant’s nutritional requirements.

Mothers need to hear “that making sure their infant is adequately fed is the most important goal of any infant feeding recommendation,” Dr. del Castillo-Hegyi said. She noted that the AAP’s rigid guidelines may be impossible for many mothers to follow.

“The pressure to meet [the AAP’s] exceedingly high expectations is causing harm to mothers and babies,” she said, referring to earlier guidelines that contained similar suggestions.

If a mother’s milk is insufficient, babies are at risk for low growth rates, jaundice, and dehydration. Mothers also can be affected if they’re made to feel shame because they cannot provide adequate amounts of breast milk and must supplement their supply with formula.

The blanket nature of the AAPs recommendations is “irresponsible,” given the fact that only about one in four nursing people can produce sufficient breast milk to feed their baby, Dr. del Castillo-Hegyi said.

“Not only is there harm to the infant, who may suffer from developmental problems as a result of the malnutrition they experience, but it harms the mother who believes in the AAP to provide responsible guidelines that help them ensure the best nutrition to their infants,” she said.

Lori Feldman-Winter, MD, chair of the AAP Section on Breastfeeding, defended the updated guidance.

The policy aims “to clarify the evidence that breastfeeding matters and to use the best evidence to equip pediatricians with the ways they can support the mother’s choice,” Dr. Feldman-Winter said in an interview. “The bottom line is that most women can exclusively breastfeed according to our recommendation, but a growing number of women have conditions that make it difficult, such as obesity. Pediatricians are essential in recognizing suboptimal intake in the breastfed infant, and the policy delineates how to do this.”

Dr. Feldman-Winter added that the criticism of the policy “is not unexpected, given the many barriers in our society for women doing the work of mothering and trying to reach their personal breastfeeding goals. We know over 60% of mothers do not reach their intended goals. These barriers are even more apparent for the populations that are underserved and least likely to breastfeed.”

But Dr. del Castillo-Hegyi pushed back on the AAP’s claim that exclusive breastfeeding of infants up to 6 months of age confers significant benefits beyond combination breastfeeding and formula feeding. The policy “fails to address the fact that many mothers do not have the biological capacity to meet the recommendation and are simply unable to exclusively breastfeed their infants” for that length of time, she said.

While the differences of opinion might leave lactating mothers in limbo, another expert pointed out that “support” of mothers is critical.

Jessica Madden, MD, a pediatrician and lactation consultant in Cleveland, Ohio, said advocates should work to normalize extended breastfeeding in the general public.

“I think everyone should work to advocate together,” Dr. Madden said. “From the professional society standpoint, advocacy for extended breastfeeding should come from the Academy of Breastfeeding Medicine and the AAP’s Section on Breastfeeding Medicine.”

She said more emphasis should be focused on the roles that pediatricians and health care providers play, along with insurers and employers, to ensure that moms are confident and comfortable with whatever breastfeeding journey they take.

The AAP will be revisiting the recommendations again soon, Dr. Feldman-Winter said. The U.S. Preventive Services Task Force has completed a systematic review but has not set a date to release findings, she said.

Among the issues the USPSTF will address are whether interventions that support breastfeeding improve outcomes for children and mothers; how to improve the initiation, duration, intensity, and exclusivity of breastfeeding; and the identification of any potential harms of interventions that support breastfeeding.

“The research plan illustrates that breastfeeding is now an active area for research, and we will continue to update our recommendations according to the best evidence,” Dr. Feldman-Winter said.

Dr. del Castillo-Hegyi, Dr. Feldman-Winter, and Dr. Madden have disclosed no relevant financial relationships.

A version of this article first appeared on Medscape.com.

How long should mothers breastfeed their babies?

The controversial question has cropped up again after the nation’s leading pediatrics group has issued new recommendations calling for women to breastfeed until their children turn 2, and possibly even longer.

The policy statement, Breastfeeding and the Use of Human Milk, was released on June 27 by the American Academy of Pediatrics. It calls out stigma, lack of support, and workplace barriers that make continued breastfeeding difficult for many mothers.

But the new policy statement isn’t going down smoothly with the Fed Is Best Foundation, a nonprofit group hoping to “debunk and sort out for the public” many of the proclamations in the AAP’s policies, said Christie del Castillo-Hegyi, MD, cofounder of the group and emergency physician at CHI St. Vincent, Little Rock, Ark.

The goal of Fed Is Best is to assist families and health care professionals with current research on the safe feeding of infants – whether with breast milk, formula, or a combination.

The AAP’s previous guidelines, issued in 2012, called for infants to be fed breast milk exclusively for their first 6 months. Continued breastfeeding was recommended while introducing complementary foods for a period of 1 year or longer, the policy stated. The updated policy extends the optimum time line for breastfeeding to up to 2 years, citing the health benefits for babies.
 

‘Tone deaf and one-sided’

The AAP policy is “tone deaf and one-sided to the 75% of the U.S. mothers who use formula either by necessity or choice,” Dr. del Castillo-Hegyi told this news organization.

She pointed to a long list of factors that could affect the health outcomes of infants with regard to breastfeeding versus formula-feeding. These include socioeconomic status, baseline maternal health and education, maternal genetics, and the effects of developing feeding complications from exclusive breastfeeding for infants whose mothers can’t produce enough milk. These issues can contribute to negative health outcomes and brain development in infants who go on to be formula fed, she said.

She also objected to the fact that the guidelines make little reference to a mother who needs to supplement breast milk with formula within 4 months – and even before that – to meet her infant’s nutritional requirements.

Mothers need to hear “that making sure their infant is adequately fed is the most important goal of any infant feeding recommendation,” Dr. del Castillo-Hegyi said. She noted that the AAP’s rigid guidelines may be impossible for many mothers to follow.

“The pressure to meet [the AAP’s] exceedingly high expectations is causing harm to mothers and babies,” she said, referring to earlier guidelines that contained similar suggestions.

If a mother’s milk is insufficient, babies are at risk for low growth rates, jaundice, and dehydration. Mothers also can be affected if they’re made to feel shame because they cannot provide adequate amounts of breast milk and must supplement their supply with formula.

The blanket nature of the AAPs recommendations is “irresponsible,” given the fact that only about one in four nursing people can produce sufficient breast milk to feed their baby, Dr. del Castillo-Hegyi said.

“Not only is there harm to the infant, who may suffer from developmental problems as a result of the malnutrition they experience, but it harms the mother who believes in the AAP to provide responsible guidelines that help them ensure the best nutrition to their infants,” she said.

Lori Feldman-Winter, MD, chair of the AAP Section on Breastfeeding, defended the updated guidance.

The policy aims “to clarify the evidence that breastfeeding matters and to use the best evidence to equip pediatricians with the ways they can support the mother’s choice,” Dr. Feldman-Winter said in an interview. “The bottom line is that most women can exclusively breastfeed according to our recommendation, but a growing number of women have conditions that make it difficult, such as obesity. Pediatricians are essential in recognizing suboptimal intake in the breastfed infant, and the policy delineates how to do this.”

Dr. Feldman-Winter added that the criticism of the policy “is not unexpected, given the many barriers in our society for women doing the work of mothering and trying to reach their personal breastfeeding goals. We know over 60% of mothers do not reach their intended goals. These barriers are even more apparent for the populations that are underserved and least likely to breastfeed.”

But Dr. del Castillo-Hegyi pushed back on the AAP’s claim that exclusive breastfeeding of infants up to 6 months of age confers significant benefits beyond combination breastfeeding and formula feeding. The policy “fails to address the fact that many mothers do not have the biological capacity to meet the recommendation and are simply unable to exclusively breastfeed their infants” for that length of time, she said.

While the differences of opinion might leave lactating mothers in limbo, another expert pointed out that “support” of mothers is critical.

Jessica Madden, MD, a pediatrician and lactation consultant in Cleveland, Ohio, said advocates should work to normalize extended breastfeeding in the general public.

“I think everyone should work to advocate together,” Dr. Madden said. “From the professional society standpoint, advocacy for extended breastfeeding should come from the Academy of Breastfeeding Medicine and the AAP’s Section on Breastfeeding Medicine.”

She said more emphasis should be focused on the roles that pediatricians and health care providers play, along with insurers and employers, to ensure that moms are confident and comfortable with whatever breastfeeding journey they take.

The AAP will be revisiting the recommendations again soon, Dr. Feldman-Winter said. The U.S. Preventive Services Task Force has completed a systematic review but has not set a date to release findings, she said.

Among the issues the USPSTF will address are whether interventions that support breastfeeding improve outcomes for children and mothers; how to improve the initiation, duration, intensity, and exclusivity of breastfeeding; and the identification of any potential harms of interventions that support breastfeeding.

“The research plan illustrates that breastfeeding is now an active area for research, and we will continue to update our recommendations according to the best evidence,” Dr. Feldman-Winter said.

Dr. del Castillo-Hegyi, Dr. Feldman-Winter, and Dr. Madden have disclosed no relevant financial relationships.

A version of this article first appeared on Medscape.com.

Four years ago, Atrium Health, in Charlotte, N.C., embarked on a dramatic change in how it cares for newborns exposed to opioids in the womb.

Until then, most of the 700 or so babies who underwent opioid withdrawal each year in the hospital system spent their first weeks in a neonatal intensive care unit (NICU), isolated from their parents and treated with regular doses of morphine to ease their symptoms.

Now, most babies stay in the hospital for just a few days under a new approach called Eat, Sleep, Console. These young patients stay in private rooms where they can bond with their parents and volunteer caregivers. The usual course of treatment is no longer extended therapy with opioid replacements. Instead, mothers are encouraged to stay overnight and are taught how to sooth their babies with swaddling, rocking, and cooing.

As a result, the average length of stay for newborns with neonatal abstinence syndrome (NAS) has dropped from 12 days to 6. Use of morphine has fallen by 79%, from 2.25 to 0.45 mg/kg per stay, according to results of a quality improvement pilot project at one of Atrium’s community hospitals.

Similar outcomes from other hospitals around the country have led to widespread uptake of Eat, Sleep, Console since its advent in 2017. That year, according to federal data, seven newborns were diagnosed with NAS for every 1,000 births.

Advocates say the family-centric model helps parents feel less stigmatized and more confident in their ability to care for their babies, who can have symptoms such as irritability and difficulty feeding for months.

The approach “really empowers families to do what they do best, which is take care of each other,” Douglas Dodds, MD, a pediatrician who led the effort at Atrium, told this news organization.
 

Questioning the old protocols

Numerous state perinatal collaboratives, hospital associations, and health systems say the program is the new standard of care for infants with NAS and neonatal opioid withdrawal syndrome (NOWS).

Twenty-six hospitals have adopted Eat, Sleep, Console as part of a clinical trial sponsored by the National Institutes of Health and a program called Advancing Clinical Trials in Neonatal Opioid Withdrawal Syndrome (ACT NOW). Researchers are comparing the approach to previous care protocols in regard to 12 outcomes, including time to medical readiness for discharge, frequency of opioid replacement therapy, and safety problems, such as seizures during treatment.

The transition has been swift. Less than a decade ago, most hospitals used the Finnegan Neonatal Abstinence Scoring System, which was developed in the 1970s to assess babies whose mothers had used heroin during pregnancy.

The Finnegan score entails monitoring babies every 3 hours for 21 symptoms, including high-pitched crying, sneezing, gastrointestinal problems, and yawning. If a baby scores an 8 or more three times in a row, most protocols using the traditional Finnegan approach recommend that providers move infants to an NICU, where they receive morphine or methadone. Once opioid replacement therapy is started, the protocols require a gradual weaning that lasts 3-4 weeks.

As the opioid epidemic grew and NICUs around the country began to fill with babies experiencing NAS or NOW, some clinicians began to question the Finnegan-driven approach.

“You have these miserable babies who are going through this really tough experience, and our first move is to separate them from their moms,” said Matthew Grossman, MD, a pediatric hospitalist at Yale New Haven Children’s Hospital, New Haven, Conn., who created Eat, Sleep, Console.

Dr. Grossman, associate professor and vice chair for quality in the department of pediatrics at Yale University, said he noticed that when mothers stayed overnight with their babies, the infants tended to have fewer withdrawal symptoms. Indeed, previous studies had demonstrated the benefits of breastfeeding and allowing mothers and babies to share a room.

“If you think of mom as a medicine, then you can’t put the baby in a unit where the mom can’t be there,” Dr. Grossman told this news organization. “It would be like taking a kid with pneumonia and putting him in a unit that doesn’t have antibiotics.”

Despite its prominence, the Finnegan score has never been validated for guiding the treatment of NAS. In addition, Finnegan scores can be inconsistent, and the assessment requires disturbing an infant to check signs such as its startle reflex, which, as Dr. Grossman and his fellow researchers pointed out, flies in the face of American Academy of Pediatrics’ recommendations to prioritize swaddling and minimize stimulation for infants with NAS.

By contrast, Eat, Sleep, Console offers a simplified assessment. Interventions are called for if a baby eats less than an ounce of food at a time/does not breastfeed, sleeps less than an hour at a stretch, or takes more than 10 minutes to be consoled. After nonpharmacologic interventions have been tried, doses of medication are used as needed. Babies who are doing well can be discharged in as few as 4 days.
 

Quashing bias against parents with substance abuse disorder

Even with the promise of shorter stays and better care, switching to nonpharmacologic care presents hurdles for hospitals. Among these is a lack of physical space for mothers to room with their babies in a quiet environment.

“In many community hospitals, the only place for infants to go is a neonatal intensive care unit, outside of the newborn nursery,” said Stephen Patrick, MD, MPH, associate professor and director of the Center for Child Health Policy at Vanderbilt University, Nashville, Tenn., who researches stigma associated with opioid use during pregnancy.

Administrators at SSM St. Mary’s Hospital in St. Louis initially balked at providing private rooms for mothers and their babies with NAS and NOWS, according to Kimberly Spence, MD, a neonatologist at SSM Health. She said the initial plan was to put the babies in a busy, brightly lit nursery.

But resistance waned as the hospital convinced health plans to pay for private rooms for the 5-7 days it typically takes a baby to go through withdrawal, said Dr. Spence, associate professor of pediatrics at Saint Louis University.

“We were able to provide enough data that this is evidence-based medicine and babies do better with their moms, and that ethically, this is the right thing to do, to reduce transfers to an NICU,” she said.

In addition, news stories about the family-centric approach and shorter stays for infants, along with SSM’s launch of an outpatient clinic to treat pregnant women with opioid use disorder, helped the system to attract more patients and increase its market share, said Dr. Spence.

Another challenge was getting physicians and nurses to set aside any judgments of parents with substance abuse disorder, according to Dr. Grossman and others.

“A lot of faculty and staff on the medical team didn’t feel like we should trust moms with their babies’ medical care” at SSM, Dr. Spence said.

Some hospitals conduct anti-bias training to teach providers that substance abuse is a disease that deserves proper medical treatment and not the moral failing of a patient. Such education may involve explaining that babies’ outcomes are improved when women undergo treatment with methadone or buprenorphine during pregnancy, even though use of those medications does pose a risk of NAS.

Creating a system that supports parents with substance abuse disorders may help to change perceptions. At Atrium Health, some staff members now enjoy working with these families because they can make a profound impact, Dr. Dodds said. He said they’ve learned that families suffering from substance abuse disorder “are not that different than any other family.”

Dr. Dodds, Dr. Patrick, Dr. Spence, and Dr. Grossman reported no relevant financial relationships.

A version of this article first appeared on Medscape.com.

Four years ago, Atrium Health, in Charlotte, N.C., embarked on a dramatic change in how it cares for newborns exposed to opioids in the womb.

Until then, most of the 700 or so babies who underwent opioid withdrawal each year in the hospital system spent their first weeks in a neonatal intensive care unit (NICU), isolated from their parents and treated with regular doses of morphine to ease their symptoms.

Now, most babies stay in the hospital for just a few days under a new approach called Eat, Sleep, Console. These young patients stay in private rooms where they can bond with their parents and volunteer caregivers. The usual course of treatment is no longer extended therapy with opioid replacements. Instead, mothers are encouraged to stay overnight and are taught how to sooth their babies with swaddling, rocking, and cooing.

As a result, the average length of stay for newborns with neonatal abstinence syndrome (NAS) has dropped from 12 days to 6. Use of morphine has fallen by 79%, from 2.25 to 0.45 mg/kg per stay, according to results of a quality improvement pilot project at one of Atrium’s community hospitals.

Similar outcomes from other hospitals around the country have led to widespread uptake of Eat, Sleep, Console since its advent in 2017. That year, according to federal data, seven newborns were diagnosed with NAS for every 1,000 births.

Advocates say the family-centric model helps parents feel less stigmatized and more confident in their ability to care for their babies, who can have symptoms such as irritability and difficulty feeding for months.

The approach “really empowers families to do what they do best, which is take care of each other,” Douglas Dodds, MD, a pediatrician who led the effort at Atrium, told this news organization.
 

Questioning the old protocols

Numerous state perinatal collaboratives, hospital associations, and health systems say the program is the new standard of care for infants with NAS and neonatal opioid withdrawal syndrome (NOWS).

Twenty-six hospitals have adopted Eat, Sleep, Console as part of a clinical trial sponsored by the National Institutes of Health and a program called Advancing Clinical Trials in Neonatal Opioid Withdrawal Syndrome (ACT NOW). Researchers are comparing the approach to previous care protocols in regard to 12 outcomes, including time to medical readiness for discharge, frequency of opioid replacement therapy, and safety problems, such as seizures during treatment.

The transition has been swift. Less than a decade ago, most hospitals used the Finnegan Neonatal Abstinence Scoring System, which was developed in the 1970s to assess babies whose mothers had used heroin during pregnancy.

The Finnegan score entails monitoring babies every 3 hours for 21 symptoms, including high-pitched crying, sneezing, gastrointestinal problems, and yawning. If a baby scores an 8 or more three times in a row, most protocols using the traditional Finnegan approach recommend that providers move infants to an NICU, where they receive morphine or methadone. Once opioid replacement therapy is started, the protocols require a gradual weaning that lasts 3-4 weeks.

As the opioid epidemic grew and NICUs around the country began to fill with babies experiencing NAS or NOW, some clinicians began to question the Finnegan-driven approach.

“You have these miserable babies who are going through this really tough experience, and our first move is to separate them from their moms,” said Matthew Grossman, MD, a pediatric hospitalist at Yale New Haven Children’s Hospital, New Haven, Conn., who created Eat, Sleep, Console.

Dr. Grossman, associate professor and vice chair for quality in the department of pediatrics at Yale University, said he noticed that when mothers stayed overnight with their babies, the infants tended to have fewer withdrawal symptoms. Indeed, previous studies had demonstrated the benefits of breastfeeding and allowing mothers and babies to share a room.

“If you think of mom as a medicine, then you can’t put the baby in a unit where the mom can’t be there,” Dr. Grossman told this news organization. “It would be like taking a kid with pneumonia and putting him in a unit that doesn’t have antibiotics.”

Despite its prominence, the Finnegan score has never been validated for guiding the treatment of NAS. In addition, Finnegan scores can be inconsistent, and the assessment requires disturbing an infant to check signs such as its startle reflex, which, as Dr. Grossman and his fellow researchers pointed out, flies in the face of American Academy of Pediatrics’ recommendations to prioritize swaddling and minimize stimulation for infants with NAS.

By contrast, Eat, Sleep, Console offers a simplified assessment. Interventions are called for if a baby eats less than an ounce of food at a time/does not breastfeed, sleeps less than an hour at a stretch, or takes more than 10 minutes to be consoled. After nonpharmacologic interventions have been tried, doses of medication are used as needed. Babies who are doing well can be discharged in as few as 4 days.
 

Quashing bias against parents with substance abuse disorder

Even with the promise of shorter stays and better care, switching to nonpharmacologic care presents hurdles for hospitals. Among these is a lack of physical space for mothers to room with their babies in a quiet environment.

“In many community hospitals, the only place for infants to go is a neonatal intensive care unit, outside of the newborn nursery,” said Stephen Patrick, MD, MPH, associate professor and director of the Center for Child Health Policy at Vanderbilt University, Nashville, Tenn., who researches stigma associated with opioid use during pregnancy.

Administrators at SSM St. Mary’s Hospital in St. Louis initially balked at providing private rooms for mothers and their babies with NAS and NOWS, according to Kimberly Spence, MD, a neonatologist at SSM Health. She said the initial plan was to put the babies in a busy, brightly lit nursery.

But resistance waned as the hospital convinced health plans to pay for private rooms for the 5-7 days it typically takes a baby to go through withdrawal, said Dr. Spence, associate professor of pediatrics at Saint Louis University.

“We were able to provide enough data that this is evidence-based medicine and babies do better with their moms, and that ethically, this is the right thing to do, to reduce transfers to an NICU,” she said.

In addition, news stories about the family-centric approach and shorter stays for infants, along with SSM’s launch of an outpatient clinic to treat pregnant women with opioid use disorder, helped the system to attract more patients and increase its market share, said Dr. Spence.

Another challenge was getting physicians and nurses to set aside any judgments of parents with substance abuse disorder, according to Dr. Grossman and others.

“A lot of faculty and staff on the medical team didn’t feel like we should trust moms with their babies’ medical care” at SSM, Dr. Spence said.

Some hospitals conduct anti-bias training to teach providers that substance abuse is a disease that deserves proper medical treatment and not the moral failing of a patient. Such education may involve explaining that babies’ outcomes are improved when women undergo treatment with methadone or buprenorphine during pregnancy, even though use of those medications does pose a risk of NAS.

Creating a system that supports parents with substance abuse disorders may help to change perceptions. At Atrium Health, some staff members now enjoy working with these families because they can make a profound impact, Dr. Dodds said. He said they’ve learned that families suffering from substance abuse disorder “are not that different than any other family.”

Dr. Dodds, Dr. Patrick, Dr. Spence, and Dr. Grossman reported no relevant financial relationships.

A version of this article first appeared on Medscape.com.

Four years ago, Atrium Health, in Charlotte, N.C., embarked on a dramatic change in how it cares for newborns exposed to opioids in the womb.

Until then, most of the 700 or so babies who underwent opioid withdrawal each year in the hospital system spent their first weeks in a neonatal intensive care unit (NICU), isolated from their parents and treated with regular doses of morphine to ease their symptoms.

Now, most babies stay in the hospital for just a few days under a new approach called Eat, Sleep, Console. These young patients stay in private rooms where they can bond with their parents and volunteer caregivers. The usual course of treatment is no longer extended therapy with opioid replacements. Instead, mothers are encouraged to stay overnight and are taught how to sooth their babies with swaddling, rocking, and cooing.

As a result, the average length of stay for newborns with neonatal abstinence syndrome (NAS) has dropped from 12 days to 6. Use of morphine has fallen by 79%, from 2.25 to 0.45 mg/kg per stay, according to results of a quality improvement pilot project at one of Atrium’s community hospitals.

Similar outcomes from other hospitals around the country have led to widespread uptake of Eat, Sleep, Console since its advent in 2017. That year, according to federal data, seven newborns were diagnosed with NAS for every 1,000 births.

Advocates say the family-centric model helps parents feel less stigmatized and more confident in their ability to care for their babies, who can have symptoms such as irritability and difficulty feeding for months.

The approach “really empowers families to do what they do best, which is take care of each other,” Douglas Dodds, MD, a pediatrician who led the effort at Atrium, told this news organization.
 

Questioning the old protocols

Numerous state perinatal collaboratives, hospital associations, and health systems say the program is the new standard of care for infants with NAS and neonatal opioid withdrawal syndrome (NOWS).

Twenty-six hospitals have adopted Eat, Sleep, Console as part of a clinical trial sponsored by the National Institutes of Health and a program called Advancing Clinical Trials in Neonatal Opioid Withdrawal Syndrome (ACT NOW). Researchers are comparing the approach to previous care protocols in regard to 12 outcomes, including time to medical readiness for discharge, frequency of opioid replacement therapy, and safety problems, such as seizures during treatment.

The transition has been swift. Less than a decade ago, most hospitals used the Finnegan Neonatal Abstinence Scoring System, which was developed in the 1970s to assess babies whose mothers had used heroin during pregnancy.

The Finnegan score entails monitoring babies every 3 hours for 21 symptoms, including high-pitched crying, sneezing, gastrointestinal problems, and yawning. If a baby scores an 8 or more three times in a row, most protocols using the traditional Finnegan approach recommend that providers move infants to an NICU, where they receive morphine or methadone. Once opioid replacement therapy is started, the protocols require a gradual weaning that lasts 3-4 weeks.

As the opioid epidemic grew and NICUs around the country began to fill with babies experiencing NAS or NOW, some clinicians began to question the Finnegan-driven approach.

“You have these miserable babies who are going through this really tough experience, and our first move is to separate them from their moms,” said Matthew Grossman, MD, a pediatric hospitalist at Yale New Haven Children’s Hospital, New Haven, Conn., who created Eat, Sleep, Console.

Dr. Grossman, associate professor and vice chair for quality in the department of pediatrics at Yale University, said he noticed that when mothers stayed overnight with their babies, the infants tended to have fewer withdrawal symptoms. Indeed, previous studies had demonstrated the benefits of breastfeeding and allowing mothers and babies to share a room.

“If you think of mom as a medicine, then you can’t put the baby in a unit where the mom can’t be there,” Dr. Grossman told this news organization. “It would be like taking a kid with pneumonia and putting him in a unit that doesn’t have antibiotics.”

Despite its prominence, the Finnegan score has never been validated for guiding the treatment of NAS. In addition, Finnegan scores can be inconsistent, and the assessment requires disturbing an infant to check signs such as its startle reflex, which, as Dr. Grossman and his fellow researchers pointed out, flies in the face of American Academy of Pediatrics’ recommendations to prioritize swaddling and minimize stimulation for infants with NAS.

By contrast, Eat, Sleep, Console offers a simplified assessment. Interventions are called for if a baby eats less than an ounce of food at a time/does not breastfeed, sleeps less than an hour at a stretch, or takes more than 10 minutes to be consoled. After nonpharmacologic interventions have been tried, doses of medication are used as needed. Babies who are doing well can be discharged in as few as 4 days.
 

Quashing bias against parents with substance abuse disorder

Even with the promise of shorter stays and better care, switching to nonpharmacologic care presents hurdles for hospitals. Among these is a lack of physical space for mothers to room with their babies in a quiet environment.

“In many community hospitals, the only place for infants to go is a neonatal intensive care unit, outside of the newborn nursery,” said Stephen Patrick, MD, MPH, associate professor and director of the Center for Child Health Policy at Vanderbilt University, Nashville, Tenn., who researches stigma associated with opioid use during pregnancy.

Administrators at SSM St. Mary’s Hospital in St. Louis initially balked at providing private rooms for mothers and their babies with NAS and NOWS, according to Kimberly Spence, MD, a neonatologist at SSM Health. She said the initial plan was to put the babies in a busy, brightly lit nursery.

But resistance waned as the hospital convinced health plans to pay for private rooms for the 5-7 days it typically takes a baby to go through withdrawal, said Dr. Spence, associate professor of pediatrics at Saint Louis University.

“We were able to provide enough data that this is evidence-based medicine and babies do better with their moms, and that ethically, this is the right thing to do, to reduce transfers to an NICU,” she said.

In addition, news stories about the family-centric approach and shorter stays for infants, along with SSM’s launch of an outpatient clinic to treat pregnant women with opioid use disorder, helped the system to attract more patients and increase its market share, said Dr. Spence.

Another challenge was getting physicians and nurses to set aside any judgments of parents with substance abuse disorder, according to Dr. Grossman and others.

“A lot of faculty and staff on the medical team didn’t feel like we should trust moms with their babies’ medical care” at SSM, Dr. Spence said.

Some hospitals conduct anti-bias training to teach providers that substance abuse is a disease that deserves proper medical treatment and not the moral failing of a patient. Such education may involve explaining that babies’ outcomes are improved when women undergo treatment with methadone or buprenorphine during pregnancy, even though use of those medications does pose a risk of NAS.

Creating a system that supports parents with substance abuse disorders may help to change perceptions. At Atrium Health, some staff members now enjoy working with these families because they can make a profound impact, Dr. Dodds said. He said they’ve learned that families suffering from substance abuse disorder “are not that different than any other family.”

Dr. Dodds, Dr. Patrick, Dr. Spence, and Dr. Grossman reported no relevant financial relationships.

A version of this article first appeared on Medscape.com.

Ob.gyns. will not have to travel to Texas to take the board certification exam this fall. 

The announcement from the American Board of Obstetrics & Gynecology follows worries from physicians that gathering in large groups for the examination would leave them vulnerable to physical or political retaliation in the wake of the Supreme Court’s decision to overturn Roe v. Wade.

ABOG is headquartered in Dallas; Texas is one of many states with a near-complete ban on abortion.

Though certification is voluntary, many doctors opt to take the 3-hour oral test to enhance their medical expertise beyond what their state requires. 

ABOG held board certification exams online during the pandemic, with plans to return to in-person testing this fall. However, last week, the board said that online testing will continue “due to the increase in COVID-19 cases across the country and concerns regarding the U.S. Supreme Court opinion on Dobbs v. Jackson Women’s Health Organization.”

More than 500 physicians petitioned against having in-person board certification exams last month in a letter addressed to the board.

“The state of Texas has severely restricted access to abortion and has allowed private citizens to take legal action against anyone suspected of assisting or performing terminations,” the letter says. “Due to the ‘aid and abet’ clause included in SB8, we may be targeted for legal or political retribution.”

SB8 is shorthand for the Texas Heartbeat Act, which authorizes anyone in the state of Texas to sue any individual whom they believe to have performed or induced an abortion, as well as people who aid or abet abortions in any way, such as paying for the abortion through their insurance.

Pregnant exam-takers also feared having to seek care for potential complications in Texas.

“We see no justifiable reason to mandate in-person oral board exams in a state that restricts basic healthcare of pregnant people and whose laws encourage vigilante targeting of physicians who perform abortions,” the letter continues.

Alice Abernathy, MD, a national clinician scholar in obstetrics and gynecology at the University of Pennsylvania, Philadelphia, signed the petition and would be required to travel to Texas for her certification exam next year if ABOG’s future exam cycles are held in person.

“My job is straightforward – I take care of patients. I will not expose myself to risk of prosecution for delivering the highest standard of comprehensive reproductive health care to my patients,” Dr. Abernathy told this news organization.

A version of this article first appeared on Medscape.com.

Ob.gyns. will not have to travel to Texas to take the board certification exam this fall. 

The announcement from the American Board of Obstetrics & Gynecology follows worries from physicians that gathering in large groups for the examination would leave them vulnerable to physical or political retaliation in the wake of the Supreme Court’s decision to overturn Roe v. Wade.

ABOG is headquartered in Dallas; Texas is one of many states with a near-complete ban on abortion.

Though certification is voluntary, many doctors opt to take the 3-hour oral test to enhance their medical expertise beyond what their state requires. 

ABOG held board certification exams online during the pandemic, with plans to return to in-person testing this fall. However, last week, the board said that online testing will continue “due to the increase in COVID-19 cases across the country and concerns regarding the U.S. Supreme Court opinion on Dobbs v. Jackson Women’s Health Organization.”

More than 500 physicians petitioned against having in-person board certification exams last month in a letter addressed to the board.

“The state of Texas has severely restricted access to abortion and has allowed private citizens to take legal action against anyone suspected of assisting or performing terminations,” the letter says. “Due to the ‘aid and abet’ clause included in SB8, we may be targeted for legal or political retribution.”

SB8 is shorthand for the Texas Heartbeat Act, which authorizes anyone in the state of Texas to sue any individual whom they believe to have performed or induced an abortion, as well as people who aid or abet abortions in any way, such as paying for the abortion through their insurance.

Pregnant exam-takers also feared having to seek care for potential complications in Texas.

“We see no justifiable reason to mandate in-person oral board exams in a state that restricts basic healthcare of pregnant people and whose laws encourage vigilante targeting of physicians who perform abortions,” the letter continues.

Alice Abernathy, MD, a national clinician scholar in obstetrics and gynecology at the University of Pennsylvania, Philadelphia, signed the petition and would be required to travel to Texas for her certification exam next year if ABOG’s future exam cycles are held in person.

“My job is straightforward – I take care of patients. I will not expose myself to risk of prosecution for delivering the highest standard of comprehensive reproductive health care to my patients,” Dr. Abernathy told this news organization.

A version of this article first appeared on Medscape.com.

Ob.gyns. will not have to travel to Texas to take the board certification exam this fall. 

The announcement from the American Board of Obstetrics & Gynecology follows worries from physicians that gathering in large groups for the examination would leave them vulnerable to physical or political retaliation in the wake of the Supreme Court’s decision to overturn Roe v. Wade.

ABOG is headquartered in Dallas; Texas is one of many states with a near-complete ban on abortion.

Though certification is voluntary, many doctors opt to take the 3-hour oral test to enhance their medical expertise beyond what their state requires. 

ABOG held board certification exams online during the pandemic, with plans to return to in-person testing this fall. However, last week, the board said that online testing will continue “due to the increase in COVID-19 cases across the country and concerns regarding the U.S. Supreme Court opinion on Dobbs v. Jackson Women’s Health Organization.”

More than 500 physicians petitioned against having in-person board certification exams last month in a letter addressed to the board.

“The state of Texas has severely restricted access to abortion and has allowed private citizens to take legal action against anyone suspected of assisting or performing terminations,” the letter says. “Due to the ‘aid and abet’ clause included in SB8, we may be targeted for legal or political retribution.”

SB8 is shorthand for the Texas Heartbeat Act, which authorizes anyone in the state of Texas to sue any individual whom they believe to have performed or induced an abortion, as well as people who aid or abet abortions in any way, such as paying for the abortion through their insurance.

Pregnant exam-takers also feared having to seek care for potential complications in Texas.

“We see no justifiable reason to mandate in-person oral board exams in a state that restricts basic healthcare of pregnant people and whose laws encourage vigilante targeting of physicians who perform abortions,” the letter continues.

Alice Abernathy, MD, a national clinician scholar in obstetrics and gynecology at the University of Pennsylvania, Philadelphia, signed the petition and would be required to travel to Texas for her certification exam next year if ABOG’s future exam cycles are held in person.

“My job is straightforward – I take care of patients. I will not expose myself to risk of prosecution for delivering the highest standard of comprehensive reproductive health care to my patients,” Dr. Abernathy told this news organization.

A version of this article first appeared on Medscape.com.

U.S. children appear to be failing an important test – of their hearts, not minds.

New research from the Ann & Robert H. Lurie Children’s Hospital of Chicago shows that heart health is a concern for many long before adulthood because fewer than one-third of children aged 2-19 years scored highly on the American Heart Association’s checklist for ideal cardiovascular fitness.

“This study gives us a new baseline for children’s heart health in the United States,” said Amanda Perak, MD, pediatric cardiologist at Ann & Robert H. Lurie Children’s Hospital of Chicago and a coauthor of the study.

Dr. Perak and colleagues published their findings in the journal Circulation.

The researchers identified 9888 children who completed the Centers for Disease Control and Prevention’s National Health and Nutrition Examination Survey between 2013 and 2018. They analyzed the available data using the AHA’s Life’s Essential 8 – a 100-point assessment of eight predictors for measuring heart health, including sleep, nicotine exposure, and blood glucose.

Data for only three metrics were available for all children in the study: diet, physical activity, and body mass index. As children aged, more metrics were averaged to obtain the overall cardiovascular health score. For instance, cholesterol/lipid levels become available at age 6 years, and blood pressure can be measured starting at age 8 years.

Only 2.2% of children in the study had optimal heart health, according to the Life’s Essential 8 scoring system, which spans poor (0-49), moderate (50-79), and high (80-100). Fewer than one in three (29.1%) overall had high scores, and scores worsened with age.

In the 2- to 5-year age group, over half (56.5%) of the children had good heart health. However, only one-third (33.5%) of 6- to 11-year-olds scored highly. Meanwhile, only 14% of adolescents had good heart scores, Dr. Perak’s group found.

Heart health scores based on diet were lowest for every age group. In the youngest age group, the average cardiovascular health (CVH) score was about 61. In the 12- to 19-year age group, however, the average CVH score decreased to 28.5, the lowest measured score for any group in the study.

With such worrisome diet scores for the 12- to 19-year-old group, public health policies need to focus on changes, like removing sugar-sweetened beverage options from schools, according to Joseph Mahgerefteh, MD, director of preventive cardiology at the Mount Sinai Kravis Children’s Heart Center, New York. He added that parents and their children also have a role to play.

“Some of our teenagers forget they can drink water when they are thirsty, and it is not necessary to drink sugar-sweetened beverages for thirst,” Dr. Mahgerefteh, who was not involved in the study, said in an interview. “Fresh vegetable intake is so low to a degree that some of our patients refuse to have any type of vegetable in their diet.”

“As a physician community caring for these patients, we need to be much more aggressive with our counseling and referral of these patients,” added Barry Love, MD, director of the congenital cardiac catheterization program at the Mount Sinai Kravis Children’s Heart Center. “These youngsters will inevitably encounter the effect of these conditions – coronary artery disease and stroke – at a much earlier adult age.”

Dr. Perak, Dr. Mahgerefteh, and Dr. Love reported no relevant financial conflicts of interest.

A version of this article first appeared on Medscape.com.

U.S. children appear to be failing an important test – of their hearts, not minds.

New research from the Ann & Robert H. Lurie Children’s Hospital of Chicago shows that heart health is a concern for many long before adulthood because fewer than one-third of children aged 2-19 years scored highly on the American Heart Association’s checklist for ideal cardiovascular fitness.

“This study gives us a new baseline for children’s heart health in the United States,” said Amanda Perak, MD, pediatric cardiologist at Ann & Robert H. Lurie Children’s Hospital of Chicago and a coauthor of the study.

Dr. Perak and colleagues published their findings in the journal Circulation.

The researchers identified 9888 children who completed the Centers for Disease Control and Prevention’s National Health and Nutrition Examination Survey between 2013 and 2018. They analyzed the available data using the AHA’s Life’s Essential 8 – a 100-point assessment of eight predictors for measuring heart health, including sleep, nicotine exposure, and blood glucose.

Data for only three metrics were available for all children in the study: diet, physical activity, and body mass index. As children aged, more metrics were averaged to obtain the overall cardiovascular health score. For instance, cholesterol/lipid levels become available at age 6 years, and blood pressure can be measured starting at age 8 years.

Only 2.2% of children in the study had optimal heart health, according to the Life’s Essential 8 scoring system, which spans poor (0-49), moderate (50-79), and high (80-100). Fewer than one in three (29.1%) overall had high scores, and scores worsened with age.

In the 2- to 5-year age group, over half (56.5%) of the children had good heart health. However, only one-third (33.5%) of 6- to 11-year-olds scored highly. Meanwhile, only 14% of adolescents had good heart scores, Dr. Perak’s group found.

Heart health scores based on diet were lowest for every age group. In the youngest age group, the average cardiovascular health (CVH) score was about 61. In the 12- to 19-year age group, however, the average CVH score decreased to 28.5, the lowest measured score for any group in the study.

With such worrisome diet scores for the 12- to 19-year-old group, public health policies need to focus on changes, like removing sugar-sweetened beverage options from schools, according to Joseph Mahgerefteh, MD, director of preventive cardiology at the Mount Sinai Kravis Children’s Heart Center, New York. He added that parents and their children also have a role to play.

“Some of our teenagers forget they can drink water when they are thirsty, and it is not necessary to drink sugar-sweetened beverages for thirst,” Dr. Mahgerefteh, who was not involved in the study, said in an interview. “Fresh vegetable intake is so low to a degree that some of our patients refuse to have any type of vegetable in their diet.”

“As a physician community caring for these patients, we need to be much more aggressive with our counseling and referral of these patients,” added Barry Love, MD, director of the congenital cardiac catheterization program at the Mount Sinai Kravis Children’s Heart Center. “These youngsters will inevitably encounter the effect of these conditions – coronary artery disease and stroke – at a much earlier adult age.”

Dr. Perak, Dr. Mahgerefteh, and Dr. Love reported no relevant financial conflicts of interest.

A version of this article first appeared on Medscape.com.

U.S. children appear to be failing an important test – of their hearts, not minds.

New research from the Ann & Robert H. Lurie Children’s Hospital of Chicago shows that heart health is a concern for many long before adulthood because fewer than one-third of children aged 2-19 years scored highly on the American Heart Association’s checklist for ideal cardiovascular fitness.

“This study gives us a new baseline for children’s heart health in the United States,” said Amanda Perak, MD, pediatric cardiologist at Ann & Robert H. Lurie Children’s Hospital of Chicago and a coauthor of the study.

Dr. Perak and colleagues published their findings in the journal Circulation.

The researchers identified 9888 children who completed the Centers for Disease Control and Prevention’s National Health and Nutrition Examination Survey between 2013 and 2018. They analyzed the available data using the AHA’s Life’s Essential 8 – a 100-point assessment of eight predictors for measuring heart health, including sleep, nicotine exposure, and blood glucose.

Data for only three metrics were available for all children in the study: diet, physical activity, and body mass index. As children aged, more metrics were averaged to obtain the overall cardiovascular health score. For instance, cholesterol/lipid levels become available at age 6 years, and blood pressure can be measured starting at age 8 years.

Only 2.2% of children in the study had optimal heart health, according to the Life’s Essential 8 scoring system, which spans poor (0-49), moderate (50-79), and high (80-100). Fewer than one in three (29.1%) overall had high scores, and scores worsened with age.

In the 2- to 5-year age group, over half (56.5%) of the children had good heart health. However, only one-third (33.5%) of 6- to 11-year-olds scored highly. Meanwhile, only 14% of adolescents had good heart scores, Dr. Perak’s group found.

Heart health scores based on diet were lowest for every age group. In the youngest age group, the average cardiovascular health (CVH) score was about 61. In the 12- to 19-year age group, however, the average CVH score decreased to 28.5, the lowest measured score for any group in the study.

With such worrisome diet scores for the 12- to 19-year-old group, public health policies need to focus on changes, like removing sugar-sweetened beverage options from schools, according to Joseph Mahgerefteh, MD, director of preventive cardiology at the Mount Sinai Kravis Children’s Heart Center, New York. He added that parents and their children also have a role to play.

“Some of our teenagers forget they can drink water when they are thirsty, and it is not necessary to drink sugar-sweetened beverages for thirst,” Dr. Mahgerefteh, who was not involved in the study, said in an interview. “Fresh vegetable intake is so low to a degree that some of our patients refuse to have any type of vegetable in their diet.”

“As a physician community caring for these patients, we need to be much more aggressive with our counseling and referral of these patients,” added Barry Love, MD, director of the congenital cardiac catheterization program at the Mount Sinai Kravis Children’s Heart Center. “These youngsters will inevitably encounter the effect of these conditions – coronary artery disease and stroke – at a much earlier adult age.”

Dr. Perak, Dr. Mahgerefteh, and Dr. Love reported no relevant financial conflicts of interest.

A version of this article first appeared on Medscape.com.

Few people like to pay taxes, and physicians are no exception.

For the Medscape Physicians and Taxes Report 2022, physicians shared information about their tax debt as well as how they feel about the U.S. tax code, audits, and the prospects for the future.

Even though it may not always seem that way to physicians, their family tax bills – around $75,406 on average – are in line with the other top 10% of U.S. taxpayers, according to an examination of IRS data by the Tax Foundation. However, when it comes to local taxes, the Tax Foundation found that physicians pay more than average. (Forty-three states collect tax on individual incomes.)

The average physician’s family pays a 35% marginal tax rate, compared with the top marginal tax rate in the United States of 37%. (The marginal tax rate is the highest amount of tax charged on each additional dollar after the IRS bracket rates are applied to your income.)

According to Alexis Gallati, founder of Cerebral Tax Advisors, a Knoxville, Tenn.–based firm that caters to medical professionals, doctors also should pay attention to their effective tax rate, or the percentage of income they pay in taxes. It takes into account differing tax rates on ordinary income, capital gains, and other income sources, she says. “It gives a better 30,000-foot view of your tax situation.”

Some high-income families are required to pay the Alternative Minimum Tax (AMT), though in 2019 that applied to only one-tenth of U.S. households. The AMT is designed to make sure that high earners with many options for exemptions and deductions still contribute a minimum amount of tax. Only 13% of physicians surveyed said they paid the AMT, though 29% were unsure.
 

Filing taxes as painful as paying them

According to a 2021 Gallup poll, 50% of Americans think they pay too much tax. (About 44% think their tax bill is about right, and a kindhearted 4% think they pay too little.) Doctors are outliers on this one, with 75% saying they pay too much in taxes.

When asked what they would do to fix the tax system, the physicians in the Medscape survey had a wide array of proposed solutions, from “drop the corporate tax rate to nearly nothing to stimulate the economy” to “everyone should pay equitably. There are too many loopholes for the very wealthy.”

Some of the complaints were less about tax rates than the process of filing. One respondent said: “I would love for this system to not be our personal responsibility. Why should it be my duty to pay someone every year to do my taxes?”

About 48% of physicians prepare their own taxes (about the same percentage as the rest of the population), with most of those filing electronically, primarily because it saves time and the software is easy to use. Intuit TurboTax was the most popular online software, with 22% of respondents saying they currently used this product.

Of those who did pay someone to prepare their taxes, the complexity of their taxes cost them; the average respondent paid about three times the average rate for the service. In the long run, the cost might have been recouped.

Navjeet Chahal, managing partner and CEO of Chahal and Associates, a San Francisco–area firm specializing in working with physicians, points out that tax advisors don’t just fill out the forms; they proactively advise physicians about how they can limit their taxes. And indeed, most respondents feel that they got their money’s worth, with 70% saying their tax preparers charged a fair fee.

Though the physicians surveyed tended to think they pay too much tax, and several mentioned particular gripes with the system, the complexity of the tax code didn’t seem to be a big issue. While 82% of Americans polled in 2021 by Pew Research said they were bothered “a lot” or “some” by the complexity of the tax system, 68% of physicians agreed or slightly agreed that the U.S. tax system “makes sense.”
 

Gimme a break

Physicians are the beneficiaries of several types of tax breaks. Contributing to a pretax 401(k) account was the most common exemption, with 60% of physicians surveyed using this plan. Other tax breaks cited by respondents were: contributing to charity (54%), home mortgage interest (46%), and writing off business expenses (39%).

About one in five physicians has experienced an audit, but that risk has declined significantly in recent years, thanks to tighter IRS budgets. Overall, only about 1 in 167 U.S. taxpayers were audited in 2020, according to the IRS. Even for taxpayers reporting $5 million or more in income, the audit rate is only about 0.25%, the Government Accountability Office says.

The odds of a physician being summoned to a meeting with an auditor probably won’t increase for a few years, Mr. Gallati said. But the good news for doctors is bad news for lower-income Americans. “The IRS is woefully understaffed and underfunded, with the result that the agency is going for lower-hanging fruit and auditing more people in lower income brackets,” she said in an interview.

While one respondent described his experience with the IRS as “the audit from hell,” others thought it not so bad, with 72% saying the auditors treated them fairly. One respondent described the audit as “boring, short, and successful for me. The IRS owed me money.”

When it comes to taxes, physician respondents, on the whole, did not seem to be optimistic about the future. About 61% expect an increase in their tax rate because of Biden administration policies. One respondent veered into hyperbole with the comment: “I believe taxes will increase for physicians until they have no more money!”

Mr. Chahal doesn’t see it that way. He pointed out that recent attempts to raise taxes completely failed. “I personally don’t see that happening unless there’s a significant shift in the House and the Senate.”

A version of this article first appeared on Medscape.com.

Few people like to pay taxes, and physicians are no exception.

For the Medscape Physicians and Taxes Report 2022, physicians shared information about their tax debt as well as how they feel about the U.S. tax code, audits, and the prospects for the future.

Even though it may not always seem that way to physicians, their family tax bills – around $75,406 on average – are in line with the other top 10% of U.S. taxpayers, according to an examination of IRS data by the Tax Foundation. However, when it comes to local taxes, the Tax Foundation found that physicians pay more than average. (Forty-three states collect tax on individual incomes.)

The average physician’s family pays a 35% marginal tax rate, compared with the top marginal tax rate in the United States of 37%. (The marginal tax rate is the highest amount of tax charged on each additional dollar after the IRS bracket rates are applied to your income.)

According to Alexis Gallati, founder of Cerebral Tax Advisors, a Knoxville, Tenn.–based firm that caters to medical professionals, doctors also should pay attention to their effective tax rate, or the percentage of income they pay in taxes. It takes into account differing tax rates on ordinary income, capital gains, and other income sources, she says. “It gives a better 30,000-foot view of your tax situation.”

Some high-income families are required to pay the Alternative Minimum Tax (AMT), though in 2019 that applied to only one-tenth of U.S. households. The AMT is designed to make sure that high earners with many options for exemptions and deductions still contribute a minimum amount of tax. Only 13% of physicians surveyed said they paid the AMT, though 29% were unsure.
 

Filing taxes as painful as paying them

According to a 2021 Gallup poll, 50% of Americans think they pay too much tax. (About 44% think their tax bill is about right, and a kindhearted 4% think they pay too little.) Doctors are outliers on this one, with 75% saying they pay too much in taxes.

When asked what they would do to fix the tax system, the physicians in the Medscape survey had a wide array of proposed solutions, from “drop the corporate tax rate to nearly nothing to stimulate the economy” to “everyone should pay equitably. There are too many loopholes for the very wealthy.”

Some of the complaints were less about tax rates than the process of filing. One respondent said: “I would love for this system to not be our personal responsibility. Why should it be my duty to pay someone every year to do my taxes?”

About 48% of physicians prepare their own taxes (about the same percentage as the rest of the population), with most of those filing electronically, primarily because it saves time and the software is easy to use. Intuit TurboTax was the most popular online software, with 22% of respondents saying they currently used this product.

Of those who did pay someone to prepare their taxes, the complexity of their taxes cost them; the average respondent paid about three times the average rate for the service. In the long run, the cost might have been recouped.

Navjeet Chahal, managing partner and CEO of Chahal and Associates, a San Francisco–area firm specializing in working with physicians, points out that tax advisors don’t just fill out the forms; they proactively advise physicians about how they can limit their taxes. And indeed, most respondents feel that they got their money’s worth, with 70% saying their tax preparers charged a fair fee.

Though the physicians surveyed tended to think they pay too much tax, and several mentioned particular gripes with the system, the complexity of the tax code didn’t seem to be a big issue. While 82% of Americans polled in 2021 by Pew Research said they were bothered “a lot” or “some” by the complexity of the tax system, 68% of physicians agreed or slightly agreed that the U.S. tax system “makes sense.”
 

Gimme a break

Physicians are the beneficiaries of several types of tax breaks. Contributing to a pretax 401(k) account was the most common exemption, with 60% of physicians surveyed using this plan. Other tax breaks cited by respondents were: contributing to charity (54%), home mortgage interest (46%), and writing off business expenses (39%).

About one in five physicians has experienced an audit, but that risk has declined significantly in recent years, thanks to tighter IRS budgets. Overall, only about 1 in 167 U.S. taxpayers were audited in 2020, according to the IRS. Even for taxpayers reporting $5 million or more in income, the audit rate is only about 0.25%, the Government Accountability Office says.

The odds of a physician being summoned to a meeting with an auditor probably won’t increase for a few years, Mr. Gallati said. But the good news for doctors is bad news for lower-income Americans. “The IRS is woefully understaffed and underfunded, with the result that the agency is going for lower-hanging fruit and auditing more people in lower income brackets,” she said in an interview.

While one respondent described his experience with the IRS as “the audit from hell,” others thought it not so bad, with 72% saying the auditors treated them fairly. One respondent described the audit as “boring, short, and successful for me. The IRS owed me money.”

When it comes to taxes, physician respondents, on the whole, did not seem to be optimistic about the future. About 61% expect an increase in their tax rate because of Biden administration policies. One respondent veered into hyperbole with the comment: “I believe taxes will increase for physicians until they have no more money!”

Mr. Chahal doesn’t see it that way. He pointed out that recent attempts to raise taxes completely failed. “I personally don’t see that happening unless there’s a significant shift in the House and the Senate.”

A version of this article first appeared on Medscape.com.

Few people like to pay taxes, and physicians are no exception.

For the Medscape Physicians and Taxes Report 2022, physicians shared information about their tax debt as well as how they feel about the U.S. tax code, audits, and the prospects for the future.

Even though it may not always seem that way to physicians, their family tax bills – around $75,406 on average – are in line with the other top 10% of U.S. taxpayers, according to an examination of IRS data by the Tax Foundation. However, when it comes to local taxes, the Tax Foundation found that physicians pay more than average. (Forty-three states collect tax on individual incomes.)

The average physician’s family pays a 35% marginal tax rate, compared with the top marginal tax rate in the United States of 37%. (The marginal tax rate is the highest amount of tax charged on each additional dollar after the IRS bracket rates are applied to your income.)

According to Alexis Gallati, founder of Cerebral Tax Advisors, a Knoxville, Tenn.–based firm that caters to medical professionals, doctors also should pay attention to their effective tax rate, or the percentage of income they pay in taxes. It takes into account differing tax rates on ordinary income, capital gains, and other income sources, she says. “It gives a better 30,000-foot view of your tax situation.”

Some high-income families are required to pay the Alternative Minimum Tax (AMT), though in 2019 that applied to only one-tenth of U.S. households. The AMT is designed to make sure that high earners with many options for exemptions and deductions still contribute a minimum amount of tax. Only 13% of physicians surveyed said they paid the AMT, though 29% were unsure.
 

Filing taxes as painful as paying them

According to a 2021 Gallup poll, 50% of Americans think they pay too much tax. (About 44% think their tax bill is about right, and a kindhearted 4% think they pay too little.) Doctors are outliers on this one, with 75% saying they pay too much in taxes.

When asked what they would do to fix the tax system, the physicians in the Medscape survey had a wide array of proposed solutions, from “drop the corporate tax rate to nearly nothing to stimulate the economy” to “everyone should pay equitably. There are too many loopholes for the very wealthy.”

Some of the complaints were less about tax rates than the process of filing. One respondent said: “I would love for this system to not be our personal responsibility. Why should it be my duty to pay someone every year to do my taxes?”

About 48% of physicians prepare their own taxes (about the same percentage as the rest of the population), with most of those filing electronically, primarily because it saves time and the software is easy to use. Intuit TurboTax was the most popular online software, with 22% of respondents saying they currently used this product.

Of those who did pay someone to prepare their taxes, the complexity of their taxes cost them; the average respondent paid about three times the average rate for the service. In the long run, the cost might have been recouped.

Navjeet Chahal, managing partner and CEO of Chahal and Associates, a San Francisco–area firm specializing in working with physicians, points out that tax advisors don’t just fill out the forms; they proactively advise physicians about how they can limit their taxes. And indeed, most respondents feel that they got their money’s worth, with 70% saying their tax preparers charged a fair fee.

Though the physicians surveyed tended to think they pay too much tax, and several mentioned particular gripes with the system, the complexity of the tax code didn’t seem to be a big issue. While 82% of Americans polled in 2021 by Pew Research said they were bothered “a lot” or “some” by the complexity of the tax system, 68% of physicians agreed or slightly agreed that the U.S. tax system “makes sense.”
 

Gimme a break

Physicians are the beneficiaries of several types of tax breaks. Contributing to a pretax 401(k) account was the most common exemption, with 60% of physicians surveyed using this plan. Other tax breaks cited by respondents were: contributing to charity (54%), home mortgage interest (46%), and writing off business expenses (39%).

About one in five physicians has experienced an audit, but that risk has declined significantly in recent years, thanks to tighter IRS budgets. Overall, only about 1 in 167 U.S. taxpayers were audited in 2020, according to the IRS. Even for taxpayers reporting $5 million or more in income, the audit rate is only about 0.25%, the Government Accountability Office says.

The odds of a physician being summoned to a meeting with an auditor probably won’t increase for a few years, Mr. Gallati said. But the good news for doctors is bad news for lower-income Americans. “The IRS is woefully understaffed and underfunded, with the result that the agency is going for lower-hanging fruit and auditing more people in lower income brackets,” she said in an interview.

While one respondent described his experience with the IRS as “the audit from hell,” others thought it not so bad, with 72% saying the auditors treated them fairly. One respondent described the audit as “boring, short, and successful for me. The IRS owed me money.”

When it comes to taxes, physician respondents, on the whole, did not seem to be optimistic about the future. About 61% expect an increase in their tax rate because of Biden administration policies. One respondent veered into hyperbole with the comment: “I believe taxes will increase for physicians until they have no more money!”

Mr. Chahal doesn’t see it that way. He pointed out that recent attempts to raise taxes completely failed. “I personally don’t see that happening unless there’s a significant shift in the House and the Senate.”

A version of this article first appeared on Medscape.com.

INDIANAPOLIS – Onset of recurrent reactive infectious mucocutaneous eruption (RIME) was most common among males between the ages of 11 and 12 years, which is younger than previously described, in a single-center retrospective study. In addition, 71% of patients with recurrent disease experienced 1-2 recurrences – episodes that were generally milder and occurred at variable intervals.

Those are among key findings from the study of 50 patients with RIME, presented by Catherina X. Pan at the annual meeting of the Society for Pediatric Dermatology.

Reactive infectious mucocutaneous eruption (RIME) is a novel term encompassing an array of rare, parainfectious mucositis diseases, noted Ms. Pan, a fourth-year medical student at Harvard Medical School, Boston. Previously known as Mycoplasma pneumoniae-induced rash and mucositis (MIRM), common clinical characteristics of RIME include less than 10% body surface area involvement of polymorphic skin lesions (vesiculobullous or targetoid macules/papules); erosive oral, genital, and/or ocular mucositis involving more than two sites, and evidence of prior infection including but not limited to upper respiratory infection, fever, and cough.

In addition to M. pneumoniae, other pathogens have been implicated, she said. “While the underlying etiology of the disease is not entirely clear, it’s become increasingly known that RIME tends to recur in a subset of patients.”

A cohort study of 13 patients with RIME found that Black race, male sex, and older age were predominant among the five patients who developed recurrent disease.

The estimated recurrence rate is between 8% and 38%, but the clinical characteristics of patients who develop recurrent RIME tend to be poorly understood, Ms. Pan said.

Along with her mentor, Sadaf Hussain, MD, of the department of dermatology at Boston Children’s Hospital, Ms. Pan conducted a retrospective chart review to characterize the clinical history and course of disease in patients diagnosed with recurrent RIME. They extracted data between January of 2000 and March of 2022 using ICD-10 codes used by board-certified dermatologists at Boston Children’s Hospital, as well as a text search for RIME or MIRM in the dermatology notes. Patients were included if they had a RIME/MIRM diagnosis by a board-certified dermatologist and/or infection on PCR/serology and mucositis involvement with limited skin involvement.

The study population included 50 patients: 24 with recurrent RIME and 26 with isolated RIME. The majority (66%) were male, and the mean age of RIME onset was between 11 and 12 years old, which is up to two years younger than previously reported in the case series of 13 patients. Most of the study participants (79%) were White, but there were no significant differences in patients who had recurrent RIME and those who had isolated RIME in terms of age, sex, or race.
 

Isolated vs. recurrent RIME

However, compared with patients who had isolated RIME, a greater proportion of those with recurrent RIME had a history of atopic disease (46% vs. 23%, respectively; P = .136), as well as a history of tonsillectomy and adenoidectomy (25% vs. 4%; P = .045). “This has not been previously observed, but it may generate a hypothesis that patients with a history of frequent infection as well as amplified immune responses may be associated with disease recurrence,” Ms. Pan said.

The average number of episodes among patients with recurrent RIME was 3.5 and the interval between episodes was variable, at a mean of 10.2 months. Ms. Pan reported that 71% of recurrent RIME patients experienced 1-2 episodes, although one patient experienced 9 episodes.

Clinically, episodes among all patients with RIME were characterized by infectious prodromal symptoms (69%), oral lesions (95%), ocular lesions (60%), genital lesions (41%) and cutaneous lesions (40%). However, RIME recurrences were less severe and more atypical, with 49% involving only one mucosal surface and 29% involving two mucosal surfaces. Also, except for oral lesions, rates of infectious prodromal symptoms and other lesions significantly decreased among recurrences compared with initial RIME.

“Notably, we found that M. pneumoniae was the most common known cause of RIME, particularly among the initial episodes,” Ms. Pan said. “However, 61% of recurrent RIME episodes did not have a known cause in terms of infectious etiology. And, concordant with prior studies, we also found decreased severity [of RIME recurrences] as indicated by decreased rates of emergency department presentation, hospitalization, and duration of hospitalization.”

In other findings, psychiatric complications such as anxiety and depression followed the onset of RIME in 33% of those with recurrent disease and 22% of those with isolated disease. In addition, the three most common treatments among all 50 patients were systemic steroids, topical steroids, and M. pneumoniae-specific antibiotics.

“While RIME is considered as typically milder than Stevens-Johnson syndrome and toxic epidermal necrolysis with low mortality rates, it can lead to severe complications including conjunctival shrinkage, corneal ulceration and scarring, blindness, and oral, ocular, urogenital synechiae,” Ms. Pan noted. “Increased use of corticosteroids and steroid-sparing agents such as IVIG have also been observed. Multidisciplinary care with ophthalmology, urology, and mental health services is critical.”

She acknowledged certain limitations of the study, including its retrospective, single-center design, and the possibility that milder cases may have been excluded due to a lack of accurate diagnosis or referral.

Carrie C. Coughlin, MD, who was asked to comment on the study results, pointed out that nearly half (24) of patients in the cohort experienced recurrent RIME. “This is a high proportion, suggesting counseling about the possibility of recurrence is more important than previously thought,” said Dr. Coughlin, director of the section of pediatric dermatology Washington University/St. Louis Children’s Hospital.

“Fortunately, recurrent cases tended to be less severe. However, many patients had more than one recurrence, making this challenging for affected patients.”

The researchers reported having no financial disclosures. Dr. Coughlin is on the board of the Pediatric Dermatology Research Alliance (PeDRA) and the International Immunosuppression and Transplant Skin Cancer Collaborative.

INDIANAPOLIS – Onset of recurrent reactive infectious mucocutaneous eruption (RIME) was most common among males between the ages of 11 and 12 years, which is younger than previously described, in a single-center retrospective study. In addition, 71% of patients with recurrent disease experienced 1-2 recurrences – episodes that were generally milder and occurred at variable intervals.

Those are among key findings from the study of 50 patients with RIME, presented by Catherina X. Pan at the annual meeting of the Society for Pediatric Dermatology.

Reactive infectious mucocutaneous eruption (RIME) is a novel term encompassing an array of rare, parainfectious mucositis diseases, noted Ms. Pan, a fourth-year medical student at Harvard Medical School, Boston. Previously known as Mycoplasma pneumoniae-induced rash and mucositis (MIRM), common clinical characteristics of RIME include less than 10% body surface area involvement of polymorphic skin lesions (vesiculobullous or targetoid macules/papules); erosive oral, genital, and/or ocular mucositis involving more than two sites, and evidence of prior infection including but not limited to upper respiratory infection, fever, and cough.

In addition to M. pneumoniae, other pathogens have been implicated, she said. “While the underlying etiology of the disease is not entirely clear, it’s become increasingly known that RIME tends to recur in a subset of patients.”

A cohort study of 13 patients with RIME found that Black race, male sex, and older age were predominant among the five patients who developed recurrent disease.

The estimated recurrence rate is between 8% and 38%, but the clinical characteristics of patients who develop recurrent RIME tend to be poorly understood, Ms. Pan said.

Along with her mentor, Sadaf Hussain, MD, of the department of dermatology at Boston Children’s Hospital, Ms. Pan conducted a retrospective chart review to characterize the clinical history and course of disease in patients diagnosed with recurrent RIME. They extracted data between January of 2000 and March of 2022 using ICD-10 codes used by board-certified dermatologists at Boston Children’s Hospital, as well as a text search for RIME or MIRM in the dermatology notes. Patients were included if they had a RIME/MIRM diagnosis by a board-certified dermatologist and/or infection on PCR/serology and mucositis involvement with limited skin involvement.

The study population included 50 patients: 24 with recurrent RIME and 26 with isolated RIME. The majority (66%) were male, and the mean age of RIME onset was between 11 and 12 years old, which is up to two years younger than previously reported in the case series of 13 patients. Most of the study participants (79%) were White, but there were no significant differences in patients who had recurrent RIME and those who had isolated RIME in terms of age, sex, or race.
 

Isolated vs. recurrent RIME

However, compared with patients who had isolated RIME, a greater proportion of those with recurrent RIME had a history of atopic disease (46% vs. 23%, respectively; P = .136), as well as a history of tonsillectomy and adenoidectomy (25% vs. 4%; P = .045). “This has not been previously observed, but it may generate a hypothesis that patients with a history of frequent infection as well as amplified immune responses may be associated with disease recurrence,” Ms. Pan said.

The average number of episodes among patients with recurrent RIME was 3.5 and the interval between episodes was variable, at a mean of 10.2 months. Ms. Pan reported that 71% of recurrent RIME patients experienced 1-2 episodes, although one patient experienced 9 episodes.

Clinically, episodes among all patients with RIME were characterized by infectious prodromal symptoms (69%), oral lesions (95%), ocular lesions (60%), genital lesions (41%) and cutaneous lesions (40%). However, RIME recurrences were less severe and more atypical, with 49% involving only one mucosal surface and 29% involving two mucosal surfaces. Also, except for oral lesions, rates of infectious prodromal symptoms and other lesions significantly decreased among recurrences compared with initial RIME.

“Notably, we found that M. pneumoniae was the most common known cause of RIME, particularly among the initial episodes,” Ms. Pan said. “However, 61% of recurrent RIME episodes did not have a known cause in terms of infectious etiology. And, concordant with prior studies, we also found decreased severity [of RIME recurrences] as indicated by decreased rates of emergency department presentation, hospitalization, and duration of hospitalization.”

In other findings, psychiatric complications such as anxiety and depression followed the onset of RIME in 33% of those with recurrent disease and 22% of those with isolated disease. In addition, the three most common treatments among all 50 patients were systemic steroids, topical steroids, and M. pneumoniae-specific antibiotics.

“While RIME is considered as typically milder than Stevens-Johnson syndrome and toxic epidermal necrolysis with low mortality rates, it can lead to severe complications including conjunctival shrinkage, corneal ulceration and scarring, blindness, and oral, ocular, urogenital synechiae,” Ms. Pan noted. “Increased use of corticosteroids and steroid-sparing agents such as IVIG have also been observed. Multidisciplinary care with ophthalmology, urology, and mental health services is critical.”

She acknowledged certain limitations of the study, including its retrospective, single-center design, and the possibility that milder cases may have been excluded due to a lack of accurate diagnosis or referral.

Carrie C. Coughlin, MD, who was asked to comment on the study results, pointed out that nearly half (24) of patients in the cohort experienced recurrent RIME. “This is a high proportion, suggesting counseling about the possibility of recurrence is more important than previously thought,” said Dr. Coughlin, director of the section of pediatric dermatology Washington University/St. Louis Children’s Hospital.

“Fortunately, recurrent cases tended to be less severe. However, many patients had more than one recurrence, making this challenging for affected patients.”

The researchers reported having no financial disclosures. Dr. Coughlin is on the board of the Pediatric Dermatology Research Alliance (PeDRA) and the International Immunosuppression and Transplant Skin Cancer Collaborative.

INDIANAPOLIS – Onset of recurrent reactive infectious mucocutaneous eruption (RIME) was most common among males between the ages of 11 and 12 years, which is younger than previously described, in a single-center retrospective study. In addition, 71% of patients with recurrent disease experienced 1-2 recurrences – episodes that were generally milder and occurred at variable intervals.

Those are among key findings from the study of 50 patients with RIME, presented by Catherina X. Pan at the annual meeting of the Society for Pediatric Dermatology.

Reactive infectious mucocutaneous eruption (RIME) is a novel term encompassing an array of rare, parainfectious mucositis diseases, noted Ms. Pan, a fourth-year medical student at Harvard Medical School, Boston. Previously known as Mycoplasma pneumoniae-induced rash and mucositis (MIRM), common clinical characteristics of RIME include less than 10% body surface area involvement of polymorphic skin lesions (vesiculobullous or targetoid macules/papules); erosive oral, genital, and/or ocular mucositis involving more than two sites, and evidence of prior infection including but not limited to upper respiratory infection, fever, and cough.

In addition to M. pneumoniae, other pathogens have been implicated, she said. “While the underlying etiology of the disease is not entirely clear, it’s become increasingly known that RIME tends to recur in a subset of patients.”

A cohort study of 13 patients with RIME found that Black race, male sex, and older age were predominant among the five patients who developed recurrent disease.

The estimated recurrence rate is between 8% and 38%, but the clinical characteristics of patients who develop recurrent RIME tend to be poorly understood, Ms. Pan said.

Along with her mentor, Sadaf Hussain, MD, of the department of dermatology at Boston Children’s Hospital, Ms. Pan conducted a retrospective chart review to characterize the clinical history and course of disease in patients diagnosed with recurrent RIME. They extracted data between January of 2000 and March of 2022 using ICD-10 codes used by board-certified dermatologists at Boston Children’s Hospital, as well as a text search for RIME or MIRM in the dermatology notes. Patients were included if they had a RIME/MIRM diagnosis by a board-certified dermatologist and/or infection on PCR/serology and mucositis involvement with limited skin involvement.

The study population included 50 patients: 24 with recurrent RIME and 26 with isolated RIME. The majority (66%) were male, and the mean age of RIME onset was between 11 and 12 years old, which is up to two years younger than previously reported in the case series of 13 patients. Most of the study participants (79%) were White, but there were no significant differences in patients who had recurrent RIME and those who had isolated RIME in terms of age, sex, or race.
 

Isolated vs. recurrent RIME

However, compared with patients who had isolated RIME, a greater proportion of those with recurrent RIME had a history of atopic disease (46% vs. 23%, respectively; P = .136), as well as a history of tonsillectomy and adenoidectomy (25% vs. 4%; P = .045). “This has not been previously observed, but it may generate a hypothesis that patients with a history of frequent infection as well as amplified immune responses may be associated with disease recurrence,” Ms. Pan said.

The average number of episodes among patients with recurrent RIME was 3.5 and the interval between episodes was variable, at a mean of 10.2 months. Ms. Pan reported that 71% of recurrent RIME patients experienced 1-2 episodes, although one patient experienced 9 episodes.

Clinically, episodes among all patients with RIME were characterized by infectious prodromal symptoms (69%), oral lesions (95%), ocular lesions (60%), genital lesions (41%) and cutaneous lesions (40%). However, RIME recurrences were less severe and more atypical, with 49% involving only one mucosal surface and 29% involving two mucosal surfaces. Also, except for oral lesions, rates of infectious prodromal symptoms and other lesions significantly decreased among recurrences compared with initial RIME.

“Notably, we found that M. pneumoniae was the most common known cause of RIME, particularly among the initial episodes,” Ms. Pan said. “However, 61% of recurrent RIME episodes did not have a known cause in terms of infectious etiology. And, concordant with prior studies, we also found decreased severity [of RIME recurrences] as indicated by decreased rates of emergency department presentation, hospitalization, and duration of hospitalization.”

In other findings, psychiatric complications such as anxiety and depression followed the onset of RIME in 33% of those with recurrent disease and 22% of those with isolated disease. In addition, the three most common treatments among all 50 patients were systemic steroids, topical steroids, and M. pneumoniae-specific antibiotics.

“While RIME is considered as typically milder than Stevens-Johnson syndrome and toxic epidermal necrolysis with low mortality rates, it can lead to severe complications including conjunctival shrinkage, corneal ulceration and scarring, blindness, and oral, ocular, urogenital synechiae,” Ms. Pan noted. “Increased use of corticosteroids and steroid-sparing agents such as IVIG have also been observed. Multidisciplinary care with ophthalmology, urology, and mental health services is critical.”

She acknowledged certain limitations of the study, including its retrospective, single-center design, and the possibility that milder cases may have been excluded due to a lack of accurate diagnosis or referral.

Carrie C. Coughlin, MD, who was asked to comment on the study results, pointed out that nearly half (24) of patients in the cohort experienced recurrent RIME. “This is a high proportion, suggesting counseling about the possibility of recurrence is more important than previously thought,” said Dr. Coughlin, director of the section of pediatric dermatology Washington University/St. Louis Children’s Hospital.

“Fortunately, recurrent cases tended to be less severe. However, many patients had more than one recurrence, making this challenging for affected patients.”

The researchers reported having no financial disclosures. Dr. Coughlin is on the board of the Pediatric Dermatology Research Alliance (PeDRA) and the International Immunosuppression and Transplant Skin Cancer Collaborative.

Since the overturn of Roe v. Wade, my mind has been flooded with the emotions of disappointment, fear, helplessness, and rage. While I process the news and try to move forward, a sense of survivor’s guilt remains. Currently, I am a Complex Family Planning fellow in California, but prior to last year, I spent my entire life in Florida. I continue to provide abortion care without the fear of prosecution. Meanwhile, my family, friends, and colleagues back home remain trapped as they scramble to figure out what to do in the aftermath of this tragedy.

The day the Supreme Court decision was announced, I was in the operating room performing an abortion. As I went through a 24-week dilation and evacuation procedure, I could hear my phone vibrating as text messages and social media alerts started to flood in. Those who have met me know how much I care about reproductive rights. I was not surprised when family, friends, and former colleagues reached out to check on me. While I appreciated the support, I could not help but think how it was not me who needed the comforting. I did not have to question whether my team could complete our full day of abortion procedures. I knew there were providers across the country making devastating calls canceling and denying appointments for patients needing abortion care. They were meeting with their staffs, administrators, and lawyers, and fielding responses from the media. I thought about all the patients and the fear they must be experiencing as they scrambled to make arrangements for possible travel to other clinics or self-management of their abortion. I know that for many, their only option is forced pregnancy.

Like any other day, the patients we cared for that day were seeking an abortion for a variety of reasons. There was a patient who recently learned her desired pregnancy was complicated by a lethal fetal malformation. One patient shared that she experienced contraception failure. Another patient feared pregnancy because her last pregnancy was complicated by severe preeclampsia and hemorrhage. Our last patient told us she missed her period and knew she did not want to be pregnant. While each individual experience is unique, these stories are not exclusive to people living in California – these stories are the same ones I heard from patients and friends seeking an abortion in Florida - across the country.

The Supreme Court majority argued it was handing the question of abortion over to the states and their voters to decide. Recent surveys found 61% of U.S. adults believe abortion should be legal in all or most cases,¹ but in several states, within hours to days of the SCOTUS decision, patients were forced to make other plans as their prior fundamental right to an abortion was immediately removed. There were no further conversations, elections, or votes. It no longer matters what the majority supports or what the details are about the lives of those people making the personal decision to have an abortion. All that matters now is the ZIP code someone happens to reside in.

After I completed the first case, the graduating resident on our team expertly completed the remaining procedures. I felt confident that she would be leaving the program able to take care of any patient needing an abortion. She would also be able to manage any emergency that requires the quick evacuation of a uterus. Dread set in as I thought about the residents back home in Florida and other restrictive states. Many of these programs already struggle to provide abortion training, and their ability to do so in a post-Roe world will be near impossible. Around 50% of current ob.gyn. residents are training in a state that is expected to or already has banned abortions.² Even in states without abortion bans, residents often are not exposed to full spectrum abortion care for a variety of reasons.

During my time in residency, a family planning rotation was developed thanks to a few dedicated educators. While there were no laws prohibiting abortion at that time, like most hospitals in the state, our primary training site only allowed terminations for a select list of indications. An all too familiar story was the transfer of a patient from a nearby hospital after a failed multiday induction for a pregnancy loss or lethal fetal anomaly. They would arrive with heavy bleeding, infections, and hemodynamic instability. Most of these patients told us they were only offered an induction because there were no providers who could or would perform a dilation and evacuation. Even at our top-rated hospital, it was often a struggle coordinating emergent care for these patients because of the limited number of proficient abortion providers. These situations will become the new norm across the country as hundreds of residents will no longer learn these critical skills. As a result, these states will see more maternal morbidity and mortality for years to come.

The reversal of Roe v. Wade affects everyone, not just people who can become pregnant. It will have a devastating effect on medical training. It will change the trajectory of people’s careers and it will result in people losing their jobs. I am so proud to be an abortion provider and cannot imagine doing anything else. I am also a proud Floridian and always envisioned a future where I could live near family while caring for the people in my community. After this decision, I don’t what my future holds. I am concerned for the next generation of health care providers. I imagine many medical students may think twice about obstetrics and gynecology given concern about prosecution for exercising the full scope of the specialty. Most importantly, I am afraid for the patients who will no longer have access to essential abortion care. While we all process this traumatic event, the prochoice community of health care providers, lawyers, politicians, researchers, students, organizers, and volunteers will continue the fight for reproductive justice. For now, I will push this feeling of guilt aside as I take advantage of working in this protected space and embrace every opportunity to provide the best abortion care possible.
 

Dr. Brown is a complex family planning fellow at the University of California, Davis.

References

1. America’s Abortion Quandary [Internet]. Pew Res. Cent. Relig. Public Life Proj. 2022.

2. Vinekar K et al. Obstet Gynecol. 2022.

Since the overturn of Roe v. Wade, my mind has been flooded with the emotions of disappointment, fear, helplessness, and rage. While I process the news and try to move forward, a sense of survivor’s guilt remains. Currently, I am a Complex Family Planning fellow in California, but prior to last year, I spent my entire life in Florida. I continue to provide abortion care without the fear of prosecution. Meanwhile, my family, friends, and colleagues back home remain trapped as they scramble to figure out what to do in the aftermath of this tragedy.

The day the Supreme Court decision was announced, I was in the operating room performing an abortion. As I went through a 24-week dilation and evacuation procedure, I could hear my phone vibrating as text messages and social media alerts started to flood in. Those who have met me know how much I care about reproductive rights. I was not surprised when family, friends, and former colleagues reached out to check on me. While I appreciated the support, I could not help but think how it was not me who needed the comforting. I did not have to question whether my team could complete our full day of abortion procedures. I knew there were providers across the country making devastating calls canceling and denying appointments for patients needing abortion care. They were meeting with their staffs, administrators, and lawyers, and fielding responses from the media. I thought about all the patients and the fear they must be experiencing as they scrambled to make arrangements for possible travel to other clinics or self-management of their abortion. I know that for many, their only option is forced pregnancy.

Like any other day, the patients we cared for that day were seeking an abortion for a variety of reasons. There was a patient who recently learned her desired pregnancy was complicated by a lethal fetal malformation. One patient shared that she experienced contraception failure. Another patient feared pregnancy because her last pregnancy was complicated by severe preeclampsia and hemorrhage. Our last patient told us she missed her period and knew she did not want to be pregnant. While each individual experience is unique, these stories are not exclusive to people living in California – these stories are the same ones I heard from patients and friends seeking an abortion in Florida - across the country.

The Supreme Court majority argued it was handing the question of abortion over to the states and their voters to decide. Recent surveys found 61% of U.S. adults believe abortion should be legal in all or most cases,¹ but in several states, within hours to days of the SCOTUS decision, patients were forced to make other plans as their prior fundamental right to an abortion was immediately removed. There were no further conversations, elections, or votes. It no longer matters what the majority supports or what the details are about the lives of those people making the personal decision to have an abortion. All that matters now is the ZIP code someone happens to reside in.

After I completed the first case, the graduating resident on our team expertly completed the remaining procedures. I felt confident that she would be leaving the program able to take care of any patient needing an abortion. She would also be able to manage any emergency that requires the quick evacuation of a uterus. Dread set in as I thought about the residents back home in Florida and other restrictive states. Many of these programs already struggle to provide abortion training, and their ability to do so in a post-Roe world will be near impossible. Around 50% of current ob.gyn. residents are training in a state that is expected to or already has banned abortions.² Even in states without abortion bans, residents often are not exposed to full spectrum abortion care for a variety of reasons.

During my time in residency, a family planning rotation was developed thanks to a few dedicated educators. While there were no laws prohibiting abortion at that time, like most hospitals in the state, our primary training site only allowed terminations for a select list of indications. An all too familiar story was the transfer of a patient from a nearby hospital after a failed multiday induction for a pregnancy loss or lethal fetal anomaly. They would arrive with heavy bleeding, infections, and hemodynamic instability. Most of these patients told us they were only offered an induction because there were no providers who could or would perform a dilation and evacuation. Even at our top-rated hospital, it was often a struggle coordinating emergent care for these patients because of the limited number of proficient abortion providers. These situations will become the new norm across the country as hundreds of residents will no longer learn these critical skills. As a result, these states will see more maternal morbidity and mortality for years to come.

The reversal of Roe v. Wade affects everyone, not just people who can become pregnant. It will have a devastating effect on medical training. It will change the trajectory of people’s careers and it will result in people losing their jobs. I am so proud to be an abortion provider and cannot imagine doing anything else. I am also a proud Floridian and always envisioned a future where I could live near family while caring for the people in my community. After this decision, I don’t what my future holds. I am concerned for the next generation of health care providers. I imagine many medical students may think twice about obstetrics and gynecology given concern about prosecution for exercising the full scope of the specialty. Most importantly, I am afraid for the patients who will no longer have access to essential abortion care. While we all process this traumatic event, the prochoice community of health care providers, lawyers, politicians, researchers, students, organizers, and volunteers will continue the fight for reproductive justice. For now, I will push this feeling of guilt aside as I take advantage of working in this protected space and embrace every opportunity to provide the best abortion care possible.
 

Dr. Brown is a complex family planning fellow at the University of California, Davis.

References

1. America’s Abortion Quandary [Internet]. Pew Res. Cent. Relig. Public Life Proj. 2022.

2. Vinekar K et al. Obstet Gynecol. 2022.

Since the overturn of Roe v. Wade, my mind has been flooded with the emotions of disappointment, fear, helplessness, and rage. While I process the news and try to move forward, a sense of survivor’s guilt remains. Currently, I am a Complex Family Planning fellow in California, but prior to last year, I spent my entire life in Florida. I continue to provide abortion care without the fear of prosecution. Meanwhile, my family, friends, and colleagues back home remain trapped as they scramble to figure out what to do in the aftermath of this tragedy.

The day the Supreme Court decision was announced, I was in the operating room performing an abortion. As I went through a 24-week dilation and evacuation procedure, I could hear my phone vibrating as text messages and social media alerts started to flood in. Those who have met me know how much I care about reproductive rights. I was not surprised when family, friends, and former colleagues reached out to check on me. While I appreciated the support, I could not help but think how it was not me who needed the comforting. I did not have to question whether my team could complete our full day of abortion procedures. I knew there were providers across the country making devastating calls canceling and denying appointments for patients needing abortion care. They were meeting with their staffs, administrators, and lawyers, and fielding responses from the media. I thought about all the patients and the fear they must be experiencing as they scrambled to make arrangements for possible travel to other clinics or self-management of their abortion. I know that for many, their only option is forced pregnancy.

Like any other day, the patients we cared for that day were seeking an abortion for a variety of reasons. There was a patient who recently learned her desired pregnancy was complicated by a lethal fetal malformation. One patient shared that she experienced contraception failure. Another patient feared pregnancy because her last pregnancy was complicated by severe preeclampsia and hemorrhage. Our last patient told us she missed her period and knew she did not want to be pregnant. While each individual experience is unique, these stories are not exclusive to people living in California – these stories are the same ones I heard from patients and friends seeking an abortion in Florida - across the country.

The Supreme Court majority argued it was handing the question of abortion over to the states and their voters to decide. Recent surveys found 61% of U.S. adults believe abortion should be legal in all or most cases,¹ but in several states, within hours to days of the SCOTUS decision, patients were forced to make other plans as their prior fundamental right to an abortion was immediately removed. There were no further conversations, elections, or votes. It no longer matters what the majority supports or what the details are about the lives of those people making the personal decision to have an abortion. All that matters now is the ZIP code someone happens to reside in.

After I completed the first case, the graduating resident on our team expertly completed the remaining procedures. I felt confident that she would be leaving the program able to take care of any patient needing an abortion. She would also be able to manage any emergency that requires the quick evacuation of a uterus. Dread set in as I thought about the residents back home in Florida and other restrictive states. Many of these programs already struggle to provide abortion training, and their ability to do so in a post-Roe world will be near impossible. Around 50% of current ob.gyn. residents are training in a state that is expected to or already has banned abortions.² Even in states without abortion bans, residents often are not exposed to full spectrum abortion care for a variety of reasons.

During my time in residency, a family planning rotation was developed thanks to a few dedicated educators. While there were no laws prohibiting abortion at that time, like most hospitals in the state, our primary training site only allowed terminations for a select list of indications. An all too familiar story was the transfer of a patient from a nearby hospital after a failed multiday induction for a pregnancy loss or lethal fetal anomaly. They would arrive with heavy bleeding, infections, and hemodynamic instability. Most of these patients told us they were only offered an induction because there were no providers who could or would perform a dilation and evacuation. Even at our top-rated hospital, it was often a struggle coordinating emergent care for these patients because of the limited number of proficient abortion providers. These situations will become the new norm across the country as hundreds of residents will no longer learn these critical skills. As a result, these states will see more maternal morbidity and mortality for years to come.

The reversal of Roe v. Wade affects everyone, not just people who can become pregnant. It will have a devastating effect on medical training. It will change the trajectory of people’s careers and it will result in people losing their jobs. I am so proud to be an abortion provider and cannot imagine doing anything else. I am also a proud Floridian and always envisioned a future where I could live near family while caring for the people in my community. After this decision, I don’t what my future holds. I am concerned for the next generation of health care providers. I imagine many medical students may think twice about obstetrics and gynecology given concern about prosecution for exercising the full scope of the specialty. Most importantly, I am afraid for the patients who will no longer have access to essential abortion care. While we all process this traumatic event, the prochoice community of health care providers, lawyers, politicians, researchers, students, organizers, and volunteers will continue the fight for reproductive justice. For now, I will push this feeling of guilt aside as I take advantage of working in this protected space and embrace every opportunity to provide the best abortion care possible.
 

Dr. Brown is a complex family planning fellow at the University of California, Davis.

References

1. America’s Abortion Quandary [Internet]. Pew Res. Cent. Relig. Public Life Proj. 2022.

2. Vinekar K et al. Obstet Gynecol. 2022.