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Can case management cut hypertension’s consequences?
MONTREAL – who received phone calls, care coordination, and coaching from a nurse case manager, according to a retrospective population-based cohort study of almost 85,000 patients with hypertension.
The reduction yielded a hazard ratio for all-cause mortality of 0.504, with a number needed to treat (NNT) of 25 (P less than .05).
Service utilization also decreased for those participating in the intervention, compared with those receiving usual care: Hospitalizations fell by 7 per 100 patient-years, with greater reductions seen in emergency department, specialist, and primary care utilization (P less than .05 for all).
At the time the study was conceived, the Hong Kong Hospital Authority cared for about 200,000 hypertensive patients, of whom more than 40% hadn’t achieved the target blood pressure of less than 140/90 mm Hg, said Dr. Yu.
Dr. Yu of the department of family medicine and primary care at the University of Hong Kong said there are challenges in bringing more hypertension patients into good blood pressure control in Hong Kong. These include the “idiosyncratic practice” of some frontline physicians, who also often have limited time for patient consultations and only limited access to the services of allied health professionals to help them in their work. Patient adherence, she said, is also an issue.
To tackle these persistent high rates of patients whose blood pressures remained too high, Dr. Yu and her colleagues at the Hospital Authority launched the Risk Assessment and Management Program – Hypertension (RAMP-HT) in 2011. The program, she said, is an “evidence-based, structured, protocol-driven, multidisciplinary program” that includes risk assessment and screening for complications, and uses a risk-guided management approach.
Patients in RAMP-HT received interventions according to a matrix for risk management of patients with hypertension. Patients with a blood pressure between 140/90 and 160/100 mm Hg who were assessed as being low and medium risk according to the Joint British Societies guidelines for cardiovascular risk continued to receive management from their primary care physician. High-risk patients with blood pressure in this range also received a statin if their low-density lipoprotein cholesterol level was suboptimal.
Patients whose blood pressure was at least 160/100 mm Hg were followed by a RAMP-HT nurse. For those with this degree of blood pressure elevation who were already on at least three antihypertensive medications, specialty appointments were also arranged.
Other targeted interventions were also available to participants, including the services of dietitians and physical therapists for those with a body mass index (BMI) of at least 27.5 kg/m2; smoking cessation and mental health services were also available, as appropriate.
After 3 years, those participating in the RAMP-HT program (n = 79,116) were compared with those in the usual care group (n = 43,901). In both arms, adult patients with complete data and without preexisting cardiovascular disease, diabetes, or end-stage renal disease were included. In each group, about 58% of participants were female, and the mean age was about 65 years.
Primary outcome measures included the incidence of cardiovascular disease, an outcome that included coronary heart disease, heart failure, and stroke; end-stage renal disease; and all-cause mortality. The significant reductions in these measures for the RAMP-HT group remained after multivariable analysis accounted for sex, age, smoking status, renal function, lipid values, BMI, comorbidities, and antihypertensive and lipid-lowering medication use.
The reduced care utilization seen among RAMP-HT participants also persisted after multivariable analysis for these potential confounders.
Dr. Yu said the systematic, protocol-driven program was a primary strength of RAMP-HT. The key to the program was use of nurses to provide patient education and physicians and allied health resources only as needed, she said; the program reinforced the importance of self-management and adherence because patients heard a unified message from many different health care professionals.
However, lifestyle factors such as diet and exercise weren’t tracked, and the retrospective study design introduced the potential for some bias, she said. In ongoing work, the long-term efficacy and cost-effectiveness of the RAMP-HT program are being tracked.
Dr. Yu reported that the study was funded by the Hong Kong Health and Medical Research Fund. She reported no relevant conflicts of interest.
SOURCE: Yu, Esther et al. NAPCRG 2017, Abstract HY33.
MONTREAL – who received phone calls, care coordination, and coaching from a nurse case manager, according to a retrospective population-based cohort study of almost 85,000 patients with hypertension.
The reduction yielded a hazard ratio for all-cause mortality of 0.504, with a number needed to treat (NNT) of 25 (P less than .05).
Service utilization also decreased for those participating in the intervention, compared with those receiving usual care: Hospitalizations fell by 7 per 100 patient-years, with greater reductions seen in emergency department, specialist, and primary care utilization (P less than .05 for all).
At the time the study was conceived, the Hong Kong Hospital Authority cared for about 200,000 hypertensive patients, of whom more than 40% hadn’t achieved the target blood pressure of less than 140/90 mm Hg, said Dr. Yu.
Dr. Yu of the department of family medicine and primary care at the University of Hong Kong said there are challenges in bringing more hypertension patients into good blood pressure control in Hong Kong. These include the “idiosyncratic practice” of some frontline physicians, who also often have limited time for patient consultations and only limited access to the services of allied health professionals to help them in their work. Patient adherence, she said, is also an issue.
To tackle these persistent high rates of patients whose blood pressures remained too high, Dr. Yu and her colleagues at the Hospital Authority launched the Risk Assessment and Management Program – Hypertension (RAMP-HT) in 2011. The program, she said, is an “evidence-based, structured, protocol-driven, multidisciplinary program” that includes risk assessment and screening for complications, and uses a risk-guided management approach.
Patients in RAMP-HT received interventions according to a matrix for risk management of patients with hypertension. Patients with a blood pressure between 140/90 and 160/100 mm Hg who were assessed as being low and medium risk according to the Joint British Societies guidelines for cardiovascular risk continued to receive management from their primary care physician. High-risk patients with blood pressure in this range also received a statin if their low-density lipoprotein cholesterol level was suboptimal.
Patients whose blood pressure was at least 160/100 mm Hg were followed by a RAMP-HT nurse. For those with this degree of blood pressure elevation who were already on at least three antihypertensive medications, specialty appointments were also arranged.
Other targeted interventions were also available to participants, including the services of dietitians and physical therapists for those with a body mass index (BMI) of at least 27.5 kg/m2; smoking cessation and mental health services were also available, as appropriate.
After 3 years, those participating in the RAMP-HT program (n = 79,116) were compared with those in the usual care group (n = 43,901). In both arms, adult patients with complete data and without preexisting cardiovascular disease, diabetes, or end-stage renal disease were included. In each group, about 58% of participants were female, and the mean age was about 65 years.
Primary outcome measures included the incidence of cardiovascular disease, an outcome that included coronary heart disease, heart failure, and stroke; end-stage renal disease; and all-cause mortality. The significant reductions in these measures for the RAMP-HT group remained after multivariable analysis accounted for sex, age, smoking status, renal function, lipid values, BMI, comorbidities, and antihypertensive and lipid-lowering medication use.
The reduced care utilization seen among RAMP-HT participants also persisted after multivariable analysis for these potential confounders.
Dr. Yu said the systematic, protocol-driven program was a primary strength of RAMP-HT. The key to the program was use of nurses to provide patient education and physicians and allied health resources only as needed, she said; the program reinforced the importance of self-management and adherence because patients heard a unified message from many different health care professionals.
However, lifestyle factors such as diet and exercise weren’t tracked, and the retrospective study design introduced the potential for some bias, she said. In ongoing work, the long-term efficacy and cost-effectiveness of the RAMP-HT program are being tracked.
Dr. Yu reported that the study was funded by the Hong Kong Health and Medical Research Fund. She reported no relevant conflicts of interest.
SOURCE: Yu, Esther et al. NAPCRG 2017, Abstract HY33.
MONTREAL – who received phone calls, care coordination, and coaching from a nurse case manager, according to a retrospective population-based cohort study of almost 85,000 patients with hypertension.
The reduction yielded a hazard ratio for all-cause mortality of 0.504, with a number needed to treat (NNT) of 25 (P less than .05).
Service utilization also decreased for those participating in the intervention, compared with those receiving usual care: Hospitalizations fell by 7 per 100 patient-years, with greater reductions seen in emergency department, specialist, and primary care utilization (P less than .05 for all).
At the time the study was conceived, the Hong Kong Hospital Authority cared for about 200,000 hypertensive patients, of whom more than 40% hadn’t achieved the target blood pressure of less than 140/90 mm Hg, said Dr. Yu.
Dr. Yu of the department of family medicine and primary care at the University of Hong Kong said there are challenges in bringing more hypertension patients into good blood pressure control in Hong Kong. These include the “idiosyncratic practice” of some frontline physicians, who also often have limited time for patient consultations and only limited access to the services of allied health professionals to help them in their work. Patient adherence, she said, is also an issue.
To tackle these persistent high rates of patients whose blood pressures remained too high, Dr. Yu and her colleagues at the Hospital Authority launched the Risk Assessment and Management Program – Hypertension (RAMP-HT) in 2011. The program, she said, is an “evidence-based, structured, protocol-driven, multidisciplinary program” that includes risk assessment and screening for complications, and uses a risk-guided management approach.
Patients in RAMP-HT received interventions according to a matrix for risk management of patients with hypertension. Patients with a blood pressure between 140/90 and 160/100 mm Hg who were assessed as being low and medium risk according to the Joint British Societies guidelines for cardiovascular risk continued to receive management from their primary care physician. High-risk patients with blood pressure in this range also received a statin if their low-density lipoprotein cholesterol level was suboptimal.
Patients whose blood pressure was at least 160/100 mm Hg were followed by a RAMP-HT nurse. For those with this degree of blood pressure elevation who were already on at least three antihypertensive medications, specialty appointments were also arranged.
Other targeted interventions were also available to participants, including the services of dietitians and physical therapists for those with a body mass index (BMI) of at least 27.5 kg/m2; smoking cessation and mental health services were also available, as appropriate.
After 3 years, those participating in the RAMP-HT program (n = 79,116) were compared with those in the usual care group (n = 43,901). In both arms, adult patients with complete data and without preexisting cardiovascular disease, diabetes, or end-stage renal disease were included. In each group, about 58% of participants were female, and the mean age was about 65 years.
Primary outcome measures included the incidence of cardiovascular disease, an outcome that included coronary heart disease, heart failure, and stroke; end-stage renal disease; and all-cause mortality. The significant reductions in these measures for the RAMP-HT group remained after multivariable analysis accounted for sex, age, smoking status, renal function, lipid values, BMI, comorbidities, and antihypertensive and lipid-lowering medication use.
The reduced care utilization seen among RAMP-HT participants also persisted after multivariable analysis for these potential confounders.
Dr. Yu said the systematic, protocol-driven program was a primary strength of RAMP-HT. The key to the program was use of nurses to provide patient education and physicians and allied health resources only as needed, she said; the program reinforced the importance of self-management and adherence because patients heard a unified message from many different health care professionals.
However, lifestyle factors such as diet and exercise weren’t tracked, and the retrospective study design introduced the potential for some bias, she said. In ongoing work, the long-term efficacy and cost-effectiveness of the RAMP-HT program are being tracked.
Dr. Yu reported that the study was funded by the Hong Kong Health and Medical Research Fund. She reported no relevant conflicts of interest.
SOURCE: Yu, Esther et al. NAPCRG 2017, Abstract HY33.
REPORTING FROM NAPCRG 2017
Key clinical point:
Major finding: The hazard ratio for all-cause mortality was 0.504 for patients in the intervention arm.
Study details: A retrospective population-based cohort study of almost 85,000 Hong Kong patients with hypertension.
Disclosures: The study was funded by the Hong Kong Health and Medical Research Fund. Dr. Yu reported no relevant financial disclosures.
Source: Yu E et al. NAPCRG 2017, Abstract HY33.
Radiation exposure in MICU may exceed recommended limit
according to results of a recent observational study.
These “substantial” radiation doses in some patients suggest that efforts are warranted to “justify, restrict and optimize” the use of radiological resources when possible, said Sudhir Krishnan, MD, of the Cleveland Clinic, and his coauthors.
The retrospective, observational study included 4,155 adult admissions to a medical intensive care unit (MICU) at an academic medical center in 2013. Investigators calculated the cumulative effective dose (CED) of radiation based on reported ionizing radiological studies for each patient.
With a median length of stay of just 6.4 days, a total of 131 admissions (3%) accrued a CED of radiation of at least 50 millisieverts (mSv), the annual limit recommended by the National Commission on Radiation Protection, and 47 of those patients (1%) accrued a CED of radiation of at least 100 mSv, the 5-year cumulative exposure limit, the authors reported.
These findings suggest that “MICU patients could be subjected to radiation doses in a matter of days that are equivalent to or more than [the] CED observed in patients with chronic diseases and patients with trauma,” wrote Dr. Krishnan and his coauthors.
As hypothesized, patients with higher severity of illness scores (APACHE III scores) received a higher CED of radiation, according to the report. Using a multivariable linear regression model, investigators found that higher CED was predicted by higher APACHE III scores, sepsis, longer MICU stay, and gastrointestinal disorders and bleeding.
CT scans were the most common source of radiation exposure in patients who exceeded a 50 mSv of radiation, accounting for 49% of the total accrued dose, with interventional radiology accounting for 38%, authors reported.
Despite concerns about “the statistical risk of latent radiogenic cancer,” radiologic studies performed in the critically ill have the potential to reduce morbidity and mortality, the authors acknowledged in a discussion of the results.
“This understandably shifts the risk-benefit ratio towards radiation exposure,” the researchers wrote. “However, complacency in this regard cannot be entirely justified.”
Of the patients in the study who were exposed to a CED of at least 50 mSv, 81% survived the hospital admission and could be subjected to even more radiation as a part of ongoing medical care, they noted.
“Robust tools for monitoring CED prospectively per episode of clinical care, counseling patients exposed to high doses of radiation, and prospective studies exploring radiogenic risk associated with medical radiation are urgently required,” the authors said.
Dr. Krishnan and his coauthors reported no significant conflicts of interest.
SOURCE: Krishnan S et al. Chest. 2018 Feb 4. doi: 10.1016/j.chest.2018.01.019.
according to results of a recent observational study.
These “substantial” radiation doses in some patients suggest that efforts are warranted to “justify, restrict and optimize” the use of radiological resources when possible, said Sudhir Krishnan, MD, of the Cleveland Clinic, and his coauthors.
The retrospective, observational study included 4,155 adult admissions to a medical intensive care unit (MICU) at an academic medical center in 2013. Investigators calculated the cumulative effective dose (CED) of radiation based on reported ionizing radiological studies for each patient.
With a median length of stay of just 6.4 days, a total of 131 admissions (3%) accrued a CED of radiation of at least 50 millisieverts (mSv), the annual limit recommended by the National Commission on Radiation Protection, and 47 of those patients (1%) accrued a CED of radiation of at least 100 mSv, the 5-year cumulative exposure limit, the authors reported.
These findings suggest that “MICU patients could be subjected to radiation doses in a matter of days that are equivalent to or more than [the] CED observed in patients with chronic diseases and patients with trauma,” wrote Dr. Krishnan and his coauthors.
As hypothesized, patients with higher severity of illness scores (APACHE III scores) received a higher CED of radiation, according to the report. Using a multivariable linear regression model, investigators found that higher CED was predicted by higher APACHE III scores, sepsis, longer MICU stay, and gastrointestinal disorders and bleeding.
CT scans were the most common source of radiation exposure in patients who exceeded a 50 mSv of radiation, accounting for 49% of the total accrued dose, with interventional radiology accounting for 38%, authors reported.
Despite concerns about “the statistical risk of latent radiogenic cancer,” radiologic studies performed in the critically ill have the potential to reduce morbidity and mortality, the authors acknowledged in a discussion of the results.
“This understandably shifts the risk-benefit ratio towards radiation exposure,” the researchers wrote. “However, complacency in this regard cannot be entirely justified.”
Of the patients in the study who were exposed to a CED of at least 50 mSv, 81% survived the hospital admission and could be subjected to even more radiation as a part of ongoing medical care, they noted.
“Robust tools for monitoring CED prospectively per episode of clinical care, counseling patients exposed to high doses of radiation, and prospective studies exploring radiogenic risk associated with medical radiation are urgently required,” the authors said.
Dr. Krishnan and his coauthors reported no significant conflicts of interest.
SOURCE: Krishnan S et al. Chest. 2018 Feb 4. doi: 10.1016/j.chest.2018.01.019.
according to results of a recent observational study.
These “substantial” radiation doses in some patients suggest that efforts are warranted to “justify, restrict and optimize” the use of radiological resources when possible, said Sudhir Krishnan, MD, of the Cleveland Clinic, and his coauthors.
The retrospective, observational study included 4,155 adult admissions to a medical intensive care unit (MICU) at an academic medical center in 2013. Investigators calculated the cumulative effective dose (CED) of radiation based on reported ionizing radiological studies for each patient.
With a median length of stay of just 6.4 days, a total of 131 admissions (3%) accrued a CED of radiation of at least 50 millisieverts (mSv), the annual limit recommended by the National Commission on Radiation Protection, and 47 of those patients (1%) accrued a CED of radiation of at least 100 mSv, the 5-year cumulative exposure limit, the authors reported.
These findings suggest that “MICU patients could be subjected to radiation doses in a matter of days that are equivalent to or more than [the] CED observed in patients with chronic diseases and patients with trauma,” wrote Dr. Krishnan and his coauthors.
As hypothesized, patients with higher severity of illness scores (APACHE III scores) received a higher CED of radiation, according to the report. Using a multivariable linear regression model, investigators found that higher CED was predicted by higher APACHE III scores, sepsis, longer MICU stay, and gastrointestinal disorders and bleeding.
CT scans were the most common source of radiation exposure in patients who exceeded a 50 mSv of radiation, accounting for 49% of the total accrued dose, with interventional radiology accounting for 38%, authors reported.
Despite concerns about “the statistical risk of latent radiogenic cancer,” radiologic studies performed in the critically ill have the potential to reduce morbidity and mortality, the authors acknowledged in a discussion of the results.
“This understandably shifts the risk-benefit ratio towards radiation exposure,” the researchers wrote. “However, complacency in this regard cannot be entirely justified.”
Of the patients in the study who were exposed to a CED of at least 50 mSv, 81% survived the hospital admission and could be subjected to even more radiation as a part of ongoing medical care, they noted.
“Robust tools for monitoring CED prospectively per episode of clinical care, counseling patients exposed to high doses of radiation, and prospective studies exploring radiogenic risk associated with medical radiation are urgently required,” the authors said.
Dr. Krishnan and his coauthors reported no significant conflicts of interest.
SOURCE: Krishnan S et al. Chest. 2018 Feb 4. doi: 10.1016/j.chest.2018.01.019.
FROM CHEST
Key clinical point: Patients admitted to MICUs may be exposed to doses of radiation that are substantial and may exceed federal occupational health limits.
Major finding: In a short span of time (median 6.4 days length of stay), 3% of MICU patients received a cumulative dose of radiation that exceeded the U.S. recommended limit, and 1% accrued enough exposure to exceed the 5-year cumulative limit.
Data source: A retrospective, observational study including 4,155 adult admissions to the MICU at an academic medical center in 2013.
Disclosures: The study authors reported no significant conflicts of interest.
Source: Krishnan S et al. Chest. 2018 Feb 4. doi: 10.1016/j.chest.2018.01.019.
Colorectal cancer deaths projected for 2018
Approximately 50,630 deaths from colorectal cancer are predicted for the year in the United States by the American Cancer Society (ACS) in its Cancer Facts & Figures 2018, based on analysis of 2001-2015 data from the National Center for Health Statistics.
Nationally, the colorectal cancer death rate has been declining for decades, but hidden inside that long-term trend are a couple of competing ones: From 2006 to 2015, mortality dropped 2.9% a year for those aged 55 years and older but increased by 1% annually for adults aged 55 and under, the ACS said.
Incidence rates for colon cancer and rectal cancer showed a similar trend: From 2005 to 2015 they were down by 3.8% (colon) and 3.5% (rectal) a year for adults aged 55 and older but rose 1.4% and 2.4%, respectively, for adults younger than 55. Accurate statistics on colon and rectal cancer deaths are not available separately “because many deaths from rectal cancer are misclassified as colon cancer on death certificates,” the ACS said.
Approximately 50,630 deaths from colorectal cancer are predicted for the year in the United States by the American Cancer Society (ACS) in its Cancer Facts & Figures 2018, based on analysis of 2001-2015 data from the National Center for Health Statistics.
Nationally, the colorectal cancer death rate has been declining for decades, but hidden inside that long-term trend are a couple of competing ones: From 2006 to 2015, mortality dropped 2.9% a year for those aged 55 years and older but increased by 1% annually for adults aged 55 and under, the ACS said.
Incidence rates for colon cancer and rectal cancer showed a similar trend: From 2005 to 2015 they were down by 3.8% (colon) and 3.5% (rectal) a year for adults aged 55 and older but rose 1.4% and 2.4%, respectively, for adults younger than 55. Accurate statistics on colon and rectal cancer deaths are not available separately “because many deaths from rectal cancer are misclassified as colon cancer on death certificates,” the ACS said.
Approximately 50,630 deaths from colorectal cancer are predicted for the year in the United States by the American Cancer Society (ACS) in its Cancer Facts & Figures 2018, based on analysis of 2001-2015 data from the National Center for Health Statistics.
Nationally, the colorectal cancer death rate has been declining for decades, but hidden inside that long-term trend are a couple of competing ones: From 2006 to 2015, mortality dropped 2.9% a year for those aged 55 years and older but increased by 1% annually for adults aged 55 and under, the ACS said.
Incidence rates for colon cancer and rectal cancer showed a similar trend: From 2005 to 2015 they were down by 3.8% (colon) and 3.5% (rectal) a year for adults aged 55 and older but rose 1.4% and 2.4%, respectively, for adults younger than 55. Accurate statistics on colon and rectal cancer deaths are not available separately “because many deaths from rectal cancer are misclassified as colon cancer on death certificates,” the ACS said.
Therapeutic horseback riding may lower veterans’ PTSD symptoms
Veterans with posttraumatic stress disorder might benefit from therapeutic horseback riding, a small study suggests.
“Our findings provide empirical evidence that [therapeutic horseback riding] is effective at improving coping skills and in lessening one’s difficulty with emotional regulation, especially with longer riding interventions,” wrote Rebecca A. Johnson, PhD, of the University of Missouri, Columbia, and her associates.
Overall, 57 veterans were recruited and 28 enrolled in the randomized trial at baseline. Those individuals were randomized into two groups: a wait-list control group and a treatment group. Eventually, all of the veterans participated in the therapeutic riding program. Meanwhile, the riding center staff were not aware of which veterans had been assigned to either group. The Professional Association of Therapeutic Horsemanship, a nonprofit group that promotes equine-related activities for people with special needs, selected the horses that were used in the study. During the data collection periods, PTSD symptoms were measured via the PTSD Checklist–Military Version, or PCL-M. This self-report measure asks patients about problems in response to “stressful military experiences,” the researchers wrote. The Coping Self-Efficacy Scale and the Difficulties in Emotion Regulation Scale were among the other instruments used.
While riding, the results showed, participants had a statistically significant decrease in PTSD symptoms over the course of the 6-week program. “,” Dr. Johnson and her associates wrote. “Further detailed examination showed that participants had a 66.7% likelihood of having lower PTSD scores at 3 weeks, and an 87.5% likelihood at 6 weeks.”
Anecdotally, some of the veterans wanted to continue therapeutic riding after the end of the program, and they were able to do so.
“We conclude that [therapeutic horseback riding] shows promise as a beneficial intervention for veterans with PTSD, but did not measure functional ability,” they wrote.
Veterans with posttraumatic stress disorder might benefit from therapeutic horseback riding, a small study suggests.
“Our findings provide empirical evidence that [therapeutic horseback riding] is effective at improving coping skills and in lessening one’s difficulty with emotional regulation, especially with longer riding interventions,” wrote Rebecca A. Johnson, PhD, of the University of Missouri, Columbia, and her associates.
Overall, 57 veterans were recruited and 28 enrolled in the randomized trial at baseline. Those individuals were randomized into two groups: a wait-list control group and a treatment group. Eventually, all of the veterans participated in the therapeutic riding program. Meanwhile, the riding center staff were not aware of which veterans had been assigned to either group. The Professional Association of Therapeutic Horsemanship, a nonprofit group that promotes equine-related activities for people with special needs, selected the horses that were used in the study. During the data collection periods, PTSD symptoms were measured via the PTSD Checklist–Military Version, or PCL-M. This self-report measure asks patients about problems in response to “stressful military experiences,” the researchers wrote. The Coping Self-Efficacy Scale and the Difficulties in Emotion Regulation Scale were among the other instruments used.
While riding, the results showed, participants had a statistically significant decrease in PTSD symptoms over the course of the 6-week program. “,” Dr. Johnson and her associates wrote. “Further detailed examination showed that participants had a 66.7% likelihood of having lower PTSD scores at 3 weeks, and an 87.5% likelihood at 6 weeks.”
Anecdotally, some of the veterans wanted to continue therapeutic riding after the end of the program, and they were able to do so.
“We conclude that [therapeutic horseback riding] shows promise as a beneficial intervention for veterans with PTSD, but did not measure functional ability,” they wrote.
Veterans with posttraumatic stress disorder might benefit from therapeutic horseback riding, a small study suggests.
“Our findings provide empirical evidence that [therapeutic horseback riding] is effective at improving coping skills and in lessening one’s difficulty with emotional regulation, especially with longer riding interventions,” wrote Rebecca A. Johnson, PhD, of the University of Missouri, Columbia, and her associates.
Overall, 57 veterans were recruited and 28 enrolled in the randomized trial at baseline. Those individuals were randomized into two groups: a wait-list control group and a treatment group. Eventually, all of the veterans participated in the therapeutic riding program. Meanwhile, the riding center staff were not aware of which veterans had been assigned to either group. The Professional Association of Therapeutic Horsemanship, a nonprofit group that promotes equine-related activities for people with special needs, selected the horses that were used in the study. During the data collection periods, PTSD symptoms were measured via the PTSD Checklist–Military Version, or PCL-M. This self-report measure asks patients about problems in response to “stressful military experiences,” the researchers wrote. The Coping Self-Efficacy Scale and the Difficulties in Emotion Regulation Scale were among the other instruments used.
While riding, the results showed, participants had a statistically significant decrease in PTSD symptoms over the course of the 6-week program. “,” Dr. Johnson and her associates wrote. “Further detailed examination showed that participants had a 66.7% likelihood of having lower PTSD scores at 3 weeks, and an 87.5% likelihood at 6 weeks.”
Anecdotally, some of the veterans wanted to continue therapeutic riding after the end of the program, and they were able to do so.
“We conclude that [therapeutic horseback riding] shows promise as a beneficial intervention for veterans with PTSD, but did not measure functional ability,” they wrote.
FROM MILITARY MEDICAL RESEARCH
Debunking Acne Myths: Does Wearing Makeup Cause Acne?
Myth: Wearing makeup causes acne breakouts
Acne breakouts caused by makeup and other skin care products, known as acne cosmetica, typically resolve when patients stop using pore-clogging products; however, the overall impact of cosmetics on the development of acne lesions is considered to be negligible. Many cosmetics are not inherently comedogenic and can be used safely by patients in combination with proper skin care techniques.
Although dermatologists may be inclined to discourage makeup use during acne treatment or breakouts due to its potential to aggravate the patient’s condition, research has shown that treatment results and quality of life (QoL) scores associated with makeup use in acne patients may improve when patients receive instruction on how to use skin care products and cosmetics effectively. In one study of 50 female acne patients, 25 participants were instructed on how to use skin care products and cosmetics, and the other 25 participants received no specific instructions from dermatologists. After 4 weeks of treatment with conventional topical and/or oral acne medications, the investigators concluded that use of skin care products did not negatively impact acne treatment, and the group that received application instructions showed more notable improvements in QoL scores versus those who did not. In another study, the overall number of acne eruptions decreased over a 2- to 4-week period in female acne patients who were trained by a makeup artist to apply cosmetics while undergoing acne treatment. These results suggest that acne patients who wear makeup may benefit from a conversation with their dermatologist about what products and skin care techniques they can use to minimize exacerbation of or even improve their condition.
When choosing makeup that will not cause or exacerbate acne breakouts, patients should look for packaging that indicates the product will not clog pores and is oil-free, noncomedogenic, and/or nonacnegenic. Some makeup products are specifically formulated to help camouflage redness and pimples, which can help improve quality of life and self-esteem in acne patients who otherwise may be self-conscious about their appearance. Mineral-based cosmetics containing powdered formulas of silica, titanium dioxide, and zinc oxide can be used to absorb oil, camouflage redness, and prevent irritation. Anti-inflammatory ingredients and antioxidants also are used in some makeup products to reduce skin irritation and promote barrier repair. Additional cosmetic ingredients that can affect the mechanisms of acne pathogenesis and may contribute to a decrease in acne lesions include nicotinamide, lactic acid, triethyl acetate/ethyllineolate, and prebiotic plant extracts.
Makeup should be applied gently to avoid irritating the skin. It also is important to remind patients not to share their makeup brushes and applicators and to clean them weekly to ensure that bacteria, dead skin cells, and oil are not spread to the skin, which can lead to new breakouts. Although patients may be compelled to scrub the skin to remove makeup, a mild cleanser should be gently applied using the fingertips and rinsed off with lukewarm water to minimize skin irritation. Any makeup remaining on the skin after washing should be gently removed with an oil-free makeup remover.
Hayashi N, Imori M, Yanagisawa M, et al. Make-up improves the quality of life of acne patients without aggravating acne eruptions during treatments. Eur J Dermatol. 2005;15:284-287.
I have acne! is it okay to wear makeup? American Academy of Dermatology website. https://www.aad.org/public/diseases/acne-and-rosacea/makeup-with-acne. Accessed February 13, 2018.
Korting HC, Borelli C, Schöllmann C. Acne vulgaris. role of cosmetics [in German]. 2010;61:126-131.
Matsuoka Y, Yoneda K, Sadahira C, et al. Effects of skin care and makeup under instructions from dermatologists on the quality of life of female patients with acne vulgaris. J Dermatol. 2006;33:745-752.
Proper skin care lays the foundation for successful acne and rosacea treatment. American Academy of Dermatology website. https://www.aad.org/media/news-releases/proper-skin-care-lays-the-foundation-for-successful-acne-and-rosacea-treatment Published July 31, 2013. Accessed February 13, 2018.
Myth: Wearing makeup causes acne breakouts
Acne breakouts caused by makeup and other skin care products, known as acne cosmetica, typically resolve when patients stop using pore-clogging products; however, the overall impact of cosmetics on the development of acne lesions is considered to be negligible. Many cosmetics are not inherently comedogenic and can be used safely by patients in combination with proper skin care techniques.
Although dermatologists may be inclined to discourage makeup use during acne treatment or breakouts due to its potential to aggravate the patient’s condition, research has shown that treatment results and quality of life (QoL) scores associated with makeup use in acne patients may improve when patients receive instruction on how to use skin care products and cosmetics effectively. In one study of 50 female acne patients, 25 participants were instructed on how to use skin care products and cosmetics, and the other 25 participants received no specific instructions from dermatologists. After 4 weeks of treatment with conventional topical and/or oral acne medications, the investigators concluded that use of skin care products did not negatively impact acne treatment, and the group that received application instructions showed more notable improvements in QoL scores versus those who did not. In another study, the overall number of acne eruptions decreased over a 2- to 4-week period in female acne patients who were trained by a makeup artist to apply cosmetics while undergoing acne treatment. These results suggest that acne patients who wear makeup may benefit from a conversation with their dermatologist about what products and skin care techniques they can use to minimize exacerbation of or even improve their condition.
When choosing makeup that will not cause or exacerbate acne breakouts, patients should look for packaging that indicates the product will not clog pores and is oil-free, noncomedogenic, and/or nonacnegenic. Some makeup products are specifically formulated to help camouflage redness and pimples, which can help improve quality of life and self-esteem in acne patients who otherwise may be self-conscious about their appearance. Mineral-based cosmetics containing powdered formulas of silica, titanium dioxide, and zinc oxide can be used to absorb oil, camouflage redness, and prevent irritation. Anti-inflammatory ingredients and antioxidants also are used in some makeup products to reduce skin irritation and promote barrier repair. Additional cosmetic ingredients that can affect the mechanisms of acne pathogenesis and may contribute to a decrease in acne lesions include nicotinamide, lactic acid, triethyl acetate/ethyllineolate, and prebiotic plant extracts.
Makeup should be applied gently to avoid irritating the skin. It also is important to remind patients not to share their makeup brushes and applicators and to clean them weekly to ensure that bacteria, dead skin cells, and oil are not spread to the skin, which can lead to new breakouts. Although patients may be compelled to scrub the skin to remove makeup, a mild cleanser should be gently applied using the fingertips and rinsed off with lukewarm water to minimize skin irritation. Any makeup remaining on the skin after washing should be gently removed with an oil-free makeup remover.
Myth: Wearing makeup causes acne breakouts
Acne breakouts caused by makeup and other skin care products, known as acne cosmetica, typically resolve when patients stop using pore-clogging products; however, the overall impact of cosmetics on the development of acne lesions is considered to be negligible. Many cosmetics are not inherently comedogenic and can be used safely by patients in combination with proper skin care techniques.
Although dermatologists may be inclined to discourage makeup use during acne treatment or breakouts due to its potential to aggravate the patient’s condition, research has shown that treatment results and quality of life (QoL) scores associated with makeup use in acne patients may improve when patients receive instruction on how to use skin care products and cosmetics effectively. In one study of 50 female acne patients, 25 participants were instructed on how to use skin care products and cosmetics, and the other 25 participants received no specific instructions from dermatologists. After 4 weeks of treatment with conventional topical and/or oral acne medications, the investigators concluded that use of skin care products did not negatively impact acne treatment, and the group that received application instructions showed more notable improvements in QoL scores versus those who did not. In another study, the overall number of acne eruptions decreased over a 2- to 4-week period in female acne patients who were trained by a makeup artist to apply cosmetics while undergoing acne treatment. These results suggest that acne patients who wear makeup may benefit from a conversation with their dermatologist about what products and skin care techniques they can use to minimize exacerbation of or even improve their condition.
When choosing makeup that will not cause or exacerbate acne breakouts, patients should look for packaging that indicates the product will not clog pores and is oil-free, noncomedogenic, and/or nonacnegenic. Some makeup products are specifically formulated to help camouflage redness and pimples, which can help improve quality of life and self-esteem in acne patients who otherwise may be self-conscious about their appearance. Mineral-based cosmetics containing powdered formulas of silica, titanium dioxide, and zinc oxide can be used to absorb oil, camouflage redness, and prevent irritation. Anti-inflammatory ingredients and antioxidants also are used in some makeup products to reduce skin irritation and promote barrier repair. Additional cosmetic ingredients that can affect the mechanisms of acne pathogenesis and may contribute to a decrease in acne lesions include nicotinamide, lactic acid, triethyl acetate/ethyllineolate, and prebiotic plant extracts.
Makeup should be applied gently to avoid irritating the skin. It also is important to remind patients not to share their makeup brushes and applicators and to clean them weekly to ensure that bacteria, dead skin cells, and oil are not spread to the skin, which can lead to new breakouts. Although patients may be compelled to scrub the skin to remove makeup, a mild cleanser should be gently applied using the fingertips and rinsed off with lukewarm water to minimize skin irritation. Any makeup remaining on the skin after washing should be gently removed with an oil-free makeup remover.
Hayashi N, Imori M, Yanagisawa M, et al. Make-up improves the quality of life of acne patients without aggravating acne eruptions during treatments. Eur J Dermatol. 2005;15:284-287.
I have acne! is it okay to wear makeup? American Academy of Dermatology website. https://www.aad.org/public/diseases/acne-and-rosacea/makeup-with-acne. Accessed February 13, 2018.
Korting HC, Borelli C, Schöllmann C. Acne vulgaris. role of cosmetics [in German]. 2010;61:126-131.
Matsuoka Y, Yoneda K, Sadahira C, et al. Effects of skin care and makeup under instructions from dermatologists on the quality of life of female patients with acne vulgaris. J Dermatol. 2006;33:745-752.
Proper skin care lays the foundation for successful acne and rosacea treatment. American Academy of Dermatology website. https://www.aad.org/media/news-releases/proper-skin-care-lays-the-foundation-for-successful-acne-and-rosacea-treatment Published July 31, 2013. Accessed February 13, 2018.
Hayashi N, Imori M, Yanagisawa M, et al. Make-up improves the quality of life of acne patients without aggravating acne eruptions during treatments. Eur J Dermatol. 2005;15:284-287.
I have acne! is it okay to wear makeup? American Academy of Dermatology website. https://www.aad.org/public/diseases/acne-and-rosacea/makeup-with-acne. Accessed February 13, 2018.
Korting HC, Borelli C, Schöllmann C. Acne vulgaris. role of cosmetics [in German]. 2010;61:126-131.
Matsuoka Y, Yoneda K, Sadahira C, et al. Effects of skin care and makeup under instructions from dermatologists on the quality of life of female patients with acne vulgaris. J Dermatol. 2006;33:745-752.
Proper skin care lays the foundation for successful acne and rosacea treatment. American Academy of Dermatology website. https://www.aad.org/media/news-releases/proper-skin-care-lays-the-foundation-for-successful-acne-and-rosacea-treatment Published July 31, 2013. Accessed February 13, 2018.
Acne is linked to higher chances of major depression
according to a retrospective cohort analysis published as a research letter.
“The onset of acne, when patients present for treatment because of active disease, is associated with a greater risk of developing depression” wrote Isabelle A. Vallerand, an MD/PhD student at the University of Calgary (Alta.), and her associates. “Although the severity of acne was not assessed directly in the current study, this finding suggests a potential dose/response relationship such that more active disease may lead to a greater risk of depression.”
In total, 134,437 acne patients and 1,731,608 patients without acne were identified from THIN. Over a 15-year follow-up, the probability of developing MDD was 18.5% among patients with acne, and 12% for those without acne. This risk was much higher within the first year after diagnosis (adjusted hazard ratio, 1.63; 95% confidence interval, 1.33-2), which subsequently decreased.
The researchers found that patients with acne tended to be younger (67.6% vs. 22.8%), female (58.6% vs. 48.6%), and of a higher socioeconomic status (24.4% vs. 22.1%) compared with patients without acne. Those with acne tended to smoke (58.4% vs. 48.6%) and to have comorbidities (17.2% vs. 13.8%). Conversely, acne patients were less likely to use alcohol (17% vs. 39%) and less likely to be obese (2.3% vs. 6.6%) (all P less than .001).
Although these results are promising, there are several limitations that could have influenced the study findings. The misclassification of patients with acne and MDD could have occurred if patients did not present themselves to a physician for treatment. Another limitation was that isotretinoin was the only acne treatment that was considered by the researchers. Considering that treatment has been shown to reduce depressive symptoms, the researchers believe that their estimates are conservative.
“Given the tremendous burden of MDD and its temporal association with active acne, it is critical that physicians monitor mood symptoms in patients with acne and initiate prompt MDD management or seek consultation from a psychiatrist when needed” wrote Ms. Vallerand and her colleagues.
Ms. Vallerand received funding for this study from the Alberta Innovates Health Solutions MD-PhD Studentship and from the Mach-Gaensslen Foundation of Canada. None of the other authors had disclosures to report.
SOURCE: Vallerand I et al. Br J Dermatol. 2018 Feb 7. doi: 10.1111/bjd.16099.
according to a retrospective cohort analysis published as a research letter.
“The onset of acne, when patients present for treatment because of active disease, is associated with a greater risk of developing depression” wrote Isabelle A. Vallerand, an MD/PhD student at the University of Calgary (Alta.), and her associates. “Although the severity of acne was not assessed directly in the current study, this finding suggests a potential dose/response relationship such that more active disease may lead to a greater risk of depression.”
In total, 134,437 acne patients and 1,731,608 patients without acne were identified from THIN. Over a 15-year follow-up, the probability of developing MDD was 18.5% among patients with acne, and 12% for those without acne. This risk was much higher within the first year after diagnosis (adjusted hazard ratio, 1.63; 95% confidence interval, 1.33-2), which subsequently decreased.
The researchers found that patients with acne tended to be younger (67.6% vs. 22.8%), female (58.6% vs. 48.6%), and of a higher socioeconomic status (24.4% vs. 22.1%) compared with patients without acne. Those with acne tended to smoke (58.4% vs. 48.6%) and to have comorbidities (17.2% vs. 13.8%). Conversely, acne patients were less likely to use alcohol (17% vs. 39%) and less likely to be obese (2.3% vs. 6.6%) (all P less than .001).
Although these results are promising, there are several limitations that could have influenced the study findings. The misclassification of patients with acne and MDD could have occurred if patients did not present themselves to a physician for treatment. Another limitation was that isotretinoin was the only acne treatment that was considered by the researchers. Considering that treatment has been shown to reduce depressive symptoms, the researchers believe that their estimates are conservative.
“Given the tremendous burden of MDD and its temporal association with active acne, it is critical that physicians monitor mood symptoms in patients with acne and initiate prompt MDD management or seek consultation from a psychiatrist when needed” wrote Ms. Vallerand and her colleagues.
Ms. Vallerand received funding for this study from the Alberta Innovates Health Solutions MD-PhD Studentship and from the Mach-Gaensslen Foundation of Canada. None of the other authors had disclosures to report.
SOURCE: Vallerand I et al. Br J Dermatol. 2018 Feb 7. doi: 10.1111/bjd.16099.
according to a retrospective cohort analysis published as a research letter.
“The onset of acne, when patients present for treatment because of active disease, is associated with a greater risk of developing depression” wrote Isabelle A. Vallerand, an MD/PhD student at the University of Calgary (Alta.), and her associates. “Although the severity of acne was not assessed directly in the current study, this finding suggests a potential dose/response relationship such that more active disease may lead to a greater risk of depression.”
In total, 134,437 acne patients and 1,731,608 patients without acne were identified from THIN. Over a 15-year follow-up, the probability of developing MDD was 18.5% among patients with acne, and 12% for those without acne. This risk was much higher within the first year after diagnosis (adjusted hazard ratio, 1.63; 95% confidence interval, 1.33-2), which subsequently decreased.
The researchers found that patients with acne tended to be younger (67.6% vs. 22.8%), female (58.6% vs. 48.6%), and of a higher socioeconomic status (24.4% vs. 22.1%) compared with patients without acne. Those with acne tended to smoke (58.4% vs. 48.6%) and to have comorbidities (17.2% vs. 13.8%). Conversely, acne patients were less likely to use alcohol (17% vs. 39%) and less likely to be obese (2.3% vs. 6.6%) (all P less than .001).
Although these results are promising, there are several limitations that could have influenced the study findings. The misclassification of patients with acne and MDD could have occurred if patients did not present themselves to a physician for treatment. Another limitation was that isotretinoin was the only acne treatment that was considered by the researchers. Considering that treatment has been shown to reduce depressive symptoms, the researchers believe that their estimates are conservative.
“Given the tremendous burden of MDD and its temporal association with active acne, it is critical that physicians monitor mood symptoms in patients with acne and initiate prompt MDD management or seek consultation from a psychiatrist when needed” wrote Ms. Vallerand and her colleagues.
Ms. Vallerand received funding for this study from the Alberta Innovates Health Solutions MD-PhD Studentship and from the Mach-Gaensslen Foundation of Canada. None of the other authors had disclosures to report.
SOURCE: Vallerand I et al. Br J Dermatol. 2018 Feb 7. doi: 10.1111/bjd.16099.
FROM BRITISH JOURNAL OF DERMATOLOGY
Key clinical point: Patients with acne have a much higher chance of developing major depressive disorder (MDD).
Major finding: The chance of developing MDD was 18.5% in patients with acne.
Study details: Analysis of retrospective cohort data obtained from the Health Improvement Network (THIN) between 1986 and 2012.
Disclosures: Ms. Vallerand received funding for this study from the Alberta Innovates Health Solutions MD-PhD Studentship and from the Mach-Gaensslen Foundation of Canada. None of the other authors had disclosures to report.
Source: Vallerand I et al. Br J Dermatol. 2018 Feb 7. doi: 10.1111/bjd.16099.
Are you as frustrated with medical care as we are?
How did the experience of office visits get to be so frustrating for both patients and doctors? Let’s put it under the microscope and examine it.
To medicine’s credit, it realized the value of looking for diseases before symptoms occurred, such as using mammograms to detect breast cancer and controlling blood pressure and blood sugar to avert comorbidities.
Today, a doctor looks at the computer screen and checks off when a mammogram was done and whether blood pressure and blood sugar are controlled. “Authorities” believe that good health is achieved by performing positive checkoffs to questions like this. This definition of quality care is, in reality, “quantity care” and can be tied to physician compensation. Physicians who did not adequately meet Physician Quality Reporting System requirements have received letters informing them that their Medicare Part B payments for 2018 will be reduced by 3%.
Many seasoned clinicians recognize that practicing good medicine involves more than following a computer printout of tests and treatments based on the patient’s symptoms, more than plugging into the diagnostic and prescription mills that are part of today’s managed care system. Making the correct diagnosis requires a carefully taken history, listening to the patients’ stories of their journeys into and through illness, and using a bio-psychosocial-spiritual approach.
Getting to know the patient as a person requires that the doctor and patient take a journey together. In that journey, when the doctor empathizes with the patient and understands what makes the patient tick, the doctor can empower the patient – giving the patient a fuller understanding of their medical conditions, greater participation in the diagnostic work-up and in treatments, and hope for success – all leading to better outcomes.
Doctors are frustrated with the current medical assembly-line system. A study has shown that physicians spend 2 hours on electronic health records and clerical work for every hour they provide direct patient care (Ann Intern Med. 2016;165[11]:753-60). Nearly half of physicians now report that they are “burned out” by the demand to achieve the quantitative requirements on the one hand and their inability to minister to the needs of their patients on the other hand. Patients are also frustrated by the system as they cope with health insurance and costs, with the short time allocated for office visits, and with a fragmented and impersonal medical system. Patients feel that they are little more than a source of information for boxes to be checked off by the physician whose eyes are forced to be on the computer and the clock.
How can we begin to integrate these measures of quality into “quantity medicine” and make the experience of medical visits less frustrating for doctors and patients? How can we reward the skills that recognize that the course of an illness is influenced by patients’ emotions and thoughts related to their problems, their supportive or stressful relationships with others, and the context within which they conceptualize their lives – particularly their religious and spiritual beliefs about life’s purpose and challenges and attitudes toward death?
Caring for patients requires a more sophisticated approach than seeing patients as computer checkoffs. Office visits need to focus on the patient who has the symptoms, not just the symptoms the patient has.
Isn’t it time to make patient-centered care a reality and not just a slogan? If this speaks to you, then what should you do? Even though solutions may not be simple, we should not be deterred from finding patient-centered systems since patients and doctors are unhappy with today’s system. Why not have patients grade their office visits?
While this approach has its shortcomings, and isn’t the only solution, it does place the patient at the center of the process, answering questions about whether the doctor listened to them, heard their concerns, and presented a reasonable plan to help them get better.
In addition, all those involved with medical care should be involved in the process to replace today’s deficient system. The nation’s main organizations representing physicians should propose solutions to support patient-centered care. Individual physicians should become involved, speaking up and sending articles and letters to medical journals and the lay press.
Patients should be empowered to open up a public discussion – in print and broadcast media – on how they want to improve their own medical experiences and the quality of their health care.
It’s worth it. It’s our health.
Dr. Banner is a practicing internist in Philadelphia and chair emeritus of the Albert Einstein Medical Center Medical Ethics Committee. Dr. Benor is a psychiatric psychotherapist in the United States and a wholistic psychotherapist in Canada. Dr. Reiser is adjunct professor, University of Texas School of Public Health, Austin, and the UT Austin Plan II Honors Program, and teaches medical history, medical ethics, and public policy. The authors are indebted to Benjamin Sharfman, PhD, and Jane Brown, PhD, for their important roles in creating this article.
How did the experience of office visits get to be so frustrating for both patients and doctors? Let’s put it under the microscope and examine it.
To medicine’s credit, it realized the value of looking for diseases before symptoms occurred, such as using mammograms to detect breast cancer and controlling blood pressure and blood sugar to avert comorbidities.
Today, a doctor looks at the computer screen and checks off when a mammogram was done and whether blood pressure and blood sugar are controlled. “Authorities” believe that good health is achieved by performing positive checkoffs to questions like this. This definition of quality care is, in reality, “quantity care” and can be tied to physician compensation. Physicians who did not adequately meet Physician Quality Reporting System requirements have received letters informing them that their Medicare Part B payments for 2018 will be reduced by 3%.
Many seasoned clinicians recognize that practicing good medicine involves more than following a computer printout of tests and treatments based on the patient’s symptoms, more than plugging into the diagnostic and prescription mills that are part of today’s managed care system. Making the correct diagnosis requires a carefully taken history, listening to the patients’ stories of their journeys into and through illness, and using a bio-psychosocial-spiritual approach.
Getting to know the patient as a person requires that the doctor and patient take a journey together. In that journey, when the doctor empathizes with the patient and understands what makes the patient tick, the doctor can empower the patient – giving the patient a fuller understanding of their medical conditions, greater participation in the diagnostic work-up and in treatments, and hope for success – all leading to better outcomes.
Doctors are frustrated with the current medical assembly-line system. A study has shown that physicians spend 2 hours on electronic health records and clerical work for every hour they provide direct patient care (Ann Intern Med. 2016;165[11]:753-60). Nearly half of physicians now report that they are “burned out” by the demand to achieve the quantitative requirements on the one hand and their inability to minister to the needs of their patients on the other hand. Patients are also frustrated by the system as they cope with health insurance and costs, with the short time allocated for office visits, and with a fragmented and impersonal medical system. Patients feel that they are little more than a source of information for boxes to be checked off by the physician whose eyes are forced to be on the computer and the clock.
How can we begin to integrate these measures of quality into “quantity medicine” and make the experience of medical visits less frustrating for doctors and patients? How can we reward the skills that recognize that the course of an illness is influenced by patients’ emotions and thoughts related to their problems, their supportive or stressful relationships with others, and the context within which they conceptualize their lives – particularly their religious and spiritual beliefs about life’s purpose and challenges and attitudes toward death?
Caring for patients requires a more sophisticated approach than seeing patients as computer checkoffs. Office visits need to focus on the patient who has the symptoms, not just the symptoms the patient has.
Isn’t it time to make patient-centered care a reality and not just a slogan? If this speaks to you, then what should you do? Even though solutions may not be simple, we should not be deterred from finding patient-centered systems since patients and doctors are unhappy with today’s system. Why not have patients grade their office visits?
While this approach has its shortcomings, and isn’t the only solution, it does place the patient at the center of the process, answering questions about whether the doctor listened to them, heard their concerns, and presented a reasonable plan to help them get better.
In addition, all those involved with medical care should be involved in the process to replace today’s deficient system. The nation’s main organizations representing physicians should propose solutions to support patient-centered care. Individual physicians should become involved, speaking up and sending articles and letters to medical journals and the lay press.
Patients should be empowered to open up a public discussion – in print and broadcast media – on how they want to improve their own medical experiences and the quality of their health care.
It’s worth it. It’s our health.
Dr. Banner is a practicing internist in Philadelphia and chair emeritus of the Albert Einstein Medical Center Medical Ethics Committee. Dr. Benor is a psychiatric psychotherapist in the United States and a wholistic psychotherapist in Canada. Dr. Reiser is adjunct professor, University of Texas School of Public Health, Austin, and the UT Austin Plan II Honors Program, and teaches medical history, medical ethics, and public policy. The authors are indebted to Benjamin Sharfman, PhD, and Jane Brown, PhD, for their important roles in creating this article.
How did the experience of office visits get to be so frustrating for both patients and doctors? Let’s put it under the microscope and examine it.
To medicine’s credit, it realized the value of looking for diseases before symptoms occurred, such as using mammograms to detect breast cancer and controlling blood pressure and blood sugar to avert comorbidities.
Today, a doctor looks at the computer screen and checks off when a mammogram was done and whether blood pressure and blood sugar are controlled. “Authorities” believe that good health is achieved by performing positive checkoffs to questions like this. This definition of quality care is, in reality, “quantity care” and can be tied to physician compensation. Physicians who did not adequately meet Physician Quality Reporting System requirements have received letters informing them that their Medicare Part B payments for 2018 will be reduced by 3%.
Many seasoned clinicians recognize that practicing good medicine involves more than following a computer printout of tests and treatments based on the patient’s symptoms, more than plugging into the diagnostic and prescription mills that are part of today’s managed care system. Making the correct diagnosis requires a carefully taken history, listening to the patients’ stories of their journeys into and through illness, and using a bio-psychosocial-spiritual approach.
Getting to know the patient as a person requires that the doctor and patient take a journey together. In that journey, when the doctor empathizes with the patient and understands what makes the patient tick, the doctor can empower the patient – giving the patient a fuller understanding of their medical conditions, greater participation in the diagnostic work-up and in treatments, and hope for success – all leading to better outcomes.
Doctors are frustrated with the current medical assembly-line system. A study has shown that physicians spend 2 hours on electronic health records and clerical work for every hour they provide direct patient care (Ann Intern Med. 2016;165[11]:753-60). Nearly half of physicians now report that they are “burned out” by the demand to achieve the quantitative requirements on the one hand and their inability to minister to the needs of their patients on the other hand. Patients are also frustrated by the system as they cope with health insurance and costs, with the short time allocated for office visits, and with a fragmented and impersonal medical system. Patients feel that they are little more than a source of information for boxes to be checked off by the physician whose eyes are forced to be on the computer and the clock.
How can we begin to integrate these measures of quality into “quantity medicine” and make the experience of medical visits less frustrating for doctors and patients? How can we reward the skills that recognize that the course of an illness is influenced by patients’ emotions and thoughts related to their problems, their supportive or stressful relationships with others, and the context within which they conceptualize their lives – particularly their religious and spiritual beliefs about life’s purpose and challenges and attitudes toward death?
Caring for patients requires a more sophisticated approach than seeing patients as computer checkoffs. Office visits need to focus on the patient who has the symptoms, not just the symptoms the patient has.
Isn’t it time to make patient-centered care a reality and not just a slogan? If this speaks to you, then what should you do? Even though solutions may not be simple, we should not be deterred from finding patient-centered systems since patients and doctors are unhappy with today’s system. Why not have patients grade their office visits?
While this approach has its shortcomings, and isn’t the only solution, it does place the patient at the center of the process, answering questions about whether the doctor listened to them, heard their concerns, and presented a reasonable plan to help them get better.
In addition, all those involved with medical care should be involved in the process to replace today’s deficient system. The nation’s main organizations representing physicians should propose solutions to support patient-centered care. Individual physicians should become involved, speaking up and sending articles and letters to medical journals and the lay press.
Patients should be empowered to open up a public discussion – in print and broadcast media – on how they want to improve their own medical experiences and the quality of their health care.
It’s worth it. It’s our health.
Dr. Banner is a practicing internist in Philadelphia and chair emeritus of the Albert Einstein Medical Center Medical Ethics Committee. Dr. Benor is a psychiatric psychotherapist in the United States and a wholistic psychotherapist in Canada. Dr. Reiser is adjunct professor, University of Texas School of Public Health, Austin, and the UT Austin Plan II Honors Program, and teaches medical history, medical ethics, and public policy. The authors are indebted to Benjamin Sharfman, PhD, and Jane Brown, PhD, for their important roles in creating this article.
MDedge Daily News: Sleep apnea protects hearts?
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
Does obstructive sleep apnea protect the heart? Just say no to routine ovarian cancer screening, why MS patients miss out in primary care, and how malpractice claims mark middle age.
Listen to the MDedge Daily News podcast for all the details on today’s top news.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
Does obstructive sleep apnea protect the heart? Just say no to routine ovarian cancer screening, why MS patients miss out in primary care, and how malpractice claims mark middle age.
Listen to the MDedge Daily News podcast for all the details on today’s top news.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
Does obstructive sleep apnea protect the heart? Just say no to routine ovarian cancer screening, why MS patients miss out in primary care, and how malpractice claims mark middle age.
Listen to the MDedge Daily News podcast for all the details on today’s top news.
Early Intervention for Mental Health Pays Off Later
The facts are dire: In 2014, people diagnosed with schizophrenia or mood disorders made 10.8 million visits to emergency departments (EDs). Between 2006 and 2014, the rate of ED visits related to mental health/substance abuse jumped 44%. The suicide rate among people with serious emotional disturbances (SEDs) is 25 times higher than that in the general population. Two million people with serious mental illness (SMI) are jailed annually, but only about 1 in 3 is currently receiving any treatment.
However, early intervention for SMI can help many people stay out of EDs and jails. That is the focus of The Way Forward: Federal Action for a System That Works for All People Living With SMI and SED and Their Families and Caregivers, a report recently released by the Substance Abuse and Mental Health Services Administration (SAMHSA).
“The emergency room is not a place for people that are experiencing exacerbations of mental health conditions,” says Elinore McCance-Katz, MD, PhD, assistant secretary for mental health and substance use at SAMHSA and chair of the Interdepartmental Serious Mental Illness Coordinating Committee, which produced the report.
In the report, the committee cited the 2003 President’s New Freedom Commission on Mental Health, which concluded that America’s mental health service delivery system was “in shambles,” with “fragmented, disconnected and often inadequate” mental health services and supports. Yet a number of the commission’s recommendations still have not been implemented or only “partially realized,” the committee notes.
In an interview with MedPageToday.com, McCance-Katz says the solution is a “national system of crisis intervention services”—a continuum of care with outpatient services as alternatives to inpatient care. Most states report insufficient psychiatric crisis response capacity, as well as insufficient numbers of inpatient psychiatric hospital beds. If the right system, one that includes community interventions and adequate resources, were in place, McCance-Katz says, “we might not need so many beds.”
The facts are dire: In 2014, people diagnosed with schizophrenia or mood disorders made 10.8 million visits to emergency departments (EDs). Between 2006 and 2014, the rate of ED visits related to mental health/substance abuse jumped 44%. The suicide rate among people with serious emotional disturbances (SEDs) is 25 times higher than that in the general population. Two million people with serious mental illness (SMI) are jailed annually, but only about 1 in 3 is currently receiving any treatment.
However, early intervention for SMI can help many people stay out of EDs and jails. That is the focus of The Way Forward: Federal Action for a System That Works for All People Living With SMI and SED and Their Families and Caregivers, a report recently released by the Substance Abuse and Mental Health Services Administration (SAMHSA).
“The emergency room is not a place for people that are experiencing exacerbations of mental health conditions,” says Elinore McCance-Katz, MD, PhD, assistant secretary for mental health and substance use at SAMHSA and chair of the Interdepartmental Serious Mental Illness Coordinating Committee, which produced the report.
In the report, the committee cited the 2003 President’s New Freedom Commission on Mental Health, which concluded that America’s mental health service delivery system was “in shambles,” with “fragmented, disconnected and often inadequate” mental health services and supports. Yet a number of the commission’s recommendations still have not been implemented or only “partially realized,” the committee notes.
In an interview with MedPageToday.com, McCance-Katz says the solution is a “national system of crisis intervention services”—a continuum of care with outpatient services as alternatives to inpatient care. Most states report insufficient psychiatric crisis response capacity, as well as insufficient numbers of inpatient psychiatric hospital beds. If the right system, one that includes community interventions and adequate resources, were in place, McCance-Katz says, “we might not need so many beds.”
The facts are dire: In 2014, people diagnosed with schizophrenia or mood disorders made 10.8 million visits to emergency departments (EDs). Between 2006 and 2014, the rate of ED visits related to mental health/substance abuse jumped 44%. The suicide rate among people with serious emotional disturbances (SEDs) is 25 times higher than that in the general population. Two million people with serious mental illness (SMI) are jailed annually, but only about 1 in 3 is currently receiving any treatment.
However, early intervention for SMI can help many people stay out of EDs and jails. That is the focus of The Way Forward: Federal Action for a System That Works for All People Living With SMI and SED and Their Families and Caregivers, a report recently released by the Substance Abuse and Mental Health Services Administration (SAMHSA).
“The emergency room is not a place for people that are experiencing exacerbations of mental health conditions,” says Elinore McCance-Katz, MD, PhD, assistant secretary for mental health and substance use at SAMHSA and chair of the Interdepartmental Serious Mental Illness Coordinating Committee, which produced the report.
In the report, the committee cited the 2003 President’s New Freedom Commission on Mental Health, which concluded that America’s mental health service delivery system was “in shambles,” with “fragmented, disconnected and often inadequate” mental health services and supports. Yet a number of the commission’s recommendations still have not been implemented or only “partially realized,” the committee notes.
In an interview with MedPageToday.com, McCance-Katz says the solution is a “national system of crisis intervention services”—a continuum of care with outpatient services as alternatives to inpatient care. Most states report insufficient psychiatric crisis response capacity, as well as insufficient numbers of inpatient psychiatric hospital beds. If the right system, one that includes community interventions and adequate resources, were in place, McCance-Katz says, “we might not need so many beds.”
Young kids with SCA not receiving recommended prophylaxis
Many young children with sickle cell anemia (SCA) may not be taking the recommended antibiotics to prevent invasive pneumococcal disease (IPD), according to research published in Pediatrics.
Results of a previous study indicated that daily treatment with penicillin could reduce the risk of IPD by 84% in young children with SCA.
In the current study, only 18% of young SCA patients received daily penicillin or an equivalent antibiotic as IPD prophylaxis.
“Most children with sickle cell anemia are not getting the antibiotics they should be to adequately protect against potentially deadly infections,” said study author Sarah Reeves, PhD, of the University of Michigan Medical School in Ann Arbor.
“Long-standing recommendations say children with sickle cell anemia should take antibiotics daily for their first 5 years of life. It can be life-saving.”
For this study, Dr Reeves and her colleagues analyzed data on 2821 SCA patients, ages 3 months to 5 years, living in Florida, Illinois, Louisiana, Michigan, South Carolina, and Texas.
The patients were continuously enrolled in the Medicaid program for at least 1 calendar year between 2005 and 2012. The researchers evaluated the receipt of antibiotics through the insurance claims for filled prescriptions.
The team found that, overall, 18% of patients received at least 300 days of antibiotics.
Sixteen percent of patients received at least 300 days of penicillin; 16% received at least 300 days of penicillin or erythromycin; 18% received at least 300 days of penicillin, erythromycin, or amoxicillin; and 22% received at least 300 days of any antibiotic to prevent Streptococcus pneumoniae.
On average, patients received 162 days of penicillin; 164 days of penicillin or erythromycin; 178 days of penicillin, erythromycin, or amoxicillin; and 193 days of any antibiotic to prevent S pneumoniae.
Multivariable analysis suggested that medical visits and a patient’s state of residence were associated with receiving at least 300 days of antibiotics.
The researchers said that each additional SCA-related outpatient visit and well-child visit was associated with incrementally increased odds of receiving at least 300 days of antibiotics. The odds ratio (OR) was 1.01 for SCA-related outpatient visits and 1.08 for well-child visits (P<0.05 for both).
Patients in Florida (OR=0.51, P<0.05), Louisiana (OR=0.57, P<0.05), Michigan (OR=0.60, P<0.05), and South Carolina (OR=0.62, P<0.05) had lower odds of receiving at least 300 days of antibiotics than patients in Illinois (OR=1.00) or Texas (OR=1.01).
The researchers did not investigate why children were not receiving recommended antibiotics, but Dr Reeves identified possible barriers to compliance. She noted that caregiver challenges include picking up prescriptions every 2 weeks from a pharmacy as well as remembering to administer an antibiotic to a young, healthy-appearing child twice a day.
“The types of challenges involved in making sure children get the recommended dose of antibiotics is exacerbated by the substantial burden of care already experienced by families to help control the symptoms of this disease,” Dr Reeves said.
She added that future studies should more deeply explore barriers preventing families from getting antibiotics and potential interventions to improve the rate of children receiving recommended prescriptions.
“Interventions to improve the receipt of antibiotics among children with sickle cell anemia should include enhanced collaboration between healthcare providers, pharmacists, and families,” Dr Reeves said.
“Doctors need to repeatedly discuss the importance of taking antibiotics with families of children with sickle cell anemia. Social factors that may impact receiving filled prescriptions should also be considered, such as the availability of transportation and time to travel to pharmacies to pick up the prescriptions.” 
Many young children with sickle cell anemia (SCA) may not be taking the recommended antibiotics to prevent invasive pneumococcal disease (IPD), according to research published in Pediatrics.
Results of a previous study indicated that daily treatment with penicillin could reduce the risk of IPD by 84% in young children with SCA.
In the current study, only 18% of young SCA patients received daily penicillin or an equivalent antibiotic as IPD prophylaxis.
“Most children with sickle cell anemia are not getting the antibiotics they should be to adequately protect against potentially deadly infections,” said study author Sarah Reeves, PhD, of the University of Michigan Medical School in Ann Arbor.
“Long-standing recommendations say children with sickle cell anemia should take antibiotics daily for their first 5 years of life. It can be life-saving.”
For this study, Dr Reeves and her colleagues analyzed data on 2821 SCA patients, ages 3 months to 5 years, living in Florida, Illinois, Louisiana, Michigan, South Carolina, and Texas.
The patients were continuously enrolled in the Medicaid program for at least 1 calendar year between 2005 and 2012. The researchers evaluated the receipt of antibiotics through the insurance claims for filled prescriptions.
The team found that, overall, 18% of patients received at least 300 days of antibiotics.
Sixteen percent of patients received at least 300 days of penicillin; 16% received at least 300 days of penicillin or erythromycin; 18% received at least 300 days of penicillin, erythromycin, or amoxicillin; and 22% received at least 300 days of any antibiotic to prevent Streptococcus pneumoniae.
On average, patients received 162 days of penicillin; 164 days of penicillin or erythromycin; 178 days of penicillin, erythromycin, or amoxicillin; and 193 days of any antibiotic to prevent S pneumoniae.
Multivariable analysis suggested that medical visits and a patient’s state of residence were associated with receiving at least 300 days of antibiotics.
The researchers said that each additional SCA-related outpatient visit and well-child visit was associated with incrementally increased odds of receiving at least 300 days of antibiotics. The odds ratio (OR) was 1.01 for SCA-related outpatient visits and 1.08 for well-child visits (P<0.05 for both).
Patients in Florida (OR=0.51, P<0.05), Louisiana (OR=0.57, P<0.05), Michigan (OR=0.60, P<0.05), and South Carolina (OR=0.62, P<0.05) had lower odds of receiving at least 300 days of antibiotics than patients in Illinois (OR=1.00) or Texas (OR=1.01).
The researchers did not investigate why children were not receiving recommended antibiotics, but Dr Reeves identified possible barriers to compliance. She noted that caregiver challenges include picking up prescriptions every 2 weeks from a pharmacy as well as remembering to administer an antibiotic to a young, healthy-appearing child twice a day.
“The types of challenges involved in making sure children get the recommended dose of antibiotics is exacerbated by the substantial burden of care already experienced by families to help control the symptoms of this disease,” Dr Reeves said.
She added that future studies should more deeply explore barriers preventing families from getting antibiotics and potential interventions to improve the rate of children receiving recommended prescriptions.
“Interventions to improve the receipt of antibiotics among children with sickle cell anemia should include enhanced collaboration between healthcare providers, pharmacists, and families,” Dr Reeves said.
“Doctors need to repeatedly discuss the importance of taking antibiotics with families of children with sickle cell anemia. Social factors that may impact receiving filled prescriptions should also be considered, such as the availability of transportation and time to travel to pharmacies to pick up the prescriptions.”
Many young children with sickle cell anemia (SCA) may not be taking the recommended antibiotics to prevent invasive pneumococcal disease (IPD), according to research published in Pediatrics.
Results of a previous study indicated that daily treatment with penicillin could reduce the risk of IPD by 84% in young children with SCA.
In the current study, only 18% of young SCA patients received daily penicillin or an equivalent antibiotic as IPD prophylaxis.
“Most children with sickle cell anemia are not getting the antibiotics they should be to adequately protect against potentially deadly infections,” said study author Sarah Reeves, PhD, of the University of Michigan Medical School in Ann Arbor.
“Long-standing recommendations say children with sickle cell anemia should take antibiotics daily for their first 5 years of life. It can be life-saving.”
For this study, Dr Reeves and her colleagues analyzed data on 2821 SCA patients, ages 3 months to 5 years, living in Florida, Illinois, Louisiana, Michigan, South Carolina, and Texas.
The patients were continuously enrolled in the Medicaid program for at least 1 calendar year between 2005 and 2012. The researchers evaluated the receipt of antibiotics through the insurance claims for filled prescriptions.
The team found that, overall, 18% of patients received at least 300 days of antibiotics.
Sixteen percent of patients received at least 300 days of penicillin; 16% received at least 300 days of penicillin or erythromycin; 18% received at least 300 days of penicillin, erythromycin, or amoxicillin; and 22% received at least 300 days of any antibiotic to prevent Streptococcus pneumoniae.
On average, patients received 162 days of penicillin; 164 days of penicillin or erythromycin; 178 days of penicillin, erythromycin, or amoxicillin; and 193 days of any antibiotic to prevent S pneumoniae.
Multivariable analysis suggested that medical visits and a patient’s state of residence were associated with receiving at least 300 days of antibiotics.
The researchers said that each additional SCA-related outpatient visit and well-child visit was associated with incrementally increased odds of receiving at least 300 days of antibiotics. The odds ratio (OR) was 1.01 for SCA-related outpatient visits and 1.08 for well-child visits (P<0.05 for both).
Patients in Florida (OR=0.51, P<0.05), Louisiana (OR=0.57, P<0.05), Michigan (OR=0.60, P<0.05), and South Carolina (OR=0.62, P<0.05) had lower odds of receiving at least 300 days of antibiotics than patients in Illinois (OR=1.00) or Texas (OR=1.01).
The researchers did not investigate why children were not receiving recommended antibiotics, but Dr Reeves identified possible barriers to compliance. She noted that caregiver challenges include picking up prescriptions every 2 weeks from a pharmacy as well as remembering to administer an antibiotic to a young, healthy-appearing child twice a day.
“The types of challenges involved in making sure children get the recommended dose of antibiotics is exacerbated by the substantial burden of care already experienced by families to help control the symptoms of this disease,” Dr Reeves said.
She added that future studies should more deeply explore barriers preventing families from getting antibiotics and potential interventions to improve the rate of children receiving recommended prescriptions.
“Interventions to improve the receipt of antibiotics among children with sickle cell anemia should include enhanced collaboration between healthcare providers, pharmacists, and families,” Dr Reeves said.
“Doctors need to repeatedly discuss the importance of taking antibiotics with families of children with sickle cell anemia. Social factors that may impact receiving filled prescriptions should also be considered, such as the availability of transportation and time to travel to pharmacies to pick up the prescriptions.”