Background: Exercise EKG is often integrated with stress echocardiography, but discordance with +EKG/–Echo has unknown significance.

Study design: Observational cohort study.

Setting: Duke University Medical Center, Durham, N.C.

Synopsis: 47,944 patients without known coronary artery disease underwent exercise stress echocardiogram (Echo) with stress EKG. Of those patients, 8.5% had +EKG/–Echo results, which was associated with annualized event rate of adverse cardiac events of 1.72%, which is higher than the 0.89% of patients with –EKG/–Echo results. This was most significant for composite major adverse cardiovascular events less than 30 days out, with an adjusted hazard ratio of 8.06 (95% confidence interval, 5.02-12.94). For major adverse cardiovascular events greater than 30 days out, HR was 1.25 (95% CI 1.02-1.53).

Bottom line: Patients with +EKG/–Echo findings appear to be at higher risk of adverse cardiac events, especially in the short term.

Citation: Daubert MA et al. Implications of abnormal exercise electrocardiography with normal stress echocardiography. JAMA Intern Med. 2020 Jan 27. doi: 10.1001/jamainternmed.2019.6958.

Dr. Ho is a hospitalist and associate professor of medicine at University of Texas Health, San Antonio.

Background: Exercise EKG is often integrated with stress echocardiography, but discordance with +EKG/–Echo has unknown significance.

Study design: Observational cohort study.

Setting: Duke University Medical Center, Durham, N.C.

Synopsis: 47,944 patients without known coronary artery disease underwent exercise stress echocardiogram (Echo) with stress EKG. Of those patients, 8.5% had +EKG/–Echo results, which was associated with annualized event rate of adverse cardiac events of 1.72%, which is higher than the 0.89% of patients with –EKG/–Echo results. This was most significant for composite major adverse cardiovascular events less than 30 days out, with an adjusted hazard ratio of 8.06 (95% confidence interval, 5.02-12.94). For major adverse cardiovascular events greater than 30 days out, HR was 1.25 (95% CI 1.02-1.53).

Bottom line: Patients with +EKG/–Echo findings appear to be at higher risk of adverse cardiac events, especially in the short term.

Citation: Daubert MA et al. Implications of abnormal exercise electrocardiography with normal stress echocardiography. JAMA Intern Med. 2020 Jan 27. doi: 10.1001/jamainternmed.2019.6958.

Dr. Ho is a hospitalist and associate professor of medicine at University of Texas Health, San Antonio.

Background: Exercise EKG is often integrated with stress echocardiography, but discordance with +EKG/–Echo has unknown significance.

Study design: Observational cohort study.

Setting: Duke University Medical Center, Durham, N.C.

Synopsis: 47,944 patients without known coronary artery disease underwent exercise stress echocardiogram (Echo) with stress EKG. Of those patients, 8.5% had +EKG/–Echo results, which was associated with annualized event rate of adverse cardiac events of 1.72%, which is higher than the 0.89% of patients with –EKG/–Echo results. This was most significant for composite major adverse cardiovascular events less than 30 days out, with an adjusted hazard ratio of 8.06 (95% confidence interval, 5.02-12.94). For major adverse cardiovascular events greater than 30 days out, HR was 1.25 (95% CI 1.02-1.53).

Bottom line: Patients with +EKG/–Echo findings appear to be at higher risk of adverse cardiac events, especially in the short term.

Citation: Daubert MA et al. Implications of abnormal exercise electrocardiography with normal stress echocardiography. JAMA Intern Med. 2020 Jan 27. doi: 10.1001/jamainternmed.2019.6958.

Dr. Ho is a hospitalist and associate professor of medicine at University of Texas Health, San Antonio.

The proportion of underrepresented groups in pediatric fellowships decreased between 2007 and 2019, while those in pediatric residencies remained stagnant, new research revealed.

Researchers acknowledged that some of the factors contributing to the low proportion of minorities in the pediatric workforce may include educational disparities starting in primary or secondary school, such as underfunded schools and lack of educational resources.

“Something I really appreciated about the paper is that this goes beyond a student stepping into medical school, finding a mentor in pediatrics, and then eventually matriculating into a pediatric residency,” said Christle Nwora, MD, an internal medicine–pediatrics resident physician at Johns Hopkins Urban Health Residency Program in Baltimore, who was not involved in the study. “I like the idea of knowing that people aren’t going into the field and being very critical as to why.”

Prior studies, including a 2019 study published in JAMA Network Open, has found that minority students remain underrepresented in medical schools. However, this most recent study, published in Pediatrics, is one of the first to report trends in the race or ethnicity of pediatric residents and fellows.

“It’s been pretty well documented throughout the medical literature that the representation of underrepresented [groups] in medicine is low among all specialties,” study author Kimberly Montez, MD, MPH, FAAP, said in an interview. “This is one of the first studies that [show this trend] in pediatrics, [but] we were kind of expecting [these findings] knowing the rest of the literature out there.”

Dr. Montez and colleagues examined self-reported race and ethnicity data from 2007 to 2019 for pediatric residents and fellows from the GME Census reports. The annual number of pediatric trainees increased from 7,964 to 8,950 between 2007 and 2019. For pediatric subspecialty fellows, that number increased from 2,684 to 3,966.

The number of underrepresented pediatric trainees also increased over time, from 1,277 to 1,478 residents and 382 to 532 subspecialty fellows. However, researchers found that the trend in proportion of underrepresented in medicine (URiM) trainees was unchanged in pediatric residencies – 16% in 2007 to 16.5% in 2019 – and, overall, decreased for URiM subspecialty fellows from 14.2% in 2007 to 13.5% in 2019.

“I was shocked at the fact that there has been no significant increase either over the last 12 years,” said Joan Park, MD, a pediatric resident at Johns Hopkins Hospital, Baltimore, who was not involved in the study. “In the news, we’re seeing way more discussions in regards to racism and representation and the fact that that hasn’t really fueled or caught fire yet in medicine at all to really move that arrow is definitely really shocking.”

The recent study also pointed out that the percentage of underrepresented groups in pediatric residencies and fellowships is considerably lower in comparison with those groups’ representations in the U.S. population. For example, Black or African American people make up 13.4% of the U.S. population but just 5.6% of pediatric trainees. Meanwhile, American Indian or Alaskan Native people make up 1.3% of the U.S. population but make up 0.2% of pediatric trainees.

Dr. Montez hypothesized that the lack of underrepresented groups as pediatric trainees – or in the medical field, in general – may have to do with systemic barriers that span the entire educational continuum and affects them even before they reach medical school, including attendance at underfunded primary and secondary schools.

“Just think about all the barriers that exist for underrepresented minorities in medicine,” said Dr. Montez, assistant professor of pediatrics at Wake Forest University, Winston-Salem, N.C. “We know that underrepresented minorities are accepted and matriculate at lower rates than [those of] their nonminority counterparts. All of this occurs even just before getting into the field of pediatrics. So multiple barriers exist.”

Those barriers may also include racism, bias, and discrimination, which may play out unconsciously when members of an underrepresented group are applying for residencies or med school, such as “recognizing a name that may be from a different ethnic or racial background and then unconsciously biasing yourself against that applicant, for example,” Dr. Montez explained.

Dr. Montez said that although there has been progress, there is still a long way to go. She hopes the study will help academic institutions and professional organizations recognize the importance of diversity in pediatrics. She noted that pediatric trainees are more likely to experience microaggressions, which could potentially cause them to leave a program.

“I hope this will galvanize pediatric programs to really think a lot about the environment that they create for underrepresented minority trainees and also about their recruitment process in terms of making sure it’s standardized, using a holistic review,” Dr. Montez explained.

In 2016, the Association of American Medical Colleges published a diversity and inclusion strategic planning guide to improve training programs. Furthermore, in 2019, the Accreditation Council for Graduate Medical Education instituted a new common program requirement on diversity that requires programs to focus on systematic recruitment and retention of a diverse and inclusive workforce of residents and fellows.

“The same way pediatricians are aware of how the environment will shape the way a child grows up, we have to be mindful of the way an environment that surrounds the medical student will shape where they eventually end up as well,” said Dr. Nwora.

The experts disclosed no conflicts of interest.

The proportion of underrepresented groups in pediatric fellowships decreased between 2007 and 2019, while those in pediatric residencies remained stagnant, new research revealed.

Researchers acknowledged that some of the factors contributing to the low proportion of minorities in the pediatric workforce may include educational disparities starting in primary or secondary school, such as underfunded schools and lack of educational resources.

“Something I really appreciated about the paper is that this goes beyond a student stepping into medical school, finding a mentor in pediatrics, and then eventually matriculating into a pediatric residency,” said Christle Nwora, MD, an internal medicine–pediatrics resident physician at Johns Hopkins Urban Health Residency Program in Baltimore, who was not involved in the study. “I like the idea of knowing that people aren’t going into the field and being very critical as to why.”

Prior studies, including a 2019 study published in JAMA Network Open, has found that minority students remain underrepresented in medical schools. However, this most recent study, published in Pediatrics, is one of the first to report trends in the race or ethnicity of pediatric residents and fellows.

“It’s been pretty well documented throughout the medical literature that the representation of underrepresented [groups] in medicine is low among all specialties,” study author Kimberly Montez, MD, MPH, FAAP, said in an interview. “This is one of the first studies that [show this trend] in pediatrics, [but] we were kind of expecting [these findings] knowing the rest of the literature out there.”

Dr. Montez and colleagues examined self-reported race and ethnicity data from 2007 to 2019 for pediatric residents and fellows from the GME Census reports. The annual number of pediatric trainees increased from 7,964 to 8,950 between 2007 and 2019. For pediatric subspecialty fellows, that number increased from 2,684 to 3,966.

The number of underrepresented pediatric trainees also increased over time, from 1,277 to 1,478 residents and 382 to 532 subspecialty fellows. However, researchers found that the trend in proportion of underrepresented in medicine (URiM) trainees was unchanged in pediatric residencies – 16% in 2007 to 16.5% in 2019 – and, overall, decreased for URiM subspecialty fellows from 14.2% in 2007 to 13.5% in 2019.

“I was shocked at the fact that there has been no significant increase either over the last 12 years,” said Joan Park, MD, a pediatric resident at Johns Hopkins Hospital, Baltimore, who was not involved in the study. “In the news, we’re seeing way more discussions in regards to racism and representation and the fact that that hasn’t really fueled or caught fire yet in medicine at all to really move that arrow is definitely really shocking.”

The recent study also pointed out that the percentage of underrepresented groups in pediatric residencies and fellowships is considerably lower in comparison with those groups’ representations in the U.S. population. For example, Black or African American people make up 13.4% of the U.S. population but just 5.6% of pediatric trainees. Meanwhile, American Indian or Alaskan Native people make up 1.3% of the U.S. population but make up 0.2% of pediatric trainees.

Dr. Montez hypothesized that the lack of underrepresented groups as pediatric trainees – or in the medical field, in general – may have to do with systemic barriers that span the entire educational continuum and affects them even before they reach medical school, including attendance at underfunded primary and secondary schools.

“Just think about all the barriers that exist for underrepresented minorities in medicine,” said Dr. Montez, assistant professor of pediatrics at Wake Forest University, Winston-Salem, N.C. “We know that underrepresented minorities are accepted and matriculate at lower rates than [those of] their nonminority counterparts. All of this occurs even just before getting into the field of pediatrics. So multiple barriers exist.”

Those barriers may also include racism, bias, and discrimination, which may play out unconsciously when members of an underrepresented group are applying for residencies or med school, such as “recognizing a name that may be from a different ethnic or racial background and then unconsciously biasing yourself against that applicant, for example,” Dr. Montez explained.

Dr. Montez said that although there has been progress, there is still a long way to go. She hopes the study will help academic institutions and professional organizations recognize the importance of diversity in pediatrics. She noted that pediatric trainees are more likely to experience microaggressions, which could potentially cause them to leave a program.

“I hope this will galvanize pediatric programs to really think a lot about the environment that they create for underrepresented minority trainees and also about their recruitment process in terms of making sure it’s standardized, using a holistic review,” Dr. Montez explained.

In 2016, the Association of American Medical Colleges published a diversity and inclusion strategic planning guide to improve training programs. Furthermore, in 2019, the Accreditation Council for Graduate Medical Education instituted a new common program requirement on diversity that requires programs to focus on systematic recruitment and retention of a diverse and inclusive workforce of residents and fellows.

“The same way pediatricians are aware of how the environment will shape the way a child grows up, we have to be mindful of the way an environment that surrounds the medical student will shape where they eventually end up as well,” said Dr. Nwora.

The experts disclosed no conflicts of interest.

The proportion of underrepresented groups in pediatric fellowships decreased between 2007 and 2019, while those in pediatric residencies remained stagnant, new research revealed.

Researchers acknowledged that some of the factors contributing to the low proportion of minorities in the pediatric workforce may include educational disparities starting in primary or secondary school, such as underfunded schools and lack of educational resources.

“Something I really appreciated about the paper is that this goes beyond a student stepping into medical school, finding a mentor in pediatrics, and then eventually matriculating into a pediatric residency,” said Christle Nwora, MD, an internal medicine–pediatrics resident physician at Johns Hopkins Urban Health Residency Program in Baltimore, who was not involved in the study. “I like the idea of knowing that people aren’t going into the field and being very critical as to why.”

Prior studies, including a 2019 study published in JAMA Network Open, has found that minority students remain underrepresented in medical schools. However, this most recent study, published in Pediatrics, is one of the first to report trends in the race or ethnicity of pediatric residents and fellows.

“It’s been pretty well documented throughout the medical literature that the representation of underrepresented [groups] in medicine is low among all specialties,” study author Kimberly Montez, MD, MPH, FAAP, said in an interview. “This is one of the first studies that [show this trend] in pediatrics, [but] we were kind of expecting [these findings] knowing the rest of the literature out there.”

Dr. Montez and colleagues examined self-reported race and ethnicity data from 2007 to 2019 for pediatric residents and fellows from the GME Census reports. The annual number of pediatric trainees increased from 7,964 to 8,950 between 2007 and 2019. For pediatric subspecialty fellows, that number increased from 2,684 to 3,966.

The number of underrepresented pediatric trainees also increased over time, from 1,277 to 1,478 residents and 382 to 532 subspecialty fellows. However, researchers found that the trend in proportion of underrepresented in medicine (URiM) trainees was unchanged in pediatric residencies – 16% in 2007 to 16.5% in 2019 – and, overall, decreased for URiM subspecialty fellows from 14.2% in 2007 to 13.5% in 2019.

“I was shocked at the fact that there has been no significant increase either over the last 12 years,” said Joan Park, MD, a pediatric resident at Johns Hopkins Hospital, Baltimore, who was not involved in the study. “In the news, we’re seeing way more discussions in regards to racism and representation and the fact that that hasn’t really fueled or caught fire yet in medicine at all to really move that arrow is definitely really shocking.”

The recent study also pointed out that the percentage of underrepresented groups in pediatric residencies and fellowships is considerably lower in comparison with those groups’ representations in the U.S. population. For example, Black or African American people make up 13.4% of the U.S. population but just 5.6% of pediatric trainees. Meanwhile, American Indian or Alaskan Native people make up 1.3% of the U.S. population but make up 0.2% of pediatric trainees.

Dr. Montez hypothesized that the lack of underrepresented groups as pediatric trainees – or in the medical field, in general – may have to do with systemic barriers that span the entire educational continuum and affects them even before they reach medical school, including attendance at underfunded primary and secondary schools.

“Just think about all the barriers that exist for underrepresented minorities in medicine,” said Dr. Montez, assistant professor of pediatrics at Wake Forest University, Winston-Salem, N.C. “We know that underrepresented minorities are accepted and matriculate at lower rates than [those of] their nonminority counterparts. All of this occurs even just before getting into the field of pediatrics. So multiple barriers exist.”

Those barriers may also include racism, bias, and discrimination, which may play out unconsciously when members of an underrepresented group are applying for residencies or med school, such as “recognizing a name that may be from a different ethnic or racial background and then unconsciously biasing yourself against that applicant, for example,” Dr. Montez explained.

Dr. Montez said that although there has been progress, there is still a long way to go. She hopes the study will help academic institutions and professional organizations recognize the importance of diversity in pediatrics. She noted that pediatric trainees are more likely to experience microaggressions, which could potentially cause them to leave a program.

“I hope this will galvanize pediatric programs to really think a lot about the environment that they create for underrepresented minority trainees and also about their recruitment process in terms of making sure it’s standardized, using a holistic review,” Dr. Montez explained.

In 2016, the Association of American Medical Colleges published a diversity and inclusion strategic planning guide to improve training programs. Furthermore, in 2019, the Accreditation Council for Graduate Medical Education instituted a new common program requirement on diversity that requires programs to focus on systematic recruitment and retention of a diverse and inclusive workforce of residents and fellows.

“The same way pediatricians are aware of how the environment will shape the way a child grows up, we have to be mindful of the way an environment that surrounds the medical student will shape where they eventually end up as well,” said Dr. Nwora.

The experts disclosed no conflicts of interest.

Dr. Michael Grunwald presents highlights in the latest studies involving several types of leukemia from the ASCO 2021 Virtual Congress.

In a dose-optimization study of ponatinib, patients with chronic-phase chronic myeloid leukemia were randomized 1:1:1 to receive 45, 30, or 15 mg daily, with dose reductions occurring once patients met the primary endpoint of ≤1% BCR-ABL1. At 12 months, response rate was highest with the 45 mg to 15 mg regimen, and 73.3% of patients in this cohort maintained response.

The phase 1/2 ZUMA-3 study evaluated KTE-X19 in adults with relapsed/refractory B-cell acute lymphoblastic leukemia. The drug’s efficacy, speed of manufacture, and ease of safety management were found to be sufficient to provide long-term clinical benefit.

Another study focused on the efficacy and safety of aspacytarabine (BST-236) for patients with acute myeloid leukemia (AML) who were unfit for chemotherapy. The rate of complete remission was 39% among the AML population, and 63% of the population in complete remission had minimal residual disease.

Dr. Grunwald closes with a study of ponatinib and blinatumomab in patients with Philadelphia chromosome–positive acute lymphoblastic leukemia. The combination of both drugs was proven to be a safe and effective chemotherapy-free regimen in both newly diagnosed patients and patients with relapsed/refractory disease.
 

--

Michael R. Grunwald, MD, Chief, Leukemia Division. Department of Hematologic Oncology and Blood Disorders. Levine Cancer Institute, Atrium Health. Charlotte, North Carolina.

Michael R. Grunwald, MD, has disclosed the following relevant financial relationships:
Serve(d) as a director, officer, partner, employee, advisor, consultant, or trustee for: AbbVie; Agios; Amgen; Astellas Pharma; Blueprint Medicines; Bristol Myers Squibb; Cardinal Health; Daiichi Sankyo; Gilead Sciences; Incyte; Karius; Pfizer; Premier Pharmaceuticals; Sierra Oncology; Stemline Therapeutics.
Received research grant from: Incyte; Janssen.
 

Dr. Michael Grunwald presents highlights in the latest studies involving several types of leukemia from the ASCO 2021 Virtual Congress.

In a dose-optimization study of ponatinib, patients with chronic-phase chronic myeloid leukemia were randomized 1:1:1 to receive 45, 30, or 15 mg daily, with dose reductions occurring once patients met the primary endpoint of ≤1% BCR-ABL1. At 12 months, response rate was highest with the 45 mg to 15 mg regimen, and 73.3% of patients in this cohort maintained response.

The phase 1/2 ZUMA-3 study evaluated KTE-X19 in adults with relapsed/refractory B-cell acute lymphoblastic leukemia. The drug’s efficacy, speed of manufacture, and ease of safety management were found to be sufficient to provide long-term clinical benefit.

Another study focused on the efficacy and safety of aspacytarabine (BST-236) for patients with acute myeloid leukemia (AML) who were unfit for chemotherapy. The rate of complete remission was 39% among the AML population, and 63% of the population in complete remission had minimal residual disease.

Dr. Grunwald closes with a study of ponatinib and blinatumomab in patients with Philadelphia chromosome–positive acute lymphoblastic leukemia. The combination of both drugs was proven to be a safe and effective chemotherapy-free regimen in both newly diagnosed patients and patients with relapsed/refractory disease.
 

--

Michael R. Grunwald, MD, Chief, Leukemia Division. Department of Hematologic Oncology and Blood Disorders. Levine Cancer Institute, Atrium Health. Charlotte, North Carolina.

Michael R. Grunwald, MD, has disclosed the following relevant financial relationships:
Serve(d) as a director, officer, partner, employee, advisor, consultant, or trustee for: AbbVie; Agios; Amgen; Astellas Pharma; Blueprint Medicines; Bristol Myers Squibb; Cardinal Health; Daiichi Sankyo; Gilead Sciences; Incyte; Karius; Pfizer; Premier Pharmaceuticals; Sierra Oncology; Stemline Therapeutics.
Received research grant from: Incyte; Janssen.
 

Dr. Michael Grunwald presents highlights in the latest studies involving several types of leukemia from the ASCO 2021 Virtual Congress.

In a dose-optimization study of ponatinib, patients with chronic-phase chronic myeloid leukemia were randomized 1:1:1 to receive 45, 30, or 15 mg daily, with dose reductions occurring once patients met the primary endpoint of ≤1% BCR-ABL1. At 12 months, response rate was highest with the 45 mg to 15 mg regimen, and 73.3% of patients in this cohort maintained response.

The phase 1/2 ZUMA-3 study evaluated KTE-X19 in adults with relapsed/refractory B-cell acute lymphoblastic leukemia. The drug’s efficacy, speed of manufacture, and ease of safety management were found to be sufficient to provide long-term clinical benefit.

Another study focused on the efficacy and safety of aspacytarabine (BST-236) for patients with acute myeloid leukemia (AML) who were unfit for chemotherapy. The rate of complete remission was 39% among the AML population, and 63% of the population in complete remission had minimal residual disease.

Dr. Grunwald closes with a study of ponatinib and blinatumomab in patients with Philadelphia chromosome–positive acute lymphoblastic leukemia. The combination of both drugs was proven to be a safe and effective chemotherapy-free regimen in both newly diagnosed patients and patients with relapsed/refractory disease.
 

--

Michael R. Grunwald, MD, Chief, Leukemia Division. Department of Hematologic Oncology and Blood Disorders. Levine Cancer Institute, Atrium Health. Charlotte, North Carolina.

Michael R. Grunwald, MD, has disclosed the following relevant financial relationships:
Serve(d) as a director, officer, partner, employee, advisor, consultant, or trustee for: AbbVie; Agios; Amgen; Astellas Pharma; Blueprint Medicines; Bristol Myers Squibb; Cardinal Health; Daiichi Sankyo; Gilead Sciences; Incyte; Karius; Pfizer; Premier Pharmaceuticals; Sierra Oncology; Stemline Therapeutics.
Received research grant from: Incyte; Janssen.
 

Centers for Medicare and Medicaid Services (CMS)–promulgated quality metrics continue to attract critics. Physicians decry that many metrics are outside their control, while patient groups are frustrated that metrics lack meaning for beneficiaries. The Hospital Readmissions Reduction Program (HRRP) reduces payments for “excess” 30-day risk-standardized readmissions for six conditions and procedures, and may be less effective in reducing readmissions than previously reported due to intentional and increasing use of hospital observation stays.¹

In this issue, Sheehy et al² report that nearly one in five rehospitalizations were unrecognized because either the index hospitalization or the rehospitalization was an observation stay, highlighting yet another challenge with the HRRP. Limitations of their study include the use of a single year of claims data and the exclusion of Medicare Advantage claims data, as one might expect lower readmission rates in this capitated program. Opportunities for improving the HRRP could consist of updating the HRRP metric to include observation stays and, for surgical hospitalizations, extended-stay surgical recovery, wherein patients may be observed for up to 2 days following a procedure. Unfortunately, despite the HRRP missing nearly one in five readmissions, CMS would likely need additional statutory authority from Congress in order to reinterpret the definition of readmission³ to include observation stays.

Challenges with the HRRP metrics raise broader concerns about the program. For decades, administrators viewed readmissions as a utilization metric, only to have the Affordable Care Act re-designate and define all-cause readmissions as a quality metric. Yet hospitals and health systems control only some factors driving readmission. Readmissions occur for a variety of reasons, including not only poor quality of initial hospital care and inadequate care coordination, but also factors that are beyond the hospital’s purview, such as lack of access to ambulatory services, multiple and severe chronic conditions that progress or remain unresponsive to intervention,⁴ and demographic and social factors such as housing instability, health literacy, or residence in a food desert. These non-hospital factors reside within the domain of other market participants or local, state, and federal government agencies.

Challenges to the utility, validity, and appropriateness of HRRP metrics should remind policymakers of the dangers of over-legislating the details of healthcare policy and the statutory inflexibility that can ensue. Clinical care evolves, and artificial constructs—including payment categories such as observation status—may age poorly over time, exemplified best by the challenges of accessing post-acute care due to the 3-day rule.⁵ Introduced as a statutory requirement in 1967, when the average length of stay was 13.8 days and observation care did not exist as a payment category, the 3-day rule requires Medicare beneficiaries to spend 3 days admitted to the hospital in order to qualify for coverage of post-acute care, creating care gaps for observation stay patients.

Observation care itself is an artificial construct of CMS payment policy. In the Medicare program, observation care falls under Part B, exposing patients to both greater financial responsibility and billing complexity through the engagement of their supplemental insurance, even though those receiving observation care experience the same care as if hospitalized— routine monitoring, nursing care, blood draws, imaging, and diagnostic tests. While CMS requires notification of observation status and explanation of the difference in patient financial responsibility, in clinical practice, patient understanding is limited. Policymakers can support both Medicare beneficiaries and hospitals by reexamining observation care as a payment category.

Sheehy and colleagues’ work simultaneously challenges the face validity of the HRRP and the reasonableness of categorizing some inpatient stays as outpatient care in the hospital—issues that policymakers can and should address.

Centers for Medicare and Medicaid Services (CMS)–promulgated quality metrics continue to attract critics. Physicians decry that many metrics are outside their control, while patient groups are frustrated that metrics lack meaning for beneficiaries. The Hospital Readmissions Reduction Program (HRRP) reduces payments for “excess” 30-day risk-standardized readmissions for six conditions and procedures, and may be less effective in reducing readmissions than previously reported due to intentional and increasing use of hospital observation stays.¹

In this issue, Sheehy et al² report that nearly one in five rehospitalizations were unrecognized because either the index hospitalization or the rehospitalization was an observation stay, highlighting yet another challenge with the HRRP. Limitations of their study include the use of a single year of claims data and the exclusion of Medicare Advantage claims data, as one might expect lower readmission rates in this capitated program. Opportunities for improving the HRRP could consist of updating the HRRP metric to include observation stays and, for surgical hospitalizations, extended-stay surgical recovery, wherein patients may be observed for up to 2 days following a procedure. Unfortunately, despite the HRRP missing nearly one in five readmissions, CMS would likely need additional statutory authority from Congress in order to reinterpret the definition of readmission³ to include observation stays.

Challenges with the HRRP metrics raise broader concerns about the program. For decades, administrators viewed readmissions as a utilization metric, only to have the Affordable Care Act re-designate and define all-cause readmissions as a quality metric. Yet hospitals and health systems control only some factors driving readmission. Readmissions occur for a variety of reasons, including not only poor quality of initial hospital care and inadequate care coordination, but also factors that are beyond the hospital’s purview, such as lack of access to ambulatory services, multiple and severe chronic conditions that progress or remain unresponsive to intervention,⁴ and demographic and social factors such as housing instability, health literacy, or residence in a food desert. These non-hospital factors reside within the domain of other market participants or local, state, and federal government agencies.

Challenges to the utility, validity, and appropriateness of HRRP metrics should remind policymakers of the dangers of over-legislating the details of healthcare policy and the statutory inflexibility that can ensue. Clinical care evolves, and artificial constructs—including payment categories such as observation status—may age poorly over time, exemplified best by the challenges of accessing post-acute care due to the 3-day rule.⁵ Introduced as a statutory requirement in 1967, when the average length of stay was 13.8 days and observation care did not exist as a payment category, the 3-day rule requires Medicare beneficiaries to spend 3 days admitted to the hospital in order to qualify for coverage of post-acute care, creating care gaps for observation stay patients.

Observation care itself is an artificial construct of CMS payment policy. In the Medicare program, observation care falls under Part B, exposing patients to both greater financial responsibility and billing complexity through the engagement of their supplemental insurance, even though those receiving observation care experience the same care as if hospitalized— routine monitoring, nursing care, blood draws, imaging, and diagnostic tests. While CMS requires notification of observation status and explanation of the difference in patient financial responsibility, in clinical practice, patient understanding is limited. Policymakers can support both Medicare beneficiaries and hospitals by reexamining observation care as a payment category.

Sheehy and colleagues’ work simultaneously challenges the face validity of the HRRP and the reasonableness of categorizing some inpatient stays as outpatient care in the hospital—issues that policymakers can and should address.

Centers for Medicare and Medicaid Services (CMS)–promulgated quality metrics continue to attract critics. Physicians decry that many metrics are outside their control, while patient groups are frustrated that metrics lack meaning for beneficiaries. The Hospital Readmissions Reduction Program (HRRP) reduces payments for “excess” 30-day risk-standardized readmissions for six conditions and procedures, and may be less effective in reducing readmissions than previously reported due to intentional and increasing use of hospital observation stays.¹

In this issue, Sheehy et al² report that nearly one in five rehospitalizations were unrecognized because either the index hospitalization or the rehospitalization was an observation stay, highlighting yet another challenge with the HRRP. Limitations of their study include the use of a single year of claims data and the exclusion of Medicare Advantage claims data, as one might expect lower readmission rates in this capitated program. Opportunities for improving the HRRP could consist of updating the HRRP metric to include observation stays and, for surgical hospitalizations, extended-stay surgical recovery, wherein patients may be observed for up to 2 days following a procedure. Unfortunately, despite the HRRP missing nearly one in five readmissions, CMS would likely need additional statutory authority from Congress in order to reinterpret the definition of readmission³ to include observation stays.

Challenges with the HRRP metrics raise broader concerns about the program. For decades, administrators viewed readmissions as a utilization metric, only to have the Affordable Care Act re-designate and define all-cause readmissions as a quality metric. Yet hospitals and health systems control only some factors driving readmission. Readmissions occur for a variety of reasons, including not only poor quality of initial hospital care and inadequate care coordination, but also factors that are beyond the hospital’s purview, such as lack of access to ambulatory services, multiple and severe chronic conditions that progress or remain unresponsive to intervention,⁴ and demographic and social factors such as housing instability, health literacy, or residence in a food desert. These non-hospital factors reside within the domain of other market participants or local, state, and federal government agencies.

Challenges to the utility, validity, and appropriateness of HRRP metrics should remind policymakers of the dangers of over-legislating the details of healthcare policy and the statutory inflexibility that can ensue. Clinical care evolves, and artificial constructs—including payment categories such as observation status—may age poorly over time, exemplified best by the challenges of accessing post-acute care due to the 3-day rule.⁵ Introduced as a statutory requirement in 1967, when the average length of stay was 13.8 days and observation care did not exist as a payment category, the 3-day rule requires Medicare beneficiaries to spend 3 days admitted to the hospital in order to qualify for coverage of post-acute care, creating care gaps for observation stay patients.

Observation care itself is an artificial construct of CMS payment policy. In the Medicare program, observation care falls under Part B, exposing patients to both greater financial responsibility and billing complexity through the engagement of their supplemental insurance, even though those receiving observation care experience the same care as if hospitalized— routine monitoring, nursing care, blood draws, imaging, and diagnostic tests. While CMS requires notification of observation status and explanation of the difference in patient financial responsibility, in clinical practice, patient understanding is limited. Policymakers can support both Medicare beneficiaries and hospitals by reexamining observation care as a payment category.

Sheehy and colleagues’ work simultaneously challenges the face validity of the HRRP and the reasonableness of categorizing some inpatient stays as outpatient care in the hospital—issues that policymakers can and should address.

“If your time to you is worth savin’

Then you better start swimmin’ or you’ll sink like a stone

For the times they are a-changin’...”

–Bob Dylan

The Accreditation Council for Graduate Medical Education requires residency programs to limit and track trainee work hours to reduce the risk of fatigue, burnout, and medical errors. These hours are documented most often by self-report, at the cost of additional administrative burden for trainees and programs, dubious accuracy, and potentially incentivizing misrepresentation.¹

Thus, the study by Soleimani and colleagues² in this issue is a welcome addition to the literature on duty-hours tracking. Using timestamp data from the electronic health record (EHR), the authors developed and collected validity evidence for an automated computerized algorithm to measure how much time trainees were spending on clinical work. The study was conducted at a large academic internal medicine residency program and tracked 203 trainees working 14,610 days. The authors compared their results to trainee self-report data. Though the approach centered on EHR access logs, it accommodated common scenarios of time away from the computer while at the hospital (eg, during patient rounds). Crucially, the algorithm included EHR access while at home. The absolute discrepancy between the algorithm and self-report averaged 1.38 hours per day. Notably, EHR work at home accounted for about an extra hour per day. When considering in-hospital work alone, the authors found 3% to 13% of trainees exceeding 80-hour workweek limits, but when adding out-of-hospital work, this percentage rose to 10% to 21%.

The authors used inventive methods to improve accuracy. They prespecified EHR functions that constituted active clinical work, classifying reading without editing notes or placing orders simply as “educational study,” which they excluded from duty hours. They ensured that time spent off-site was included and that logins from personal devices while in-hospital were not double-counted. Caveats to the study include the limited generalizability for institutions without the computational resources to replicate the model. The authors acknowledged the inherent flaw in using trainee self-report as the “gold standard,” and potentially some subset of the results could have been corroborated with time-motion observation studies.³ The decision to exclude passive medical record review at home as work arguably discounts the integral value that the “chart biopsy” has on direct patient care; it probably led to systematic underestimation of duty hours for junior and senior residents, who may be most likely to contribute in this way. Similarly, not counting time spent with patients at the end of the day after sign-out risks undercounting hours as well. Nonetheless, this study represents a rigorously designed and scalable approach to meeting regulatory requirements that can potentially lighten the administrative task load for trainees, improve reporting accuracy, and facilitate research comparing work hours to other variables of interest (eg, efficiency). The model can be generalized to other specialties and could document workload for staff physicians as well.

Merits of the study aside, the algorithm underscores troubling realities about the practice of medicine in the 21st century. Do we now equate clinical work with time on the computer? Is our contribution as physicians defined primarily by our presence at the keyboard, rather than the bedside?⁴ Future research facilitated by automated hours tracking is likely to further elucidate a connection between time spent in the EHR with burnout⁴ and job dissatisfaction, and the premise of this study is emblematic of the erosion of clinical work-life boundaries that began even before the pandemic.⁵ While the “times they are a-changin’,” in this respect, it may not be for the better.

“If your time to you is worth savin’

Then you better start swimmin’ or you’ll sink like a stone

For the times they are a-changin’...”

–Bob Dylan

The Accreditation Council for Graduate Medical Education requires residency programs to limit and track trainee work hours to reduce the risk of fatigue, burnout, and medical errors. These hours are documented most often by self-report, at the cost of additional administrative burden for trainees and programs, dubious accuracy, and potentially incentivizing misrepresentation.¹

Thus, the study by Soleimani and colleagues² in this issue is a welcome addition to the literature on duty-hours tracking. Using timestamp data from the electronic health record (EHR), the authors developed and collected validity evidence for an automated computerized algorithm to measure how much time trainees were spending on clinical work. The study was conducted at a large academic internal medicine residency program and tracked 203 trainees working 14,610 days. The authors compared their results to trainee self-report data. Though the approach centered on EHR access logs, it accommodated common scenarios of time away from the computer while at the hospital (eg, during patient rounds). Crucially, the algorithm included EHR access while at home. The absolute discrepancy between the algorithm and self-report averaged 1.38 hours per day. Notably, EHR work at home accounted for about an extra hour per day. When considering in-hospital work alone, the authors found 3% to 13% of trainees exceeding 80-hour workweek limits, but when adding out-of-hospital work, this percentage rose to 10% to 21%.

The authors used inventive methods to improve accuracy. They prespecified EHR functions that constituted active clinical work, classifying reading without editing notes or placing orders simply as “educational study,” which they excluded from duty hours. They ensured that time spent off-site was included and that logins from personal devices while in-hospital were not double-counted. Caveats to the study include the limited generalizability for institutions without the computational resources to replicate the model. The authors acknowledged the inherent flaw in using trainee self-report as the “gold standard,” and potentially some subset of the results could have been corroborated with time-motion observation studies.³ The decision to exclude passive medical record review at home as work arguably discounts the integral value that the “chart biopsy” has on direct patient care; it probably led to systematic underestimation of duty hours for junior and senior residents, who may be most likely to contribute in this way. Similarly, not counting time spent with patients at the end of the day after sign-out risks undercounting hours as well. Nonetheless, this study represents a rigorously designed and scalable approach to meeting regulatory requirements that can potentially lighten the administrative task load for trainees, improve reporting accuracy, and facilitate research comparing work hours to other variables of interest (eg, efficiency). The model can be generalized to other specialties and could document workload for staff physicians as well.

Merits of the study aside, the algorithm underscores troubling realities about the practice of medicine in the 21st century. Do we now equate clinical work with time on the computer? Is our contribution as physicians defined primarily by our presence at the keyboard, rather than the bedside?⁴ Future research facilitated by automated hours tracking is likely to further elucidate a connection between time spent in the EHR with burnout⁴ and job dissatisfaction, and the premise of this study is emblematic of the erosion of clinical work-life boundaries that began even before the pandemic.⁵ While the “times they are a-changin’,” in this respect, it may not be for the better.

“If your time to you is worth savin’

Then you better start swimmin’ or you’ll sink like a stone

For the times they are a-changin’...”

–Bob Dylan

The Accreditation Council for Graduate Medical Education requires residency programs to limit and track trainee work hours to reduce the risk of fatigue, burnout, and medical errors. These hours are documented most often by self-report, at the cost of additional administrative burden for trainees and programs, dubious accuracy, and potentially incentivizing misrepresentation.¹

Thus, the study by Soleimani and colleagues² in this issue is a welcome addition to the literature on duty-hours tracking. Using timestamp data from the electronic health record (EHR), the authors developed and collected validity evidence for an automated computerized algorithm to measure how much time trainees were spending on clinical work. The study was conducted at a large academic internal medicine residency program and tracked 203 trainees working 14,610 days. The authors compared their results to trainee self-report data. Though the approach centered on EHR access logs, it accommodated common scenarios of time away from the computer while at the hospital (eg, during patient rounds). Crucially, the algorithm included EHR access while at home. The absolute discrepancy between the algorithm and self-report averaged 1.38 hours per day. Notably, EHR work at home accounted for about an extra hour per day. When considering in-hospital work alone, the authors found 3% to 13% of trainees exceeding 80-hour workweek limits, but when adding out-of-hospital work, this percentage rose to 10% to 21%.

The authors used inventive methods to improve accuracy. They prespecified EHR functions that constituted active clinical work, classifying reading without editing notes or placing orders simply as “educational study,” which they excluded from duty hours. They ensured that time spent off-site was included and that logins from personal devices while in-hospital were not double-counted. Caveats to the study include the limited generalizability for institutions without the computational resources to replicate the model. The authors acknowledged the inherent flaw in using trainee self-report as the “gold standard,” and potentially some subset of the results could have been corroborated with time-motion observation studies.³ The decision to exclude passive medical record review at home as work arguably discounts the integral value that the “chart biopsy” has on direct patient care; it probably led to systematic underestimation of duty hours for junior and senior residents, who may be most likely to contribute in this way. Similarly, not counting time spent with patients at the end of the day after sign-out risks undercounting hours as well. Nonetheless, this study represents a rigorously designed and scalable approach to meeting regulatory requirements that can potentially lighten the administrative task load for trainees, improve reporting accuracy, and facilitate research comparing work hours to other variables of interest (eg, efficiency). The model can be generalized to other specialties and could document workload for staff physicians as well.

Merits of the study aside, the algorithm underscores troubling realities about the practice of medicine in the 21st century. Do we now equate clinical work with time on the computer? Is our contribution as physicians defined primarily by our presence at the keyboard, rather than the bedside?⁴ Future research facilitated by automated hours tracking is likely to further elucidate a connection between time spent in the EHR with burnout⁴ and job dissatisfaction, and the premise of this study is emblematic of the erosion of clinical work-life boundaries that began even before the pandemic.⁵ While the “times they are a-changin’,” in this respect, it may not be for the better.

Although malpractice “crises” come and go, liability fears persist near top of mind for most physicians.¹ Liability insurance premiums have plateaued in recent years, but remain at high levels, and the prospect of being reported to the National Practitioner Data Bank (NPDB) or listed on a state medical board’s website for a paid liability claim is unsettling. The high-acuity setting and the absence of longitudinal patient relationships in hospital medicine may theoretically raise malpractice risk, yet hospitalists’ liability risk remains understudied.²

The contribution by Schaffer and colleagues³ in this issue of the Journal of Hospital Medicine is thus welcome and illuminating. The researchers examine the liability risk of hospitalists compared to that of other specialties by utilizing a large database of malpractice claims compiled from multiple insurers across a decade.³ In a field of research plagued by inadequate data, the Comparative Benchmarking System (CBS) built by CRICO/RMF is a treasure. Unlike the primary national database of malpractice claims, the NPDB, the CBS contains information on claims that did not result in a payment, as well as physicians’ specialty and detailed information on the allegations, injuries, and their causes. The CBS contains almost a third of all medical liability claims made in the United States during the study period, supporting generalizability.

Schaffer and colleagues¹ found that hospitalists had a lower claims rate than physicians in emergency medicine or neurosurgery. The rate was on par with that for non-hospital general internists, even though hospitalists often care for higher-acuity patients. Although claims rates dropped over the study period for physicians in neurosurgery, emergency medicine, psychiatry, and internal medicine subspecialties, the rate for hospitalists did not change significantly. Further, the median payout on claims against hospitalists was the highest of all the specialties examined, except neurosurgery. This reflects higher injury severity in hospitalist cases: half the claims against hospitalists involved death and three-quarters were high severity.

The study is not without limitations. Due to missing data, only a fraction of the claims (8.2% to 11%) in the full dataset are used in the claims rate analysis. Regression models predicting a payment are based on a small number of payments for hospitalists (n = 363). Further, the authors advance, as a potential explanation for hospitalists’ higher liability risk, that hospitalists are disproportionately young compared to other specialists, but the dataset lacks age data. These limitations suggest caution in the authors’ overall conclusion that “the malpractice environment for hospitalists is becoming less favorable.”

Nevertheless, several important insights emerge from their analysis. The very existence of claims demonstrates that patient harm continues. The contributing factors and judgment errors found in these claims demonstrate that much of this harm is potentially preventable and a risk to patient safety. Whether or not the authors’ young-hospitalist hypothesis is ultimately proven, it is difficult to argue with more mentorship as a means to improve safety. Also, preventing or intercepting judgment errors remains a vexing challenge in medicine that undoubtedly calls for creative clinical decision support solutions. Schaffer and colleagues¹ also note that hospitalists are increasingly co-managing patients with other specialties, such as orthopedic surgery. Whether this new practice model drives hospitalist liability risk because hospitalists are practicing in areas in which they have less experience (as the authors posit) or whether hospitalists are simply more likely to be named in a suit as part of a specialty team with higher liability risk remains unknown and merits further investigation.

Ultimately, regardless of whether the liability environment is worsening for hospitalists, the need to improve our liability system is clear. There is room to improve the system on a number of metrics, including properly compensating negligently harmed patients without unduly burdening providers. The system also induces defensive medicine and has not driven safety improvements as expected. The liability environment, as a result, remains challenging not just for hospitalists, but for all patients and physicians as well.

Although malpractice “crises” come and go, liability fears persist near top of mind for most physicians.¹ Liability insurance premiums have plateaued in recent years, but remain at high levels, and the prospect of being reported to the National Practitioner Data Bank (NPDB) or listed on a state medical board’s website for a paid liability claim is unsettling. The high-acuity setting and the absence of longitudinal patient relationships in hospital medicine may theoretically raise malpractice risk, yet hospitalists’ liability risk remains understudied.²

The contribution by Schaffer and colleagues³ in this issue of the Journal of Hospital Medicine is thus welcome and illuminating. The researchers examine the liability risk of hospitalists compared to that of other specialties by utilizing a large database of malpractice claims compiled from multiple insurers across a decade.³ In a field of research plagued by inadequate data, the Comparative Benchmarking System (CBS) built by CRICO/RMF is a treasure. Unlike the primary national database of malpractice claims, the NPDB, the CBS contains information on claims that did not result in a payment, as well as physicians’ specialty and detailed information on the allegations, injuries, and their causes. The CBS contains almost a third of all medical liability claims made in the United States during the study period, supporting generalizability.

Schaffer and colleagues¹ found that hospitalists had a lower claims rate than physicians in emergency medicine or neurosurgery. The rate was on par with that for non-hospital general internists, even though hospitalists often care for higher-acuity patients. Although claims rates dropped over the study period for physicians in neurosurgery, emergency medicine, psychiatry, and internal medicine subspecialties, the rate for hospitalists did not change significantly. Further, the median payout on claims against hospitalists was the highest of all the specialties examined, except neurosurgery. This reflects higher injury severity in hospitalist cases: half the claims against hospitalists involved death and three-quarters were high severity.

The study is not without limitations. Due to missing data, only a fraction of the claims (8.2% to 11%) in the full dataset are used in the claims rate analysis. Regression models predicting a payment are based on a small number of payments for hospitalists (n = 363). Further, the authors advance, as a potential explanation for hospitalists’ higher liability risk, that hospitalists are disproportionately young compared to other specialists, but the dataset lacks age data. These limitations suggest caution in the authors’ overall conclusion that “the malpractice environment for hospitalists is becoming less favorable.”

Nevertheless, several important insights emerge from their analysis. The very existence of claims demonstrates that patient harm continues. The contributing factors and judgment errors found in these claims demonstrate that much of this harm is potentially preventable and a risk to patient safety. Whether or not the authors’ young-hospitalist hypothesis is ultimately proven, it is difficult to argue with more mentorship as a means to improve safety. Also, preventing or intercepting judgment errors remains a vexing challenge in medicine that undoubtedly calls for creative clinical decision support solutions. Schaffer and colleagues¹ also note that hospitalists are increasingly co-managing patients with other specialties, such as orthopedic surgery. Whether this new practice model drives hospitalist liability risk because hospitalists are practicing in areas in which they have less experience (as the authors posit) or whether hospitalists are simply more likely to be named in a suit as part of a specialty team with higher liability risk remains unknown and merits further investigation.

Ultimately, regardless of whether the liability environment is worsening for hospitalists, the need to improve our liability system is clear. There is room to improve the system on a number of metrics, including properly compensating negligently harmed patients without unduly burdening providers. The system also induces defensive medicine and has not driven safety improvements as expected. The liability environment, as a result, remains challenging not just for hospitalists, but for all patients and physicians as well.

Although malpractice “crises” come and go, liability fears persist near top of mind for most physicians.¹ Liability insurance premiums have plateaued in recent years, but remain at high levels, and the prospect of being reported to the National Practitioner Data Bank (NPDB) or listed on a state medical board’s website for a paid liability claim is unsettling. The high-acuity setting and the absence of longitudinal patient relationships in hospital medicine may theoretically raise malpractice risk, yet hospitalists’ liability risk remains understudied.²

The contribution by Schaffer and colleagues³ in this issue of the Journal of Hospital Medicine is thus welcome and illuminating. The researchers examine the liability risk of hospitalists compared to that of other specialties by utilizing a large database of malpractice claims compiled from multiple insurers across a decade.³ In a field of research plagued by inadequate data, the Comparative Benchmarking System (CBS) built by CRICO/RMF is a treasure. Unlike the primary national database of malpractice claims, the NPDB, the CBS contains information on claims that did not result in a payment, as well as physicians’ specialty and detailed information on the allegations, injuries, and their causes. The CBS contains almost a third of all medical liability claims made in the United States during the study period, supporting generalizability.

Schaffer and colleagues¹ found that hospitalists had a lower claims rate than physicians in emergency medicine or neurosurgery. The rate was on par with that for non-hospital general internists, even though hospitalists often care for higher-acuity patients. Although claims rates dropped over the study period for physicians in neurosurgery, emergency medicine, psychiatry, and internal medicine subspecialties, the rate for hospitalists did not change significantly. Further, the median payout on claims against hospitalists was the highest of all the specialties examined, except neurosurgery. This reflects higher injury severity in hospitalist cases: half the claims against hospitalists involved death and three-quarters were high severity.

The study is not without limitations. Due to missing data, only a fraction of the claims (8.2% to 11%) in the full dataset are used in the claims rate analysis. Regression models predicting a payment are based on a small number of payments for hospitalists (n = 363). Further, the authors advance, as a potential explanation for hospitalists’ higher liability risk, that hospitalists are disproportionately young compared to other specialists, but the dataset lacks age data. These limitations suggest caution in the authors’ overall conclusion that “the malpractice environment for hospitalists is becoming less favorable.”

Nevertheless, several important insights emerge from their analysis. The very existence of claims demonstrates that patient harm continues. The contributing factors and judgment errors found in these claims demonstrate that much of this harm is potentially preventable and a risk to patient safety. Whether or not the authors’ young-hospitalist hypothesis is ultimately proven, it is difficult to argue with more mentorship as a means to improve safety. Also, preventing or intercepting judgment errors remains a vexing challenge in medicine that undoubtedly calls for creative clinical decision support solutions. Schaffer and colleagues¹ also note that hospitalists are increasingly co-managing patients with other specialties, such as orthopedic surgery. Whether this new practice model drives hospitalist liability risk because hospitalists are practicing in areas in which they have less experience (as the authors posit) or whether hospitalists are simply more likely to be named in a suit as part of a specialty team with higher liability risk remains unknown and merits further investigation.

Ultimately, regardless of whether the liability environment is worsening for hospitalists, the need to improve our liability system is clear. There is room to improve the system on a number of metrics, including properly compensating negligently harmed patients without unduly burdening providers. The system also induces defensive medicine and has not driven safety improvements as expected. The liability environment, as a result, remains challenging not just for hospitalists, but for all patients and physicians as well.

“As we work to create light for others, we naturally light our own way.”

– Mary Anne Radmacher

Perhaps unknowingly, hospitalists establish microcultures in their everyday work. Hospitalists’ interactions with colleagues often occur in the context of shared workspaces. The nature of these seemingly minor exchanges shapes the microculture, often described as the culture shared by a small group based on location within an organization. Hospitalists have an opportunity to cultivate well-being within these microcultures through gracious and thoughtful acknowledgments of their peers. Collegial support at the micro level influences wellness at the organizational level. A larger shared culture of wellness is necessary to nurture physicians’ personal fulfillment and professional development.¹

We propose the CARE framework for cultivating well-being within the microcultures of hospital medicine shared workspaces. CARE consists of Capitalization, Active listening, Recognition, and Empathy. This framework is based on positive psychology research and inspired by lessons from The Happiness Advantage by Shawn Achor.²

Capitalization. Capitalization is defined as sharing upbeat news and receiving a positive reaction. Emotional support during good times, more so than during bad times, strengthens relationships. When a peer shares good news, show enthusiasm and counter with an active, constructive response to maximize the validation she perceives.²

For example, Alex sits at her desk and says to Kristen: “

My workshop proposal was accepted for medical education day!” “

Congratulations, Alex! Tell me more about the workshop.”

Active listening. Active listening requires concentration and observation of body language. Show engagement by maintaining an open posture, using positive facial expressions, and providing occasional cues that you’re paying attention. Paraphrasing and asking targeted questions to dive deeper demonstrates genuine interest. 

“Katie, I could use your advice. Do you have a minute?”

Katie turns to face John and smiles. “Of course. How can I help?”

“My team seems drained after a code this morning. I planned a lecture for later, but I’m not sure this is the right time.”

Katie nods. “I think you’re right, John. How have you thought about handling the situation?”

Recognition. Acts of recognition and encouragement are catalysts for boosting morale. Even brief expressions of gratitude can have a significant emotional impact. Recognition is most meaningful when delivered deliberately and with warmth.

Kevin walks into the hospitalist workroom. “Diane, congratulations on your publication! I plan to make a medication interaction review part of my discharge workflow.”

Leah turns to Diane. “Diane, that’s great news! Can you send me the link to your article?”

Empathy. Burnout is prevalent in medicine, and our fellow hospitalists deserve empathy. Showing empathy reduces stress and promotes connectedness. Sense when your colleagues are in distress and take time to share in their feelings and emotions. Draw on your own clinical experience to find common ground and convey understanding.

“I transferred another patient with COVID-19 to the ICU. I spent the last hour talking to family.”

“Ashwin, you’ve had a tough week. I know how you must feel—I had to transfer a patient yesterday. Want to take a quick walk outside?”

Hospitalists are inherently busy while on service, but these four interventions are brief, requiring only several minutes. Each small investment of your time will pay significant emotional dividends. These practices will not only enhance your colleagues’ sense of well-being, but will also bolster your happiness and productivity. A positive mindset fosters creative thinking and enhances complex problem solving. Recharging the microcultures of hospitalist workspaces with positivity will spark a larger transformation at the organizational level. That’s because positive actions are contagious.² One hospitalist’s commitment to CARE will encourage other hospitalists to adopt these behaviors, establishing a virtuous cycle that sustains an organization’s culture of wellness.

“As we work to create light for others, we naturally light our own way.”

– Mary Anne Radmacher

Perhaps unknowingly, hospitalists establish microcultures in their everyday work. Hospitalists’ interactions with colleagues often occur in the context of shared workspaces. The nature of these seemingly minor exchanges shapes the microculture, often described as the culture shared by a small group based on location within an organization. Hospitalists have an opportunity to cultivate well-being within these microcultures through gracious and thoughtful acknowledgments of their peers. Collegial support at the micro level influences wellness at the organizational level. A larger shared culture of wellness is necessary to nurture physicians’ personal fulfillment and professional development.¹

We propose the CARE framework for cultivating well-being within the microcultures of hospital medicine shared workspaces. CARE consists of Capitalization, Active listening, Recognition, and Empathy. This framework is based on positive psychology research and inspired by lessons from The Happiness Advantage by Shawn Achor.²

Capitalization. Capitalization is defined as sharing upbeat news and receiving a positive reaction. Emotional support during good times, more so than during bad times, strengthens relationships. When a peer shares good news, show enthusiasm and counter with an active, constructive response to maximize the validation she perceives.²

For example, Alex sits at her desk and says to Kristen: “

My workshop proposal was accepted for medical education day!” “

Congratulations, Alex! Tell me more about the workshop.”

Active listening. Active listening requires concentration and observation of body language. Show engagement by maintaining an open posture, using positive facial expressions, and providing occasional cues that you’re paying attention. Paraphrasing and asking targeted questions to dive deeper demonstrates genuine interest. 

“Katie, I could use your advice. Do you have a minute?”

Katie turns to face John and smiles. “Of course. How can I help?”

“My team seems drained after a code this morning. I planned a lecture for later, but I’m not sure this is the right time.”

Katie nods. “I think you’re right, John. How have you thought about handling the situation?”

Recognition. Acts of recognition and encouragement are catalysts for boosting morale. Even brief expressions of gratitude can have a significant emotional impact. Recognition is most meaningful when delivered deliberately and with warmth.

Kevin walks into the hospitalist workroom. “Diane, congratulations on your publication! I plan to make a medication interaction review part of my discharge workflow.”

Leah turns to Diane. “Diane, that’s great news! Can you send me the link to your article?”

Empathy. Burnout is prevalent in medicine, and our fellow hospitalists deserve empathy. Showing empathy reduces stress and promotes connectedness. Sense when your colleagues are in distress and take time to share in their feelings and emotions. Draw on your own clinical experience to find common ground and convey understanding.

“I transferred another patient with COVID-19 to the ICU. I spent the last hour talking to family.”

“Ashwin, you’ve had a tough week. I know how you must feel—I had to transfer a patient yesterday. Want to take a quick walk outside?”

Hospitalists are inherently busy while on service, but these four interventions are brief, requiring only several minutes. Each small investment of your time will pay significant emotional dividends. These practices will not only enhance your colleagues’ sense of well-being, but will also bolster your happiness and productivity. A positive mindset fosters creative thinking and enhances complex problem solving. Recharging the microcultures of hospitalist workspaces with positivity will spark a larger transformation at the organizational level. That’s because positive actions are contagious.² One hospitalist’s commitment to CARE will encourage other hospitalists to adopt these behaviors, establishing a virtuous cycle that sustains an organization’s culture of wellness.

“As we work to create light for others, we naturally light our own way.”

– Mary Anne Radmacher

Perhaps unknowingly, hospitalists establish microcultures in their everyday work. Hospitalists’ interactions with colleagues often occur in the context of shared workspaces. The nature of these seemingly minor exchanges shapes the microculture, often described as the culture shared by a small group based on location within an organization. Hospitalists have an opportunity to cultivate well-being within these microcultures through gracious and thoughtful acknowledgments of their peers. Collegial support at the micro level influences wellness at the organizational level. A larger shared culture of wellness is necessary to nurture physicians’ personal fulfillment and professional development.¹

We propose the CARE framework for cultivating well-being within the microcultures of hospital medicine shared workspaces. CARE consists of Capitalization, Active listening, Recognition, and Empathy. This framework is based on positive psychology research and inspired by lessons from The Happiness Advantage by Shawn Achor.²

Capitalization. Capitalization is defined as sharing upbeat news and receiving a positive reaction. Emotional support during good times, more so than during bad times, strengthens relationships. When a peer shares good news, show enthusiasm and counter with an active, constructive response to maximize the validation she perceives.²

For example, Alex sits at her desk and says to Kristen: “

My workshop proposal was accepted for medical education day!” “

Congratulations, Alex! Tell me more about the workshop.”

Active listening. Active listening requires concentration and observation of body language. Show engagement by maintaining an open posture, using positive facial expressions, and providing occasional cues that you’re paying attention. Paraphrasing and asking targeted questions to dive deeper demonstrates genuine interest. 

“Katie, I could use your advice. Do you have a minute?”

Katie turns to face John and smiles. “Of course. How can I help?”

“My team seems drained after a code this morning. I planned a lecture for later, but I’m not sure this is the right time.”

Katie nods. “I think you’re right, John. How have you thought about handling the situation?”

Recognition. Acts of recognition and encouragement are catalysts for boosting morale. Even brief expressions of gratitude can have a significant emotional impact. Recognition is most meaningful when delivered deliberately and with warmth.

Kevin walks into the hospitalist workroom. “Diane, congratulations on your publication! I plan to make a medication interaction review part of my discharge workflow.”

Leah turns to Diane. “Diane, that’s great news! Can you send me the link to your article?”

Empathy. Burnout is prevalent in medicine, and our fellow hospitalists deserve empathy. Showing empathy reduces stress and promotes connectedness. Sense when your colleagues are in distress and take time to share in their feelings and emotions. Draw on your own clinical experience to find common ground and convey understanding.

“I transferred another patient with COVID-19 to the ICU. I spent the last hour talking to family.”

“Ashwin, you’ve had a tough week. I know how you must feel—I had to transfer a patient yesterday. Want to take a quick walk outside?”

Hospitalists are inherently busy while on service, but these four interventions are brief, requiring only several minutes. Each small investment of your time will pay significant emotional dividends. These practices will not only enhance your colleagues’ sense of well-being, but will also bolster your happiness and productivity. A positive mindset fosters creative thinking and enhances complex problem solving. Recharging the microcultures of hospitalist workspaces with positivity will spark a larger transformation at the organizational level. That’s because positive actions are contagious.² One hospitalist’s commitment to CARE will encourage other hospitalists to adopt these behaviors, establishing a virtuous cycle that sustains an organization’s culture of wellness.

Young adults who use cannabis – either sporadically, daily, or those who have cannabis use disorder – have a significantly increased risk for suicidal thoughts and actions, according to U.S. national drug survey data.

The risks appear greater for women than men and remained regardless of whether the individual was depressed.

“We cannot establish that cannabis use caused increased suicidality,” Nora Volkow, MD, director, National Institute on Drug Abuse (NIDA), told this news organization.

“However, it is likely that these two factors influence one another bidirectionally, meaning people with suicidal thinking might be more vulnerable to cannabis use to self-medicate their distress, and cannabis use may trigger negative moods and suicidal thinking in some people,” said Dr. Volkow.

“It is also possible that these factors are not causally linked to one another at all but rather reflect the common and related risk factors underlying both suicidality and substance use. For instance, one’s genetics may put them at a higher risk for both suicide and for using marijuana,” she added.

The study was published online June 22 in JAMA Network Open.
 

Marked increase in use

Cannabis use among U.S. adults has increased markedly over the past 10 years, with a parallel increase in suicidality. However, the links between cannabis use and suicidality among young adults are poorly understood.

NIDA researchers sought to fill this gap. They examined data on 281,650 young men and women aged 18 to 34 years who participated in National Surveys on Drug Use and Health from 2008 to 2019.

Status regarding past-year cannabis use was categorized as past-year daily or near-daily use (greater than or equal to 300 days), non-daily use, and no cannabis use.

Although suicidality was associated with cannabis use, even young adults who did not use cannabis on a daily basis were more likely to have suicidal thoughts or actions than those who did not use the drug at all, the researchers found.

Among young adults without a major depressive episode, about 3% of those who did not use cannabis had suicidal ideation, compared with about 7% of non-daily cannabis users, about 9% of daily cannabis users, and 14% of those with a cannabis use disorder.

Among young adults with depression, the corresponding percentages were 35%, 44%, 53%, and 50%.

Similar trends existed for the associations between the different levels of cannabis use and suicide plan or attempt.
 

Women at greatest risk

Gender differences also emerged. Women who used cannabis at any level were more likely to have suicidal ideation or report a suicide plan or attempt than men with the same levels of cannabis use.

Among those without a major depressive episode, the prevalence of suicidal ideation for those with versus without a cannabis use disorder was around 14% versus 4.0% among women and 10% versus 3.0% among men.

Among young adults with both cannabis use disorder and major depressive episode, the prevalence of past-year suicide plan was 52% higher for women (24%) than for men (16%).

“Suicide is a leading cause of death among young adults in the United States, and the findings of this study offer important information that may help us reduce this risk,” lead author and NIDA researcher Beth Han, MD, PhD, MPH, said in a news release.

“Depression and cannabis use disorder are treatable conditions, and cannabis use can be modified. Through better understanding the associations of different risk factors for suicidality, we hope to offer new targets for prevention and intervention in individuals that we know may be at high risk. These findings also underscore the importance of tailoring interventions in a way that takes sex and gender into account,” said Dr. Han.

“Additional research is needed to better understand these complex associations, especially given the great burden of suicide on young adults,” said Dr. Volkow.
 

Gender difference ‘striking’

Commenting on the findings for this news organization, Charles B. Nemeroff, MD, PhD, professor and chair, department of psychiatry and behavioral sciences, Dell Medical School, University of Texas at Austin, said this study is “clearly of great interest; of course correlation and causality are completely distinct entities, and this study is all about correlation.

“This does not, of course, mean that cannabis use causes suicide but suggests that in individuals who use cannabis, suicidality in the broadest sense is increased in prevalence rate,” said Dr. Nemeroff, who serves as principal investigator of the Texas Child Trauma Network.

Dr. Nemeroff said “the most striking finding” was the larger effect in women than men – “striking because suicide is, in almost all cultures, higher in prevalence in men versus women.”

Dr. Nemeroff said he’d like to know more about other potential contributing factors, “which would include a history of child abuse and neglect, a major vulnerability factor for suicidality, comorbid alcohol and other substance abuse, [and] comorbid psychiatric diagnosis such as posttraumatic stress disorder.”

The study was sponsored by NIDA, of the National Institutes of Health. Dr. Volkow, Dr. Han, and Dr. Nemeroff have disclosed no relevant financial relationships.

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

Young adults who use cannabis – either sporadically, daily, or those who have cannabis use disorder – have a significantly increased risk for suicidal thoughts and actions, according to U.S. national drug survey data.

The risks appear greater for women than men and remained regardless of whether the individual was depressed.

“We cannot establish that cannabis use caused increased suicidality,” Nora Volkow, MD, director, National Institute on Drug Abuse (NIDA), told this news organization.

“However, it is likely that these two factors influence one another bidirectionally, meaning people with suicidal thinking might be more vulnerable to cannabis use to self-medicate their distress, and cannabis use may trigger negative moods and suicidal thinking in some people,” said Dr. Volkow.

“It is also possible that these factors are not causally linked to one another at all but rather reflect the common and related risk factors underlying both suicidality and substance use. For instance, one’s genetics may put them at a higher risk for both suicide and for using marijuana,” she added.

The study was published online June 22 in JAMA Network Open.
 

Marked increase in use

Cannabis use among U.S. adults has increased markedly over the past 10 years, with a parallel increase in suicidality. However, the links between cannabis use and suicidality among young adults are poorly understood.

NIDA researchers sought to fill this gap. They examined data on 281,650 young men and women aged 18 to 34 years who participated in National Surveys on Drug Use and Health from 2008 to 2019.

Status regarding past-year cannabis use was categorized as past-year daily or near-daily use (greater than or equal to 300 days), non-daily use, and no cannabis use.

Although suicidality was associated with cannabis use, even young adults who did not use cannabis on a daily basis were more likely to have suicidal thoughts or actions than those who did not use the drug at all, the researchers found.

Among young adults without a major depressive episode, about 3% of those who did not use cannabis had suicidal ideation, compared with about 7% of non-daily cannabis users, about 9% of daily cannabis users, and 14% of those with a cannabis use disorder.

Among young adults with depression, the corresponding percentages were 35%, 44%, 53%, and 50%.

Similar trends existed for the associations between the different levels of cannabis use and suicide plan or attempt.
 

Women at greatest risk

Gender differences also emerged. Women who used cannabis at any level were more likely to have suicidal ideation or report a suicide plan or attempt than men with the same levels of cannabis use.

Among those without a major depressive episode, the prevalence of suicidal ideation for those with versus without a cannabis use disorder was around 14% versus 4.0% among women and 10% versus 3.0% among men.

Among young adults with both cannabis use disorder and major depressive episode, the prevalence of past-year suicide plan was 52% higher for women (24%) than for men (16%).

“Suicide is a leading cause of death among young adults in the United States, and the findings of this study offer important information that may help us reduce this risk,” lead author and NIDA researcher Beth Han, MD, PhD, MPH, said in a news release.

“Depression and cannabis use disorder are treatable conditions, and cannabis use can be modified. Through better understanding the associations of different risk factors for suicidality, we hope to offer new targets for prevention and intervention in individuals that we know may be at high risk. These findings also underscore the importance of tailoring interventions in a way that takes sex and gender into account,” said Dr. Han.

“Additional research is needed to better understand these complex associations, especially given the great burden of suicide on young adults,” said Dr. Volkow.
 

Gender difference ‘striking’

Commenting on the findings for this news organization, Charles B. Nemeroff, MD, PhD, professor and chair, department of psychiatry and behavioral sciences, Dell Medical School, University of Texas at Austin, said this study is “clearly of great interest; of course correlation and causality are completely distinct entities, and this study is all about correlation.

“This does not, of course, mean that cannabis use causes suicide but suggests that in individuals who use cannabis, suicidality in the broadest sense is increased in prevalence rate,” said Dr. Nemeroff, who serves as principal investigator of the Texas Child Trauma Network.

Dr. Nemeroff said “the most striking finding” was the larger effect in women than men – “striking because suicide is, in almost all cultures, higher in prevalence in men versus women.”

Dr. Nemeroff said he’d like to know more about other potential contributing factors, “which would include a history of child abuse and neglect, a major vulnerability factor for suicidality, comorbid alcohol and other substance abuse, [and] comorbid psychiatric diagnosis such as posttraumatic stress disorder.”

The study was sponsored by NIDA, of the National Institutes of Health. Dr. Volkow, Dr. Han, and Dr. Nemeroff have disclosed no relevant financial relationships.

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

Young adults who use cannabis – either sporadically, daily, or those who have cannabis use disorder – have a significantly increased risk for suicidal thoughts and actions, according to U.S. national drug survey data.

The risks appear greater for women than men and remained regardless of whether the individual was depressed.

“We cannot establish that cannabis use caused increased suicidality,” Nora Volkow, MD, director, National Institute on Drug Abuse (NIDA), told this news organization.

“However, it is likely that these two factors influence one another bidirectionally, meaning people with suicidal thinking might be more vulnerable to cannabis use to self-medicate their distress, and cannabis use may trigger negative moods and suicidal thinking in some people,” said Dr. Volkow.

“It is also possible that these factors are not causally linked to one another at all but rather reflect the common and related risk factors underlying both suicidality and substance use. For instance, one’s genetics may put them at a higher risk for both suicide and for using marijuana,” she added.

The study was published online June 22 in JAMA Network Open.
 

Marked increase in use

Cannabis use among U.S. adults has increased markedly over the past 10 years, with a parallel increase in suicidality. However, the links between cannabis use and suicidality among young adults are poorly understood.

NIDA researchers sought to fill this gap. They examined data on 281,650 young men and women aged 18 to 34 years who participated in National Surveys on Drug Use and Health from 2008 to 2019.

Status regarding past-year cannabis use was categorized as past-year daily or near-daily use (greater than or equal to 300 days), non-daily use, and no cannabis use.

Although suicidality was associated with cannabis use, even young adults who did not use cannabis on a daily basis were more likely to have suicidal thoughts or actions than those who did not use the drug at all, the researchers found.

Among young adults without a major depressive episode, about 3% of those who did not use cannabis had suicidal ideation, compared with about 7% of non-daily cannabis users, about 9% of daily cannabis users, and 14% of those with a cannabis use disorder.

Among young adults with depression, the corresponding percentages were 35%, 44%, 53%, and 50%.

Similar trends existed for the associations between the different levels of cannabis use and suicide plan or attempt.
 

Women at greatest risk

Gender differences also emerged. Women who used cannabis at any level were more likely to have suicidal ideation or report a suicide plan or attempt than men with the same levels of cannabis use.

Among those without a major depressive episode, the prevalence of suicidal ideation for those with versus without a cannabis use disorder was around 14% versus 4.0% among women and 10% versus 3.0% among men.

Among young adults with both cannabis use disorder and major depressive episode, the prevalence of past-year suicide plan was 52% higher for women (24%) than for men (16%).

“Suicide is a leading cause of death among young adults in the United States, and the findings of this study offer important information that may help us reduce this risk,” lead author and NIDA researcher Beth Han, MD, PhD, MPH, said in a news release.

“Depression and cannabis use disorder are treatable conditions, and cannabis use can be modified. Through better understanding the associations of different risk factors for suicidality, we hope to offer new targets for prevention and intervention in individuals that we know may be at high risk. These findings also underscore the importance of tailoring interventions in a way that takes sex and gender into account,” said Dr. Han.

“Additional research is needed to better understand these complex associations, especially given the great burden of suicide on young adults,” said Dr. Volkow.
 

Gender difference ‘striking’

Commenting on the findings for this news organization, Charles B. Nemeroff, MD, PhD, professor and chair, department of psychiatry and behavioral sciences, Dell Medical School, University of Texas at Austin, said this study is “clearly of great interest; of course correlation and causality are completely distinct entities, and this study is all about correlation.

“This does not, of course, mean that cannabis use causes suicide but suggests that in individuals who use cannabis, suicidality in the broadest sense is increased in prevalence rate,” said Dr. Nemeroff, who serves as principal investigator of the Texas Child Trauma Network.

Dr. Nemeroff said “the most striking finding” was the larger effect in women than men – “striking because suicide is, in almost all cultures, higher in prevalence in men versus women.”

Dr. Nemeroff said he’d like to know more about other potential contributing factors, “which would include a history of child abuse and neglect, a major vulnerability factor for suicidality, comorbid alcohol and other substance abuse, [and] comorbid psychiatric diagnosis such as posttraumatic stress disorder.”

The study was sponsored by NIDA, of the National Institutes of Health. Dr. Volkow, Dr. Han, and Dr. Nemeroff have disclosed no relevant financial relationships.

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

Dr Mark A. Socinski, executive medical director of AdventHealth Cancer Institute in Orlando, Florida, highlights studies in advanced non–small cell lung cancer (NSCLC) presented at the 2021 annual meeting of the American Society of Clinical Oncology.
First, Dr Socinski reports on the updated results of the CheckMate 9LA study showing continued benefit of nivolumab and ipilimumab plus chemotherapy vs chemotherapy alone.

He also outlines an FDA pooled analysis of randomized controlled trials showing that patients with PD-L1 scores between 1% and 49% benefit most from immunotherapy plus chemotherapy compared with immunotherapy alone.

Dr Socinski then takes us through one of his own studies showing that immune-related adverse events are actually associated with better outcomes, and reports some sobering data from two studies suggesting that biomarker testing is lagging behind in NSCLC patients, especially among African Americans. He closes by reviewing updated results of the CodeBreak 100 trial which showed encouraging response to sotorasib among patients with G12C KRAS mutations.

--

Mark A. Socinski, MD, Executive Medical Director, AdventHealth Cancer Institute, Orlando, Florida.

Mark A. Socinski, MD, has disclosed the following relevant financial relationships:
Serve(d) as a speaker or a member of a speakers bureau for: Genentech; Novartis; Guardant; AstraZeneca; Eli Lilly and Company; Blueprint
Received research grant from: Genentech; AstraZeneca; Novartis; Spectrum; Cullinan.

Dr Mark A. Socinski, executive medical director of AdventHealth Cancer Institute in Orlando, Florida, highlights studies in advanced non–small cell lung cancer (NSCLC) presented at the 2021 annual meeting of the American Society of Clinical Oncology.
First, Dr Socinski reports on the updated results of the CheckMate 9LA study showing continued benefit of nivolumab and ipilimumab plus chemotherapy vs chemotherapy alone.

He also outlines an FDA pooled analysis of randomized controlled trials showing that patients with PD-L1 scores between 1% and 49% benefit most from immunotherapy plus chemotherapy compared with immunotherapy alone.

Dr Socinski then takes us through one of his own studies showing that immune-related adverse events are actually associated with better outcomes, and reports some sobering data from two studies suggesting that biomarker testing is lagging behind in NSCLC patients, especially among African Americans. He closes by reviewing updated results of the CodeBreak 100 trial which showed encouraging response to sotorasib among patients with G12C KRAS mutations.

--

Mark A. Socinski, MD, Executive Medical Director, AdventHealth Cancer Institute, Orlando, Florida.

Mark A. Socinski, MD, has disclosed the following relevant financial relationships:
Serve(d) as a speaker or a member of a speakers bureau for: Genentech; Novartis; Guardant; AstraZeneca; Eli Lilly and Company; Blueprint
Received research grant from: Genentech; AstraZeneca; Novartis; Spectrum; Cullinan.

Dr Mark A. Socinski, executive medical director of AdventHealth Cancer Institute in Orlando, Florida, highlights studies in advanced non–small cell lung cancer (NSCLC) presented at the 2021 annual meeting of the American Society of Clinical Oncology.
First, Dr Socinski reports on the updated results of the CheckMate 9LA study showing continued benefit of nivolumab and ipilimumab plus chemotherapy vs chemotherapy alone.

He also outlines an FDA pooled analysis of randomized controlled trials showing that patients with PD-L1 scores between 1% and 49% benefit most from immunotherapy plus chemotherapy compared with immunotherapy alone.

Dr Socinski then takes us through one of his own studies showing that immune-related adverse events are actually associated with better outcomes, and reports some sobering data from two studies suggesting that biomarker testing is lagging behind in NSCLC patients, especially among African Americans. He closes by reviewing updated results of the CodeBreak 100 trial which showed encouraging response to sotorasib among patients with G12C KRAS mutations.

--

Mark A. Socinski, MD, Executive Medical Director, AdventHealth Cancer Institute, Orlando, Florida.

Mark A. Socinski, MD, has disclosed the following relevant financial relationships:
Serve(d) as a speaker or a member of a speakers bureau for: Genentech; Novartis; Guardant; AstraZeneca; Eli Lilly and Company; Blueprint
Received research grant from: Genentech; AstraZeneca; Novartis; Spectrum; Cullinan.

A single, simple question about sleep habits asked to people with diabetes in the UK Biobank database identified a subgroup with a nearly doubled mortality rate during almost 9 years of follow-up: those who said they usually had sleep disturbances.

The question was: Do you never, rarely, sometimes, or usually have trouble falling asleep, or waking in the middle of the night?

Adults in the UK Biobank with any form of self-reported diabetes or insulin use who answered that they usually have sleep disturbances had a significant 87% higher mortality rate than did those without diabetes who said they never or rarely had sleep disturbances, in a fully adjusted model with an average follow-up of 8.9 years, Kristen L. Knutson, PhD, and coauthors reported in the Journal of Sleep Research.

Mortality was 11% higher in respondents who reported frequent sleep disturbances but had no diabetes than in those without frequent sleep disturbances. Furthermore, those with diabetes but without frequent sleep disturbances had a 67% higher mortality rate, compared with those without diabetes. Both differences were statistically significant in a model that adjusted for age, sex, ethnicity, smoking, sleep duration, body mass index, and other covariates.

The findings suggest that diabetes and frequent sleep disturbances act in a roughly additive way to raise mortality risk, said Dr. Knutson, an epidemiologist and neurologist who specializes in sleep medicine at Northwestern University, Chicago.

She suggested that, based on these findings, clinicians should consider annually asking patients with diabetes this key question about the frequency of their sleep disturbances. They should then follow up with patients who report usual disturbances by referring them to a sleep clinic to test for a sleep disorders such as insomnia or sleep apnea. Sleep apnea especially is “particularly common in patients with type 2 diabetes,” Dr. Knutson noted in an interview.
 

A need to ‘spread awareness’ about diabetes and disturbed sleep.

The study run by Dr. Knutson and associates “is one of the largest population-based studies” to examine the relationship between sleep disturbances, diabetes, and mortality, commented Sirimon Reutrakul, MD, an endocrinologist and diabetes specialist at the University of Illinois Hospital in Chicago.

“This study highlights the detrimental effects of sleep disturbances in people with or without diabetes, and adds to the effects of sleep disturbances such as insomnia symptoms. People with diabetes often have sleep disturbances. Obstructive sleep apnea is very common in people with diabetes, and insomnia symptoms could be present in people with obstructive sleep apnea or it could be a separate problem,” Dr. Reutrakul said in an interview. Sleep disturbances can arise from direct effects of diabetes, such as nocturia, worry about glucose levels, pain, depressive symptoms, and anxiety, or can result from comorbidities that interfere with sleep.

“It is prudent to ask patients with diabetes about sleep patterns,” said Dr. Reutrakul, and she endorsed the specific question that Dr. Knutson recommended asking patients. Other aspects of sleep quality that could be helpful for a diagnosis include sleep duration, sleep timing, and snoring. “Some physicians ask these questions, but we need to spread awareness,” she added.

Prior to referring patients to a sleep clinic, Dr. Reutrakul suggested that clinicians could also assess possible triggers such as inadequate glucose control, pain, and anxiety, and they could also recommend good sleep hygiene strategies such as what’s recommended by the Sleep Foundation.
 

Sleep disturbances ‘highly prevalent’ among U.K. adults.

The UK Biobank enrolled just over 500,000 people aged 37-73 years during 2006-2010, and 487,728 of these people had data available that allowed their inclusion in the analysis. That group averaged about 57 years of age, 54% were women, 94% were White, and their average body mass index was 27-28 kg/m2.

More than a quarter of these people reported having “usual” sleep disturbances, showing that sleep disturbances are “highly prevalent” among U.K. residents, noted the authors. Just under a quarter of the subjects reported they never or rarely had sleep disturbances, and the remaining half of subjects said they “sometimes” had sleep disturbances.

In addition, 69% reported neither diabetes nor frequent sleep disturbances, 26% had frequent sleep disturbances but no diabetes, 3% had diabetes but not frequent sleep disturbances, and 2% had both diabetes and frequent sleep disturbances.

During the average 8.9-year follow-up, 19,177 people died from any cause (4%), and 3,874 of these deaths involved cardiovascular disease causes. Despite the significant association of diabetes and frequent sleep disturbances with an increased rate of all-cause mortality, the same combination showed no significant link with cardiovascular mortality in the study’s full-adjusted model. This may be because “frequent sleep disturbances can lead to a variety of causes of death,” Dr. Knutson suggested.

The information collected by the UK Biobank did not allow the researchers to distinguish between type 1 and type 2 diabetes.

The findings “suggest that regardless of the cause of sleep disturbance, reporting sleep disturbances on a frequent basis is an important signal of elevated risk of mortality. Such symptoms should therefore be investigated further by physicians, particularly in patients who have also been diagnosed with diabetes,” wrote Dr. Knutson and coauthors. “This is the first study to examine the effect of the combination of insomnia and diabetes on mortality risk.”

But Dr. Knutson highlighted that “sleep problems are important for everyone, not just people with diabetes.

Neither Dr. Knutson and coauthors nor Dr. Reutrakul had no disclosures.

[email protected]

A single, simple question about sleep habits asked to people with diabetes in the UK Biobank database identified a subgroup with a nearly doubled mortality rate during almost 9 years of follow-up: those who said they usually had sleep disturbances.

The question was: Do you never, rarely, sometimes, or usually have trouble falling asleep, or waking in the middle of the night?

Adults in the UK Biobank with any form of self-reported diabetes or insulin use who answered that they usually have sleep disturbances had a significant 87% higher mortality rate than did those without diabetes who said they never or rarely had sleep disturbances, in a fully adjusted model with an average follow-up of 8.9 years, Kristen L. Knutson, PhD, and coauthors reported in the Journal of Sleep Research.

Mortality was 11% higher in respondents who reported frequent sleep disturbances but had no diabetes than in those without frequent sleep disturbances. Furthermore, those with diabetes but without frequent sleep disturbances had a 67% higher mortality rate, compared with those without diabetes. Both differences were statistically significant in a model that adjusted for age, sex, ethnicity, smoking, sleep duration, body mass index, and other covariates.

The findings suggest that diabetes and frequent sleep disturbances act in a roughly additive way to raise mortality risk, said Dr. Knutson, an epidemiologist and neurologist who specializes in sleep medicine at Northwestern University, Chicago.

She suggested that, based on these findings, clinicians should consider annually asking patients with diabetes this key question about the frequency of their sleep disturbances. They should then follow up with patients who report usual disturbances by referring them to a sleep clinic to test for a sleep disorders such as insomnia or sleep apnea. Sleep apnea especially is “particularly common in patients with type 2 diabetes,” Dr. Knutson noted in an interview.
 

A need to ‘spread awareness’ about diabetes and disturbed sleep.

The study run by Dr. Knutson and associates “is one of the largest population-based studies” to examine the relationship between sleep disturbances, diabetes, and mortality, commented Sirimon Reutrakul, MD, an endocrinologist and diabetes specialist at the University of Illinois Hospital in Chicago.

“This study highlights the detrimental effects of sleep disturbances in people with or without diabetes, and adds to the effects of sleep disturbances such as insomnia symptoms. People with diabetes often have sleep disturbances. Obstructive sleep apnea is very common in people with diabetes, and insomnia symptoms could be present in people with obstructive sleep apnea or it could be a separate problem,” Dr. Reutrakul said in an interview. Sleep disturbances can arise from direct effects of diabetes, such as nocturia, worry about glucose levels, pain, depressive symptoms, and anxiety, or can result from comorbidities that interfere with sleep.

“It is prudent to ask patients with diabetes about sleep patterns,” said Dr. Reutrakul, and she endorsed the specific question that Dr. Knutson recommended asking patients. Other aspects of sleep quality that could be helpful for a diagnosis include sleep duration, sleep timing, and snoring. “Some physicians ask these questions, but we need to spread awareness,” she added.

Prior to referring patients to a sleep clinic, Dr. Reutrakul suggested that clinicians could also assess possible triggers such as inadequate glucose control, pain, and anxiety, and they could also recommend good sleep hygiene strategies such as what’s recommended by the Sleep Foundation.
 

Sleep disturbances ‘highly prevalent’ among U.K. adults.

The UK Biobank enrolled just over 500,000 people aged 37-73 years during 2006-2010, and 487,728 of these people had data available that allowed their inclusion in the analysis. That group averaged about 57 years of age, 54% were women, 94% were White, and their average body mass index was 27-28 kg/m2.

More than a quarter of these people reported having “usual” sleep disturbances, showing that sleep disturbances are “highly prevalent” among U.K. residents, noted the authors. Just under a quarter of the subjects reported they never or rarely had sleep disturbances, and the remaining half of subjects said they “sometimes” had sleep disturbances.

In addition, 69% reported neither diabetes nor frequent sleep disturbances, 26% had frequent sleep disturbances but no diabetes, 3% had diabetes but not frequent sleep disturbances, and 2% had both diabetes and frequent sleep disturbances.

During the average 8.9-year follow-up, 19,177 people died from any cause (4%), and 3,874 of these deaths involved cardiovascular disease causes. Despite the significant association of diabetes and frequent sleep disturbances with an increased rate of all-cause mortality, the same combination showed no significant link with cardiovascular mortality in the study’s full-adjusted model. This may be because “frequent sleep disturbances can lead to a variety of causes of death,” Dr. Knutson suggested.

The information collected by the UK Biobank did not allow the researchers to distinguish between type 1 and type 2 diabetes.

The findings “suggest that regardless of the cause of sleep disturbance, reporting sleep disturbances on a frequent basis is an important signal of elevated risk of mortality. Such symptoms should therefore be investigated further by physicians, particularly in patients who have also been diagnosed with diabetes,” wrote Dr. Knutson and coauthors. “This is the first study to examine the effect of the combination of insomnia and diabetes on mortality risk.”

But Dr. Knutson highlighted that “sleep problems are important for everyone, not just people with diabetes.

Neither Dr. Knutson and coauthors nor Dr. Reutrakul had no disclosures.

[email protected]

A single, simple question about sleep habits asked to people with diabetes in the UK Biobank database identified a subgroup with a nearly doubled mortality rate during almost 9 years of follow-up: those who said they usually had sleep disturbances.

The question was: Do you never, rarely, sometimes, or usually have trouble falling asleep, or waking in the middle of the night?

Adults in the UK Biobank with any form of self-reported diabetes or insulin use who answered that they usually have sleep disturbances had a significant 87% higher mortality rate than did those without diabetes who said they never or rarely had sleep disturbances, in a fully adjusted model with an average follow-up of 8.9 years, Kristen L. Knutson, PhD, and coauthors reported in the Journal of Sleep Research.

Mortality was 11% higher in respondents who reported frequent sleep disturbances but had no diabetes than in those without frequent sleep disturbances. Furthermore, those with diabetes but without frequent sleep disturbances had a 67% higher mortality rate, compared with those without diabetes. Both differences were statistically significant in a model that adjusted for age, sex, ethnicity, smoking, sleep duration, body mass index, and other covariates.

The findings suggest that diabetes and frequent sleep disturbances act in a roughly additive way to raise mortality risk, said Dr. Knutson, an epidemiologist and neurologist who specializes in sleep medicine at Northwestern University, Chicago.

She suggested that, based on these findings, clinicians should consider annually asking patients with diabetes this key question about the frequency of their sleep disturbances. They should then follow up with patients who report usual disturbances by referring them to a sleep clinic to test for a sleep disorders such as insomnia or sleep apnea. Sleep apnea especially is “particularly common in patients with type 2 diabetes,” Dr. Knutson noted in an interview.
 

A need to ‘spread awareness’ about diabetes and disturbed sleep.

The study run by Dr. Knutson and associates “is one of the largest population-based studies” to examine the relationship between sleep disturbances, diabetes, and mortality, commented Sirimon Reutrakul, MD, an endocrinologist and diabetes specialist at the University of Illinois Hospital in Chicago.

“This study highlights the detrimental effects of sleep disturbances in people with or without diabetes, and adds to the effects of sleep disturbances such as insomnia symptoms. People with diabetes often have sleep disturbances. Obstructive sleep apnea is very common in people with diabetes, and insomnia symptoms could be present in people with obstructive sleep apnea or it could be a separate problem,” Dr. Reutrakul said in an interview. Sleep disturbances can arise from direct effects of diabetes, such as nocturia, worry about glucose levels, pain, depressive symptoms, and anxiety, or can result from comorbidities that interfere with sleep.

“It is prudent to ask patients with diabetes about sleep patterns,” said Dr. Reutrakul, and she endorsed the specific question that Dr. Knutson recommended asking patients. Other aspects of sleep quality that could be helpful for a diagnosis include sleep duration, sleep timing, and snoring. “Some physicians ask these questions, but we need to spread awareness,” she added.

Prior to referring patients to a sleep clinic, Dr. Reutrakul suggested that clinicians could also assess possible triggers such as inadequate glucose control, pain, and anxiety, and they could also recommend good sleep hygiene strategies such as what’s recommended by the Sleep Foundation.
 

Sleep disturbances ‘highly prevalent’ among U.K. adults.

The UK Biobank enrolled just over 500,000 people aged 37-73 years during 2006-2010, and 487,728 of these people had data available that allowed their inclusion in the analysis. That group averaged about 57 years of age, 54% were women, 94% were White, and their average body mass index was 27-28 kg/m2.

More than a quarter of these people reported having “usual” sleep disturbances, showing that sleep disturbances are “highly prevalent” among U.K. residents, noted the authors. Just under a quarter of the subjects reported they never or rarely had sleep disturbances, and the remaining half of subjects said they “sometimes” had sleep disturbances.

In addition, 69% reported neither diabetes nor frequent sleep disturbances, 26% had frequent sleep disturbances but no diabetes, 3% had diabetes but not frequent sleep disturbances, and 2% had both diabetes and frequent sleep disturbances.

During the average 8.9-year follow-up, 19,177 people died from any cause (4%), and 3,874 of these deaths involved cardiovascular disease causes. Despite the significant association of diabetes and frequent sleep disturbances with an increased rate of all-cause mortality, the same combination showed no significant link with cardiovascular mortality in the study’s full-adjusted model. This may be because “frequent sleep disturbances can lead to a variety of causes of death,” Dr. Knutson suggested.

The information collected by the UK Biobank did not allow the researchers to distinguish between type 1 and type 2 diabetes.

The findings “suggest that regardless of the cause of sleep disturbance, reporting sleep disturbances on a frequent basis is an important signal of elevated risk of mortality. Such symptoms should therefore be investigated further by physicians, particularly in patients who have also been diagnosed with diabetes,” wrote Dr. Knutson and coauthors. “This is the first study to examine the effect of the combination of insomnia and diabetes on mortality risk.”

But Dr. Knutson highlighted that “sleep problems are important for everyone, not just people with diabetes.

Neither Dr. Knutson and coauthors nor Dr. Reutrakul had no disclosures.

[email protected]