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VA shares its best practices to achieve HCV ‘cascade of cure’
The U.S. Department of Veterans Affairs (VA) cares for more patients with hepatitis C virus than any other care provider in the country, and has achieved a rapid and sharp reduction in hepatitis C virus (HCV) infection among veterans over the past 3 years.
The VA has treated more than 92,000 HCV-infected individuals since the advent of oral direct-acting antiviral (DAA) therapy in 2014. The number of veterans with HCV who were eligible for treatment was 168,000 in 2014 and 51,000 in July 2017, according to an article in Annals of Internal Medicine (2017 Sep 26. doi: 10.7326/M17-1073).
Given that success in HCV treatment, with a cure rate that exceeds 90% for those prescribed DAAs, the VA is well positioned to share best practices with other organizations, according to Pamela S. Belperio, PharmD, and her coauthors. The best practices harmonize with the recently outlined national strategy to eliminate hepatitis B and C from the National Academies of Sciences, Engineering, and Medicine.
“The leveraging of health systems data transforms numbers into knowledge” that is used both by individual providers and the VA as a whole, wrote Dr. Belperio, national public health pharmacist in the VA’s public health division, and her coauthors.
Identifying veterans who were infected with HCV is simplified by means of electronic point-of-care reminders that prompt providers to conduct HCV risk assessment and testing. Veterans eligible for testing also receive automated letters that serve as a laboratory order form for HCV testing at a VA laboratory.
Adding HCV birth cohort screening as a performance measure and recommending reflex confirmatory HCV RNA testing for positive antibody tests were additional initiatives that contributed to the 3%-4% annual increase in veterans receiving HCV testing, “substantially higher than in other health care systems,” wrote Dr. Belperio and her colleagues.
To respect regional variations in practice within the VA system, multidisciplinary innovation teams meet in each region to identify opportunities for improving and streamlining HCV testing and treatment, using lean process improvement techniques. Regions also share innovations with each other.
The VA used a multipronged approach to raise awareness about HCV testing and treatment among VA health care providers and veterans. Provider reach has been expanded by extensive use of telemedicine, including real-time video calls between providers and patients or other providers at remote locations. Those telemedicine initiatives allow pharmacists and mental health providers to lend their expertise to physicians and other providers, who are themselves directly caring for HCV-infected individuals.
Patients at more than half of VA facilities receive care from physician assistants, nurse practitioners, and clinical pharmacy specialists, “who have been recognized as delivering the same quality of care and providing more timely access to HCV treatment,” wrote Dr. Belperio and her collaborators. Expanding the use of advanced practice providers allows more targeted use of specialists, and “is an important practice that can be adapted into other health care systems,” they noted.
Non–evidence-based criteria for HCV treatment eligibility remain a major barrier for HCV-infected individuals nationwide, despite VA studies showing “cure rates among veterans with alcohol, substance use, and mental health disorders that are similar to cure rates in those without these conditions,” said Dr. Belperio and her colleagues.
Within the VA, involving alcohol and substance use specialists, mental health providers, case managers, and social workers in the patient’s care team is an approach that can increase adherence and up the chance for a cure among the most vulnerable veterans.
The VA has been able to negotiate reduced pricing for the expensive DAAs, and has continued to receive additional appropriations to fund DAAs and other HCV-related resources. “Financing for HCV treatment and infrastructure resources, coupled with reduced drug prices, has been paramount to the VA’s success in curing HCV infection,” said Dr. Belperio and her colleagues.
However, they added, individual private insurers may not reap the benefits of achieving sweeping HCV cures within their particular patient panel, because patients frequently switch insurers. Still, “consistent leveraging of drug prices and removal of restrictions to HCV treatment among all insurers would help assuage this gap,” they wrote.
Dr. Belperio described the VA’s vision of a “hepatitis C cascade of cure” that occurs when individuals with chronic HCV are identified, linked to care, treated with DAAs, and achieve sustained viral response. The comprehensive strategies employed by the VA have meant that, from 2014 to 2016, the percentage of HCV-infected individuals who have been linked to care and treatment increased from 27% to 59%. Of those treated, SVR rates have risen from 51% to 84% during the same period, said Dr. Belperio and her coauthors.
It will not be easy to extend that success into the nongovernment sector, the article’s authors acknowledged. Still, “the VA recognizes the resources necessary to realize this goal and the innovations that could make it possible, and is poised to extend best practices to other health care organizations and providers delivering HCV care.”
None of the study authors reported conflicts of interest.
[email protected]
On Twitter @karioakes
The U.S. Department of Veterans Affairs (VA) cares for more patients with hepatitis C virus than any other care provider in the country, and has achieved a rapid and sharp reduction in hepatitis C virus (HCV) infection among veterans over the past 3 years.
The VA has treated more than 92,000 HCV-infected individuals since the advent of oral direct-acting antiviral (DAA) therapy in 2014. The number of veterans with HCV who were eligible for treatment was 168,000 in 2014 and 51,000 in July 2017, according to an article in Annals of Internal Medicine (2017 Sep 26. doi: 10.7326/M17-1073).
Given that success in HCV treatment, with a cure rate that exceeds 90% for those prescribed DAAs, the VA is well positioned to share best practices with other organizations, according to Pamela S. Belperio, PharmD, and her coauthors. The best practices harmonize with the recently outlined national strategy to eliminate hepatitis B and C from the National Academies of Sciences, Engineering, and Medicine.
“The leveraging of health systems data transforms numbers into knowledge” that is used both by individual providers and the VA as a whole, wrote Dr. Belperio, national public health pharmacist in the VA’s public health division, and her coauthors.
Identifying veterans who were infected with HCV is simplified by means of electronic point-of-care reminders that prompt providers to conduct HCV risk assessment and testing. Veterans eligible for testing also receive automated letters that serve as a laboratory order form for HCV testing at a VA laboratory.
Adding HCV birth cohort screening as a performance measure and recommending reflex confirmatory HCV RNA testing for positive antibody tests were additional initiatives that contributed to the 3%-4% annual increase in veterans receiving HCV testing, “substantially higher than in other health care systems,” wrote Dr. Belperio and her colleagues.
To respect regional variations in practice within the VA system, multidisciplinary innovation teams meet in each region to identify opportunities for improving and streamlining HCV testing and treatment, using lean process improvement techniques. Regions also share innovations with each other.
The VA used a multipronged approach to raise awareness about HCV testing and treatment among VA health care providers and veterans. Provider reach has been expanded by extensive use of telemedicine, including real-time video calls between providers and patients or other providers at remote locations. Those telemedicine initiatives allow pharmacists and mental health providers to lend their expertise to physicians and other providers, who are themselves directly caring for HCV-infected individuals.
Patients at more than half of VA facilities receive care from physician assistants, nurse practitioners, and clinical pharmacy specialists, “who have been recognized as delivering the same quality of care and providing more timely access to HCV treatment,” wrote Dr. Belperio and her collaborators. Expanding the use of advanced practice providers allows more targeted use of specialists, and “is an important practice that can be adapted into other health care systems,” they noted.
Non–evidence-based criteria for HCV treatment eligibility remain a major barrier for HCV-infected individuals nationwide, despite VA studies showing “cure rates among veterans with alcohol, substance use, and mental health disorders that are similar to cure rates in those without these conditions,” said Dr. Belperio and her colleagues.
Within the VA, involving alcohol and substance use specialists, mental health providers, case managers, and social workers in the patient’s care team is an approach that can increase adherence and up the chance for a cure among the most vulnerable veterans.
The VA has been able to negotiate reduced pricing for the expensive DAAs, and has continued to receive additional appropriations to fund DAAs and other HCV-related resources. “Financing for HCV treatment and infrastructure resources, coupled with reduced drug prices, has been paramount to the VA’s success in curing HCV infection,” said Dr. Belperio and her colleagues.
However, they added, individual private insurers may not reap the benefits of achieving sweeping HCV cures within their particular patient panel, because patients frequently switch insurers. Still, “consistent leveraging of drug prices and removal of restrictions to HCV treatment among all insurers would help assuage this gap,” they wrote.
Dr. Belperio described the VA’s vision of a “hepatitis C cascade of cure” that occurs when individuals with chronic HCV are identified, linked to care, treated with DAAs, and achieve sustained viral response. The comprehensive strategies employed by the VA have meant that, from 2014 to 2016, the percentage of HCV-infected individuals who have been linked to care and treatment increased from 27% to 59%. Of those treated, SVR rates have risen from 51% to 84% during the same period, said Dr. Belperio and her coauthors.
It will not be easy to extend that success into the nongovernment sector, the article’s authors acknowledged. Still, “the VA recognizes the resources necessary to realize this goal and the innovations that could make it possible, and is poised to extend best practices to other health care organizations and providers delivering HCV care.”
None of the study authors reported conflicts of interest.
[email protected]
On Twitter @karioakes
The U.S. Department of Veterans Affairs (VA) cares for more patients with hepatitis C virus than any other care provider in the country, and has achieved a rapid and sharp reduction in hepatitis C virus (HCV) infection among veterans over the past 3 years.
The VA has treated more than 92,000 HCV-infected individuals since the advent of oral direct-acting antiviral (DAA) therapy in 2014. The number of veterans with HCV who were eligible for treatment was 168,000 in 2014 and 51,000 in July 2017, according to an article in Annals of Internal Medicine (2017 Sep 26. doi: 10.7326/M17-1073).
Given that success in HCV treatment, with a cure rate that exceeds 90% for those prescribed DAAs, the VA is well positioned to share best practices with other organizations, according to Pamela S. Belperio, PharmD, and her coauthors. The best practices harmonize with the recently outlined national strategy to eliminate hepatitis B and C from the National Academies of Sciences, Engineering, and Medicine.
“The leveraging of health systems data transforms numbers into knowledge” that is used both by individual providers and the VA as a whole, wrote Dr. Belperio, national public health pharmacist in the VA’s public health division, and her coauthors.
Identifying veterans who were infected with HCV is simplified by means of electronic point-of-care reminders that prompt providers to conduct HCV risk assessment and testing. Veterans eligible for testing also receive automated letters that serve as a laboratory order form for HCV testing at a VA laboratory.
Adding HCV birth cohort screening as a performance measure and recommending reflex confirmatory HCV RNA testing for positive antibody tests were additional initiatives that contributed to the 3%-4% annual increase in veterans receiving HCV testing, “substantially higher than in other health care systems,” wrote Dr. Belperio and her colleagues.
To respect regional variations in practice within the VA system, multidisciplinary innovation teams meet in each region to identify opportunities for improving and streamlining HCV testing and treatment, using lean process improvement techniques. Regions also share innovations with each other.
The VA used a multipronged approach to raise awareness about HCV testing and treatment among VA health care providers and veterans. Provider reach has been expanded by extensive use of telemedicine, including real-time video calls between providers and patients or other providers at remote locations. Those telemedicine initiatives allow pharmacists and mental health providers to lend their expertise to physicians and other providers, who are themselves directly caring for HCV-infected individuals.
Patients at more than half of VA facilities receive care from physician assistants, nurse practitioners, and clinical pharmacy specialists, “who have been recognized as delivering the same quality of care and providing more timely access to HCV treatment,” wrote Dr. Belperio and her collaborators. Expanding the use of advanced practice providers allows more targeted use of specialists, and “is an important practice that can be adapted into other health care systems,” they noted.
Non–evidence-based criteria for HCV treatment eligibility remain a major barrier for HCV-infected individuals nationwide, despite VA studies showing “cure rates among veterans with alcohol, substance use, and mental health disorders that are similar to cure rates in those without these conditions,” said Dr. Belperio and her colleagues.
Within the VA, involving alcohol and substance use specialists, mental health providers, case managers, and social workers in the patient’s care team is an approach that can increase adherence and up the chance for a cure among the most vulnerable veterans.
The VA has been able to negotiate reduced pricing for the expensive DAAs, and has continued to receive additional appropriations to fund DAAs and other HCV-related resources. “Financing for HCV treatment and infrastructure resources, coupled with reduced drug prices, has been paramount to the VA’s success in curing HCV infection,” said Dr. Belperio and her colleagues.
However, they added, individual private insurers may not reap the benefits of achieving sweeping HCV cures within their particular patient panel, because patients frequently switch insurers. Still, “consistent leveraging of drug prices and removal of restrictions to HCV treatment among all insurers would help assuage this gap,” they wrote.
Dr. Belperio described the VA’s vision of a “hepatitis C cascade of cure” that occurs when individuals with chronic HCV are identified, linked to care, treated with DAAs, and achieve sustained viral response. The comprehensive strategies employed by the VA have meant that, from 2014 to 2016, the percentage of HCV-infected individuals who have been linked to care and treatment increased from 27% to 59%. Of those treated, SVR rates have risen from 51% to 84% during the same period, said Dr. Belperio and her coauthors.
It will not be easy to extend that success into the nongovernment sector, the article’s authors acknowledged. Still, “the VA recognizes the resources necessary to realize this goal and the innovations that could make it possible, and is poised to extend best practices to other health care organizations and providers delivering HCV care.”
None of the study authors reported conflicts of interest.
[email protected]
On Twitter @karioakes
FROM ANNALS OF INTERNAL MEDICINE
Higher BP targets suggested for elderly, cognitively impaired
SAN FRANCISCO – Lowering blood pressure below 140/90 mm Hg might not be a good idea in the very elderly, especially if they have cognitive impairment, according to Philip Gorelick, MD.
“Lower blood pressure” in those patients “may be associated with worse cognitive outcomes,” he said at the joint scientific sessions of AHA Council on Hypertension, AHA Council on Kidney in Cardiovascular Disease, and American Society of Hypertension.
The problem is that higher pressures may be needed to maintain cerebral perfusion. It’s possible the very elderly have impaired cerebral autoregulation, especially if there’s a history of hypertension. A little extra pressure is needed to overcome increased cerebral vascular resistance.
“Cautious blood pressure–lowering with a target of about 150 mm Hg systolic, may be prudent,” said Dr. Gorelick, professor of translational science and molecular medicine at Michigan State University in Grand Rapids. Meanwhile, “for those without cognitive impairment and who have intact cerebral autoregulation, lower blood pressure targets may be beneficial to preserve cognition.
It’s become clear in recent years that cognitive decline is not a strictly neurologic issue, but rather related to cardiovascular health, at least in some people. Good blood pressure control in midlife, in particular, seems to be important for prevention.
“The same risk factors for atherosclerotic disease [are] risks for Alzheimer’s disease. Vascular risks play a role in cognitive impairment, including Alzheimer’s,” he said.
But the evidence is not clear for blood pressure lowering after the age of 80. Several studies have suggested that angiotensin receptor blockers and other hypertension medications reduce pathologic and clinical changes associated with Alzheimer’s. “However, there’s certainly a downside” to using them in the elderly. “Everything that glistens is not gold,” Dr. Gorelick said.
“There have been studies in older persons with mild cognitive deficits who are placed on antihypertensives, and they actually have lower brain volumes: The brain is shrinking, possibly at a faster rate. Other studies have suggested that people around 80 years of age may have greater cognitive decline with lower blood pressure,” he said.
For those older than 80 and patients with cognitive impairment, the usefulness of blood pressure–lowering for prevention of dementia has not been established. Relaxing the blood pressure control targets might prevent harm, he said.
“There’s going to be a window of opportunity where were are going to see some benefit” in using, for instance, ARBs to slow cognitive decline, but “we have to be smart enough to find the right patients and the right window. We’re not there yet,” he said.
Dr. Gorelick is a consultant for Bayer, Novartis, and Amgen.
SAN FRANCISCO – Lowering blood pressure below 140/90 mm Hg might not be a good idea in the very elderly, especially if they have cognitive impairment, according to Philip Gorelick, MD.
“Lower blood pressure” in those patients “may be associated with worse cognitive outcomes,” he said at the joint scientific sessions of AHA Council on Hypertension, AHA Council on Kidney in Cardiovascular Disease, and American Society of Hypertension.
The problem is that higher pressures may be needed to maintain cerebral perfusion. It’s possible the very elderly have impaired cerebral autoregulation, especially if there’s a history of hypertension. A little extra pressure is needed to overcome increased cerebral vascular resistance.
“Cautious blood pressure–lowering with a target of about 150 mm Hg systolic, may be prudent,” said Dr. Gorelick, professor of translational science and molecular medicine at Michigan State University in Grand Rapids. Meanwhile, “for those without cognitive impairment and who have intact cerebral autoregulation, lower blood pressure targets may be beneficial to preserve cognition.
It’s become clear in recent years that cognitive decline is not a strictly neurologic issue, but rather related to cardiovascular health, at least in some people. Good blood pressure control in midlife, in particular, seems to be important for prevention.
“The same risk factors for atherosclerotic disease [are] risks for Alzheimer’s disease. Vascular risks play a role in cognitive impairment, including Alzheimer’s,” he said.
But the evidence is not clear for blood pressure lowering after the age of 80. Several studies have suggested that angiotensin receptor blockers and other hypertension medications reduce pathologic and clinical changes associated with Alzheimer’s. “However, there’s certainly a downside” to using them in the elderly. “Everything that glistens is not gold,” Dr. Gorelick said.
“There have been studies in older persons with mild cognitive deficits who are placed on antihypertensives, and they actually have lower brain volumes: The brain is shrinking, possibly at a faster rate. Other studies have suggested that people around 80 years of age may have greater cognitive decline with lower blood pressure,” he said.
For those older than 80 and patients with cognitive impairment, the usefulness of blood pressure–lowering for prevention of dementia has not been established. Relaxing the blood pressure control targets might prevent harm, he said.
“There’s going to be a window of opportunity where were are going to see some benefit” in using, for instance, ARBs to slow cognitive decline, but “we have to be smart enough to find the right patients and the right window. We’re not there yet,” he said.
Dr. Gorelick is a consultant for Bayer, Novartis, and Amgen.
SAN FRANCISCO – Lowering blood pressure below 140/90 mm Hg might not be a good idea in the very elderly, especially if they have cognitive impairment, according to Philip Gorelick, MD.
“Lower blood pressure” in those patients “may be associated with worse cognitive outcomes,” he said at the joint scientific sessions of AHA Council on Hypertension, AHA Council on Kidney in Cardiovascular Disease, and American Society of Hypertension.
The problem is that higher pressures may be needed to maintain cerebral perfusion. It’s possible the very elderly have impaired cerebral autoregulation, especially if there’s a history of hypertension. A little extra pressure is needed to overcome increased cerebral vascular resistance.
“Cautious blood pressure–lowering with a target of about 150 mm Hg systolic, may be prudent,” said Dr. Gorelick, professor of translational science and molecular medicine at Michigan State University in Grand Rapids. Meanwhile, “for those without cognitive impairment and who have intact cerebral autoregulation, lower blood pressure targets may be beneficial to preserve cognition.
It’s become clear in recent years that cognitive decline is not a strictly neurologic issue, but rather related to cardiovascular health, at least in some people. Good blood pressure control in midlife, in particular, seems to be important for prevention.
“The same risk factors for atherosclerotic disease [are] risks for Alzheimer’s disease. Vascular risks play a role in cognitive impairment, including Alzheimer’s,” he said.
But the evidence is not clear for blood pressure lowering after the age of 80. Several studies have suggested that angiotensin receptor blockers and other hypertension medications reduce pathologic and clinical changes associated with Alzheimer’s. “However, there’s certainly a downside” to using them in the elderly. “Everything that glistens is not gold,” Dr. Gorelick said.
“There have been studies in older persons with mild cognitive deficits who are placed on antihypertensives, and they actually have lower brain volumes: The brain is shrinking, possibly at a faster rate. Other studies have suggested that people around 80 years of age may have greater cognitive decline with lower blood pressure,” he said.
For those older than 80 and patients with cognitive impairment, the usefulness of blood pressure–lowering for prevention of dementia has not been established. Relaxing the blood pressure control targets might prevent harm, he said.
“There’s going to be a window of opportunity where were are going to see some benefit” in using, for instance, ARBs to slow cognitive decline, but “we have to be smart enough to find the right patients and the right window. We’re not there yet,” he said.
Dr. Gorelick is a consultant for Bayer, Novartis, and Amgen.
EXPERT ANALYSIS FROM Joint Hypertension 2017
Are Bladder Dysfunction and Falls Related in MS?
Urinary urgency with incontinence is associated with recurrent falls in people with relapsing-remitting multiple sclerosis (MS) with mild to moderate disability, according to data published in the July–August issue of International Journal of MS Care. Urinary urgency with incontinence often responds to physical, behavioral, and pharmaceutical interventions, and neurologists should ask patients with MS about bladder symptoms and fall history, according to the authors.
Bladder dysfunction and falls are highly prevalent among people with MS, and bladder dysfunction is associated with falls in older adults. Studies of the association between bladder dysfunction and falls in people with MS, however, are limited and have produced mixed results. Jaime E. Zelaya, PhD, a doctoral student at Oregon Health and Science University in Portland, and colleagues conducted a longitudinal observational cohort study to clarify the possible association between baseline urinary symptoms and future falls.
Participants Prospectively Recorded Falls
The investigators recruited participants from outpatient MS clinics in the Veterans Affairs Portland Health Care System, Oregon Health and Science University MS clinics, and the surrounding community. Eligible participants had a diagnosis of relapsing-remitting MS, mild to moderate MS-related disability, and no relapse within 30 days of baseline. Patients with another condition that affected their balance or gait were excluded from the study.
At baseline, Dr. Zelaya and colleagues asked participants whether they had urinary incontinence, urinary frequency, or urinary urgency. Participants then prospectively recorded their number of falls each day using fall calendars. They were asked to return their calendars to the investigators at the end of each month. The researchers defined four patient categories based on the number of falls during three months. Recurrent fallers fell two or more times, nonrecurrent fallers fell once or not at all, fallers had one fall or more, and nonfallers did not fall. The investigators analyzed the data using age, sex, and disability as potential confounders.
Most Patients Fell at Least Once
The final analysis included 51 participants (37 women). Mean age was 40, and median Expanded Disability Status Scale (EDSS) score was 3.0. In all, 15 participants (29%) were recurrent fallers, and 36 (71%) were nonrecurrent fallers. Furthermore, 32 (63%) participants were fallers, and 19 (37%) were nonfallers.
Urinary dysfunction was more prevalent in fallers and recurrent fallers than in nonrecurrent fallers or nonfallers. In the adjusted analyses, urinary urgency with incontinence was significantly associated with recurrent falls (odds ratio [OR], 57.57). The researchers did not find a significant association between urinary urgency without incontinence and recurrent falls, or between urinary frequency and recurrent falls. They also did not find significant associations between urinary urgency with incontinence, urinary urgency without incontinence, or urinary frequency and sustaining one or more falls.
The high prevalence of falls and bladder dysfunction in this population and previous studies “suggests that both falls and bladder dysfunction are common, early, and persistent symptoms in MS,” said the authors. The findings suggest that fall-prevention programs “should particularly be considered for reducing fall risk in recurrent fallers, and that such programs should include strategies for managing urinary urgency with incontinence,” they concluded.
—Erik Greb
Suggested Reading
Zelaya JE, Murchison C, Cameron M. Associations between bladder dysfunction and falls in people with relapsing-remitting multiple sclerosis. Int J MS Care. 2017;19(4):184-190.
Urinary urgency with incontinence is associated with recurrent falls in people with relapsing-remitting multiple sclerosis (MS) with mild to moderate disability, according to data published in the July–August issue of International Journal of MS Care. Urinary urgency with incontinence often responds to physical, behavioral, and pharmaceutical interventions, and neurologists should ask patients with MS about bladder symptoms and fall history, according to the authors.
Bladder dysfunction and falls are highly prevalent among people with MS, and bladder dysfunction is associated with falls in older adults. Studies of the association between bladder dysfunction and falls in people with MS, however, are limited and have produced mixed results. Jaime E. Zelaya, PhD, a doctoral student at Oregon Health and Science University in Portland, and colleagues conducted a longitudinal observational cohort study to clarify the possible association between baseline urinary symptoms and future falls.
Participants Prospectively Recorded Falls
The investigators recruited participants from outpatient MS clinics in the Veterans Affairs Portland Health Care System, Oregon Health and Science University MS clinics, and the surrounding community. Eligible participants had a diagnosis of relapsing-remitting MS, mild to moderate MS-related disability, and no relapse within 30 days of baseline. Patients with another condition that affected their balance or gait were excluded from the study.
At baseline, Dr. Zelaya and colleagues asked participants whether they had urinary incontinence, urinary frequency, or urinary urgency. Participants then prospectively recorded their number of falls each day using fall calendars. They were asked to return their calendars to the investigators at the end of each month. The researchers defined four patient categories based on the number of falls during three months. Recurrent fallers fell two or more times, nonrecurrent fallers fell once or not at all, fallers had one fall or more, and nonfallers did not fall. The investigators analyzed the data using age, sex, and disability as potential confounders.
Most Patients Fell at Least Once
The final analysis included 51 participants (37 women). Mean age was 40, and median Expanded Disability Status Scale (EDSS) score was 3.0. In all, 15 participants (29%) were recurrent fallers, and 36 (71%) were nonrecurrent fallers. Furthermore, 32 (63%) participants were fallers, and 19 (37%) were nonfallers.
Urinary dysfunction was more prevalent in fallers and recurrent fallers than in nonrecurrent fallers or nonfallers. In the adjusted analyses, urinary urgency with incontinence was significantly associated with recurrent falls (odds ratio [OR], 57.57). The researchers did not find a significant association between urinary urgency without incontinence and recurrent falls, or between urinary frequency and recurrent falls. They also did not find significant associations between urinary urgency with incontinence, urinary urgency without incontinence, or urinary frequency and sustaining one or more falls.
The high prevalence of falls and bladder dysfunction in this population and previous studies “suggests that both falls and bladder dysfunction are common, early, and persistent symptoms in MS,” said the authors. The findings suggest that fall-prevention programs “should particularly be considered for reducing fall risk in recurrent fallers, and that such programs should include strategies for managing urinary urgency with incontinence,” they concluded.
—Erik Greb
Suggested Reading
Zelaya JE, Murchison C, Cameron M. Associations between bladder dysfunction and falls in people with relapsing-remitting multiple sclerosis. Int J MS Care. 2017;19(4):184-190.
Urinary urgency with incontinence is associated with recurrent falls in people with relapsing-remitting multiple sclerosis (MS) with mild to moderate disability, according to data published in the July–August issue of International Journal of MS Care. Urinary urgency with incontinence often responds to physical, behavioral, and pharmaceutical interventions, and neurologists should ask patients with MS about bladder symptoms and fall history, according to the authors.
Bladder dysfunction and falls are highly prevalent among people with MS, and bladder dysfunction is associated with falls in older adults. Studies of the association between bladder dysfunction and falls in people with MS, however, are limited and have produced mixed results. Jaime E. Zelaya, PhD, a doctoral student at Oregon Health and Science University in Portland, and colleagues conducted a longitudinal observational cohort study to clarify the possible association between baseline urinary symptoms and future falls.
Participants Prospectively Recorded Falls
The investigators recruited participants from outpatient MS clinics in the Veterans Affairs Portland Health Care System, Oregon Health and Science University MS clinics, and the surrounding community. Eligible participants had a diagnosis of relapsing-remitting MS, mild to moderate MS-related disability, and no relapse within 30 days of baseline. Patients with another condition that affected their balance or gait were excluded from the study.
At baseline, Dr. Zelaya and colleagues asked participants whether they had urinary incontinence, urinary frequency, or urinary urgency. Participants then prospectively recorded their number of falls each day using fall calendars. They were asked to return their calendars to the investigators at the end of each month. The researchers defined four patient categories based on the number of falls during three months. Recurrent fallers fell two or more times, nonrecurrent fallers fell once or not at all, fallers had one fall or more, and nonfallers did not fall. The investigators analyzed the data using age, sex, and disability as potential confounders.
Most Patients Fell at Least Once
The final analysis included 51 participants (37 women). Mean age was 40, and median Expanded Disability Status Scale (EDSS) score was 3.0. In all, 15 participants (29%) were recurrent fallers, and 36 (71%) were nonrecurrent fallers. Furthermore, 32 (63%) participants were fallers, and 19 (37%) were nonfallers.
Urinary dysfunction was more prevalent in fallers and recurrent fallers than in nonrecurrent fallers or nonfallers. In the adjusted analyses, urinary urgency with incontinence was significantly associated with recurrent falls (odds ratio [OR], 57.57). The researchers did not find a significant association between urinary urgency without incontinence and recurrent falls, or between urinary frequency and recurrent falls. They also did not find significant associations between urinary urgency with incontinence, urinary urgency without incontinence, or urinary frequency and sustaining one or more falls.
The high prevalence of falls and bladder dysfunction in this population and previous studies “suggests that both falls and bladder dysfunction are common, early, and persistent symptoms in MS,” said the authors. The findings suggest that fall-prevention programs “should particularly be considered for reducing fall risk in recurrent fallers, and that such programs should include strategies for managing urinary urgency with incontinence,” they concluded.
—Erik Greb
Suggested Reading
Zelaya JE, Murchison C, Cameron M. Associations between bladder dysfunction and falls in people with relapsing-remitting multiple sclerosis. Int J MS Care. 2017;19(4):184-190.
Endometrial Evaluation: Are You Still Relying on a Blind Biopsy?
One-third of patients who visit a gynecologist are there because of abnormal uterine bleeding (AUB), which is believed to account for more than 70% of gyneco¬logic consults in perimenopausal and postmenopausal women. The American College of Obstetricians and Gynecologists Practice Bulle¬tin on AUB now states that a negative blind endometrial biopsy is not a stopping point in persistent bleeding.
In this supplement, learn about the advantages of diagnosing AUB using a hysteroscope.
- Authors:
- Steven R. Goldstein, MD, CCD, NCMP, FACOG
- New York University Medical Center New York, New York
- Ted L. Anderson, MD, PhD
- Vanderbilt University Medical School Nashville, Tennessee
- Click here to read this supplement.
To access the posttest and evaluation, visit
www.worldclasscme.com/endometrialevaluation
One-third of patients who visit a gynecologist are there because of abnormal uterine bleeding (AUB), which is believed to account for more than 70% of gyneco¬logic consults in perimenopausal and postmenopausal women. The American College of Obstetricians and Gynecologists Practice Bulle¬tin on AUB now states that a negative blind endometrial biopsy is not a stopping point in persistent bleeding.
In this supplement, learn about the advantages of diagnosing AUB using a hysteroscope.
- Authors:
- Steven R. Goldstein, MD, CCD, NCMP, FACOG
- New York University Medical Center New York, New York
- Ted L. Anderson, MD, PhD
- Vanderbilt University Medical School Nashville, Tennessee
- Click here to read this supplement.
To access the posttest and evaluation, visit
www.worldclasscme.com/endometrialevaluation
One-third of patients who visit a gynecologist are there because of abnormal uterine bleeding (AUB), which is believed to account for more than 70% of gyneco¬logic consults in perimenopausal and postmenopausal women. The American College of Obstetricians and Gynecologists Practice Bulle¬tin on AUB now states that a negative blind endometrial biopsy is not a stopping point in persistent bleeding.
In this supplement, learn about the advantages of diagnosing AUB using a hysteroscope.
- Authors:
- Steven R. Goldstein, MD, CCD, NCMP, FACOG
- New York University Medical Center New York, New York
- Ted L. Anderson, MD, PhD
- Vanderbilt University Medical School Nashville, Tennessee
- Click here to read this supplement.
To access the posttest and evaluation, visit
www.worldclasscme.com/endometrialevaluation
Study shows childhood IBD increased cancer risk in adulthood
Children who had developed inflammatory bowel disease had an 18-fold greater risk of gastrointestinal cancers in later life, a new study suggests.
The cohort study found that the risk of all cancers was elevated in individuals with childhood-onset inflammatory bowel disease, but particularly in those with primary sclerosing cholangitis and ulcerative colitis.
Researchers followed 9,405 patients with childhood-onset inflammatory bowel disease to a mean age of 27 years using a Swedish national patient register (BMJ. 2017 Sep 21. doi: 10.1136/bmj.j3951).
Analysis revealed that individuals with childhood-onset inflammatory bowel disease had double the risk of any cancer, compared with the general population (hazard ratio, 2.2; 95% confidence interval, 2.0-2.5), and a 2.7-fold greater risk of developing cancer before the age of 18 years.
Primary sclerosing cholangitis was associated with a sixfold greater risk of cancer, ulcerative colitis was associated with a 2.6-fold greater risk, and patients who had had colitis for 10 years or more had a nearly fourfold greater risk of cancer (HR, 3.9).
The study also found that childhood-onset inflammatory bowel disease was associated with an 18-fold greater risk of gastrointestinal cancer, compared with the general population, matched for age, sex, birth year, and county.
The risk was particularly high in patients with ulcerative colitis, who showed a 33-fold higher risk of colorectal cancer, while patients with Crohn’s disease had a nearly 6-fold higher risk.
“Colorectal cancer is a major cause of cancer mortality in the population, and even a moderately increased incidence is likely to have a large effect on patients with inflammatory bowel disease,” wrote Ola Olén, MD, of Karolinska Institutet, Stockholm, and coauthors.
When the researchers looked in more detail at the type of cancers, they saw the greatest increases in risk were for colorectal cancer (HR, 19.5) and small intestinal cancer (HR, 12.8), while the risk of liver cancer was 134 times higher (95% CI, 59.6-382).
The researchers also saw a 2.7-fold increased risk of lymphoid neoplasms associated with childhood inflammatory bowel disease, particularly in individuals with ulcerative colitis or Crohn’s disease. The most common lymphoid neoplasms were non-Hodgkin lymphomas, followed by Hodgkin lymphomas.
Commenting on possible explanations for the associations seen in the study, the authors said that patients with inflammatory bowel disease may have their gastrointestinal cancers diagnosed earlier than the general population because of regular endoscopies.
They also said that thiopurines and TNF inhibitors – both used to treat inflammatory bowel disease – could not be ruled out as a possible cause of the increase in cancer risk, but their study was not powered to pick up such an effect.
“Instead, we suggest that extent and duration of chronic inflammation might be the main driving mechanisms underlying the increased risk of cancer,” they wrote.
The authors noted that their study did not include data on the smoking status of individuals, which could be significant, because smoking is known to reduce the risk of ulcerative colitis and increase the risk of Crohn’s disease and cancer. However, they pointed out that the majority of patients would not have been smoking at the time of their initial inflammatory bowel disease diagnosis, and would have been unlikely to take up the habit after their diagnosis.
With the observation that the risk of cancer in inflammatory bowel disease was higher in patients who were younger when diagnosed with the disease, the authors suggested that age of onset be considered when designing surveillance strategies for cancer in this group.
The Stockholm County Council and the Karolinska Institutet, the Swedish Cancer Society, the Swedish Research Council, and the Swedish Foundation for Strategic Research supported the study. One author received grants from the Swedish Medical Society, Magtarmfonden, the Jane and Dan Olsson Foundation, the Mjölkdroppen Foundation, the Bengt Ihre Research Fellowship in gastroenterology, and the Karolinska Institutet Foundations. No conflicts of interest were declared.
Children who had developed inflammatory bowel disease had an 18-fold greater risk of gastrointestinal cancers in later life, a new study suggests.
The cohort study found that the risk of all cancers was elevated in individuals with childhood-onset inflammatory bowel disease, but particularly in those with primary sclerosing cholangitis and ulcerative colitis.
Researchers followed 9,405 patients with childhood-onset inflammatory bowel disease to a mean age of 27 years using a Swedish national patient register (BMJ. 2017 Sep 21. doi: 10.1136/bmj.j3951).
Analysis revealed that individuals with childhood-onset inflammatory bowel disease had double the risk of any cancer, compared with the general population (hazard ratio, 2.2; 95% confidence interval, 2.0-2.5), and a 2.7-fold greater risk of developing cancer before the age of 18 years.
Primary sclerosing cholangitis was associated with a sixfold greater risk of cancer, ulcerative colitis was associated with a 2.6-fold greater risk, and patients who had had colitis for 10 years or more had a nearly fourfold greater risk of cancer (HR, 3.9).
The study also found that childhood-onset inflammatory bowel disease was associated with an 18-fold greater risk of gastrointestinal cancer, compared with the general population, matched for age, sex, birth year, and county.
The risk was particularly high in patients with ulcerative colitis, who showed a 33-fold higher risk of colorectal cancer, while patients with Crohn’s disease had a nearly 6-fold higher risk.
“Colorectal cancer is a major cause of cancer mortality in the population, and even a moderately increased incidence is likely to have a large effect on patients with inflammatory bowel disease,” wrote Ola Olén, MD, of Karolinska Institutet, Stockholm, and coauthors.
When the researchers looked in more detail at the type of cancers, they saw the greatest increases in risk were for colorectal cancer (HR, 19.5) and small intestinal cancer (HR, 12.8), while the risk of liver cancer was 134 times higher (95% CI, 59.6-382).
The researchers also saw a 2.7-fold increased risk of lymphoid neoplasms associated with childhood inflammatory bowel disease, particularly in individuals with ulcerative colitis or Crohn’s disease. The most common lymphoid neoplasms were non-Hodgkin lymphomas, followed by Hodgkin lymphomas.
Commenting on possible explanations for the associations seen in the study, the authors said that patients with inflammatory bowel disease may have their gastrointestinal cancers diagnosed earlier than the general population because of regular endoscopies.
They also said that thiopurines and TNF inhibitors – both used to treat inflammatory bowel disease – could not be ruled out as a possible cause of the increase in cancer risk, but their study was not powered to pick up such an effect.
“Instead, we suggest that extent and duration of chronic inflammation might be the main driving mechanisms underlying the increased risk of cancer,” they wrote.
The authors noted that their study did not include data on the smoking status of individuals, which could be significant, because smoking is known to reduce the risk of ulcerative colitis and increase the risk of Crohn’s disease and cancer. However, they pointed out that the majority of patients would not have been smoking at the time of their initial inflammatory bowel disease diagnosis, and would have been unlikely to take up the habit after their diagnosis.
With the observation that the risk of cancer in inflammatory bowel disease was higher in patients who were younger when diagnosed with the disease, the authors suggested that age of onset be considered when designing surveillance strategies for cancer in this group.
The Stockholm County Council and the Karolinska Institutet, the Swedish Cancer Society, the Swedish Research Council, and the Swedish Foundation for Strategic Research supported the study. One author received grants from the Swedish Medical Society, Magtarmfonden, the Jane and Dan Olsson Foundation, the Mjölkdroppen Foundation, the Bengt Ihre Research Fellowship in gastroenterology, and the Karolinska Institutet Foundations. No conflicts of interest were declared.
Children who had developed inflammatory bowel disease had an 18-fold greater risk of gastrointestinal cancers in later life, a new study suggests.
The cohort study found that the risk of all cancers was elevated in individuals with childhood-onset inflammatory bowel disease, but particularly in those with primary sclerosing cholangitis and ulcerative colitis.
Researchers followed 9,405 patients with childhood-onset inflammatory bowel disease to a mean age of 27 years using a Swedish national patient register (BMJ. 2017 Sep 21. doi: 10.1136/bmj.j3951).
Analysis revealed that individuals with childhood-onset inflammatory bowel disease had double the risk of any cancer, compared with the general population (hazard ratio, 2.2; 95% confidence interval, 2.0-2.5), and a 2.7-fold greater risk of developing cancer before the age of 18 years.
Primary sclerosing cholangitis was associated with a sixfold greater risk of cancer, ulcerative colitis was associated with a 2.6-fold greater risk, and patients who had had colitis for 10 years or more had a nearly fourfold greater risk of cancer (HR, 3.9).
The study also found that childhood-onset inflammatory bowel disease was associated with an 18-fold greater risk of gastrointestinal cancer, compared with the general population, matched for age, sex, birth year, and county.
The risk was particularly high in patients with ulcerative colitis, who showed a 33-fold higher risk of colorectal cancer, while patients with Crohn’s disease had a nearly 6-fold higher risk.
“Colorectal cancer is a major cause of cancer mortality in the population, and even a moderately increased incidence is likely to have a large effect on patients with inflammatory bowel disease,” wrote Ola Olén, MD, of Karolinska Institutet, Stockholm, and coauthors.
When the researchers looked in more detail at the type of cancers, they saw the greatest increases in risk were for colorectal cancer (HR, 19.5) and small intestinal cancer (HR, 12.8), while the risk of liver cancer was 134 times higher (95% CI, 59.6-382).
The researchers also saw a 2.7-fold increased risk of lymphoid neoplasms associated with childhood inflammatory bowel disease, particularly in individuals with ulcerative colitis or Crohn’s disease. The most common lymphoid neoplasms were non-Hodgkin lymphomas, followed by Hodgkin lymphomas.
Commenting on possible explanations for the associations seen in the study, the authors said that patients with inflammatory bowel disease may have their gastrointestinal cancers diagnosed earlier than the general population because of regular endoscopies.
They also said that thiopurines and TNF inhibitors – both used to treat inflammatory bowel disease – could not be ruled out as a possible cause of the increase in cancer risk, but their study was not powered to pick up such an effect.
“Instead, we suggest that extent and duration of chronic inflammation might be the main driving mechanisms underlying the increased risk of cancer,” they wrote.
The authors noted that their study did not include data on the smoking status of individuals, which could be significant, because smoking is known to reduce the risk of ulcerative colitis and increase the risk of Crohn’s disease and cancer. However, they pointed out that the majority of patients would not have been smoking at the time of their initial inflammatory bowel disease diagnosis, and would have been unlikely to take up the habit after their diagnosis.
With the observation that the risk of cancer in inflammatory bowel disease was higher in patients who were younger when diagnosed with the disease, the authors suggested that age of onset be considered when designing surveillance strategies for cancer in this group.
The Stockholm County Council and the Karolinska Institutet, the Swedish Cancer Society, the Swedish Research Council, and the Swedish Foundation for Strategic Research supported the study. One author received grants from the Swedish Medical Society, Magtarmfonden, the Jane and Dan Olsson Foundation, the Mjölkdroppen Foundation, the Bengt Ihre Research Fellowship in gastroenterology, and the Karolinska Institutet Foundations. No conflicts of interest were declared.
FROM BMJ
Key clinical point: Childhood inflammatory bowel disease was associated with significant increases in the risk of cancer – particularly gastrointestinal cancer – in later life.
Major finding: Individuals diagnosed with inflammatory bowel disease in childhood have an 18-fold greater risk of gastrointestinal cancer, and a twofold higher risk of any cancer, compared with the general population.
Data source: A cohort study of 9,405 patients with childhood-onset inflammatory bowel disease.
Disclosures: The Stockholm County Council and the Karolinska Institutet, the Swedish Cancer Society, the Swedish Research Council, and the Swedish Foundation for Strategic Research supported the study. One author received grants from the Swedish Medical Society, Magtarmfonden, the Jane and Dan Olsson Foundation, the Mjölkdroppen Foundation, the Bengt Ihre Research Fellowship in gastroenterology, and the Karolinska Institutet Foundations. No conflicts of interest were declared.
Everything We Say And Do: The physician patient
Editor’s note: “Everything We Say and Do” provides readers with thoughtful and actionable communication tactics that can positively impact patients’ experience of care. In the next series of columns, physicians will share how their experiences as patients have shaped their professional approach.
In May 2007, I received my acceptance letter for medical school. One month later, I was diagnosed with cancer.
The clinic visit was only supposed to be a routine postoperative follow-up after a simple cyst resection. I really hoped that my doctor was mistaken as he walked me through what to expect, and when he was finished, the desperate look in my eyes demanded answers.
After I fully absorbed the initial shock of the grave news, I eventually found the strength to analyze the situation at hand. Ultimately, I adopted a more positive outlook and fought cancer head on. Contending with cancer while tackling the rigors of medical school was tedious, but despite the hardships, my experience catalyzed my determination and molded my personality as a physician.
What I say and do
I employ active listening and practice patience, especially when it comes to family members.
As both a cancer survivor and a physician, I am able to integrate empathy and diligence by putting myself in my patients’ shoes. My experience in a hospital bed during medical school granted me an extremely intriguing perspective towards medicine.
Why I do it
When I was a patient, the most crucial thing to my family was information. Most physicians did not take the time to explain my course of care, which elevated my family’s angst and anxiety. The experience taught me the importance of patience and communication.
But there were good examples. I still remember the physician who comforted my mother and assuaged her concerns. She held my mother’s hand and showed empathy. When my mother cried, she cried. That physician taught me that it was acceptable for physicians to express emotions.
When my surgeon rounded on me in the morning after my procedure, she was not wearing a white coat, which made her appear relatable. Her contagious confidence and humble demeanor were endorsement enough for her capabilities, showing me that a physician’s persona supersedes the conventional coat.
How I do it
I try to put myself in my patients’ shoes. I rejoice with them. I mourn with them. My uninhibited display of emotions affirms empathy. I dissolve all barriers by not wearing a white coat and ask my patients for a partnership. After all, I once walked miles in those shoes.
Dr. Sharma is a chief hospitalist for Sound Physicians at the Sierra Campus of The Hospitals of Providence, El Paso, Texas. She is a columnist for the El Paso Times and the medical contributor for KVIA Channel 7 ABC News. Her work has appeared on kevinmd.com, Thrive Global, and in El Paso magazine.
Editor’s note: “Everything We Say and Do” provides readers with thoughtful and actionable communication tactics that can positively impact patients’ experience of care. In the next series of columns, physicians will share how their experiences as patients have shaped their professional approach.
In May 2007, I received my acceptance letter for medical school. One month later, I was diagnosed with cancer.
The clinic visit was only supposed to be a routine postoperative follow-up after a simple cyst resection. I really hoped that my doctor was mistaken as he walked me through what to expect, and when he was finished, the desperate look in my eyes demanded answers.
After I fully absorbed the initial shock of the grave news, I eventually found the strength to analyze the situation at hand. Ultimately, I adopted a more positive outlook and fought cancer head on. Contending with cancer while tackling the rigors of medical school was tedious, but despite the hardships, my experience catalyzed my determination and molded my personality as a physician.
What I say and do
I employ active listening and practice patience, especially when it comes to family members.
As both a cancer survivor and a physician, I am able to integrate empathy and diligence by putting myself in my patients’ shoes. My experience in a hospital bed during medical school granted me an extremely intriguing perspective towards medicine.
Why I do it
When I was a patient, the most crucial thing to my family was information. Most physicians did not take the time to explain my course of care, which elevated my family’s angst and anxiety. The experience taught me the importance of patience and communication.
But there were good examples. I still remember the physician who comforted my mother and assuaged her concerns. She held my mother’s hand and showed empathy. When my mother cried, she cried. That physician taught me that it was acceptable for physicians to express emotions.
When my surgeon rounded on me in the morning after my procedure, she was not wearing a white coat, which made her appear relatable. Her contagious confidence and humble demeanor were endorsement enough for her capabilities, showing me that a physician’s persona supersedes the conventional coat.
How I do it
I try to put myself in my patients’ shoes. I rejoice with them. I mourn with them. My uninhibited display of emotions affirms empathy. I dissolve all barriers by not wearing a white coat and ask my patients for a partnership. After all, I once walked miles in those shoes.
Dr. Sharma is a chief hospitalist for Sound Physicians at the Sierra Campus of The Hospitals of Providence, El Paso, Texas. She is a columnist for the El Paso Times and the medical contributor for KVIA Channel 7 ABC News. Her work has appeared on kevinmd.com, Thrive Global, and in El Paso magazine.
Editor’s note: “Everything We Say and Do” provides readers with thoughtful and actionable communication tactics that can positively impact patients’ experience of care. In the next series of columns, physicians will share how their experiences as patients have shaped their professional approach.
In May 2007, I received my acceptance letter for medical school. One month later, I was diagnosed with cancer.
The clinic visit was only supposed to be a routine postoperative follow-up after a simple cyst resection. I really hoped that my doctor was mistaken as he walked me through what to expect, and when he was finished, the desperate look in my eyes demanded answers.
After I fully absorbed the initial shock of the grave news, I eventually found the strength to analyze the situation at hand. Ultimately, I adopted a more positive outlook and fought cancer head on. Contending with cancer while tackling the rigors of medical school was tedious, but despite the hardships, my experience catalyzed my determination and molded my personality as a physician.
What I say and do
I employ active listening and practice patience, especially when it comes to family members.
As both a cancer survivor and a physician, I am able to integrate empathy and diligence by putting myself in my patients’ shoes. My experience in a hospital bed during medical school granted me an extremely intriguing perspective towards medicine.
Why I do it
When I was a patient, the most crucial thing to my family was information. Most physicians did not take the time to explain my course of care, which elevated my family’s angst and anxiety. The experience taught me the importance of patience and communication.
But there were good examples. I still remember the physician who comforted my mother and assuaged her concerns. She held my mother’s hand and showed empathy. When my mother cried, she cried. That physician taught me that it was acceptable for physicians to express emotions.
When my surgeon rounded on me in the morning after my procedure, she was not wearing a white coat, which made her appear relatable. Her contagious confidence and humble demeanor were endorsement enough for her capabilities, showing me that a physician’s persona supersedes the conventional coat.
How I do it
I try to put myself in my patients’ shoes. I rejoice with them. I mourn with them. My uninhibited display of emotions affirms empathy. I dissolve all barriers by not wearing a white coat and ask my patients for a partnership. After all, I once walked miles in those shoes.
Dr. Sharma is a chief hospitalist for Sound Physicians at the Sierra Campus of The Hospitals of Providence, El Paso, Texas. She is a columnist for the El Paso Times and the medical contributor for KVIA Channel 7 ABC News. Her work has appeared on kevinmd.com, Thrive Global, and in El Paso magazine.
Early ankylosing spondylitis treatment stops transition from inflammatory to bone-forming fatty lesions
Structural damage in axial and peripheral ankylosing spondylitis is the result of a combination of destruction and new bone formation, which can be halted if treated early and for long enough, according to Dirk Elewaut, MD, PhD.
“There is a longstanding paradox in the field of ankylosing spondylitis, as to whether there is a strict relationship between the inflammation that leads to the signs and symptoms in patients, and the structural progression,” said Dr. Elewaut, who spoke at the annual Perspectives in Rheumatic Diseases held by Global Academy for Medical Education. “ ”
One key reason why the early TNF inhibition trials showed no effect of treatment on structural progression stemmed from inadequate study design. “The original studies were underpowered, and the patients used NSAIDs,” he said. “We also know that the anti-inflammatory effect [of TNF inhibition] is not 100%. So you have a clear drop in inflammation with biologics, but it’s not completely stopped. This led to a lot of speculation as to whether inflammation and ankyloses are coupled or not.”
More recently, researchers have honed in on the transition from acute inflammatory lesions visible on MRI by bone marrow edema to so-called fatty lesions, which are also visible on MRI. They have observed that fatty lesions are associated with new bone formation. “Lesions containing more fat are thought to be more difficult to modulate by biological therapy,” Dr. Elewaut said. “Once you have a fatty lesion, you have some kind of metabolic disease of the bone, and it’s a one-way road to the development of new syndesmophytes. So in other words, it is essential to assess the relationship between inflammation and new bone formation with both the STIR [short tau inversion recovery images] and T1-weighted MRI.”
A working hypothesis among AS researchers is that the effect of anti-TNF therapy on radiologic progression depends on the relative number of acute and mature inflammatory lesions that individual patients have. “Early diagnosis is a prerequisite for advances in disease modification,” he said. At least three “windows of opportunity” for disease modification exist, Dr. Elewaut continued. One is that the link between inflammation as measured by clinical parameters and new bone formation will be more evident in early AS. The second is that early treatment of patients with axial AS and spinal inflammation with anti-TNF agents will prevent new bone formation. The third is that reduction of new bone formation in established AS will be observed only with long-term anti-TNF therapy after mature lesions have resolved/repaired, and no new inflammatory lesions are being formed. One study found that patients with a delay of more than 10 years starting anti-TNF therapy were more likely to progress, compared with patients who received therapy earlier (odds ratio, 2.4; P = .03; see Arthritis Rheum. 2013;65:645-54). “The message here is quite clear,” Dr. Elewaut said. “The earlier we treat intensively, the better impact you have on structural outcomes.”
In a trial known as CRESPA (Clinical Remission in peripheral SPondyloArthritis), researchers including Dr. Elewaut evaluated the efficacy and safety of golimumab (Simponi) to induce clinical remission in patients with early, active peripheral AS (Ann Rheum Dis. 2017;76:1389-95). In all, 60 patients were randomized to golimumab or placebo for 24 weeks. At week 24, a significantly higher percentage of patients receiving golimumab achieved clinical remission, compared with placebo (75% vs. 20%, respectively; P less than .001). At week 12, similar results were observed (70% vs. 15%; P less than .001).
“These were very striking results in this early disease population,” Dr. Elewaut said. In a follow-up analysis, the researchers withdrew therapy in patients who reached clinical remission, to see what would happen. “At 1.5 years of follow-up, 57% of patients are in drug-free remission,” Dr. Elewaut said. “This is interesting and suggests that at least in a fraction of those patients, you can actually achieve a drug-free remission.” Predictors for relapse included pre-existing psoriasis and having more than five swollen joints.
Dr. Elewaut disclosed that he is a member of the speakers bureau for AbbVie, Novartis, Pfizer, and UCB. Global Academy for Medical Education and this news organization are owned by the same parent company.
Structural damage in axial and peripheral ankylosing spondylitis is the result of a combination of destruction and new bone formation, which can be halted if treated early and for long enough, according to Dirk Elewaut, MD, PhD.
“There is a longstanding paradox in the field of ankylosing spondylitis, as to whether there is a strict relationship between the inflammation that leads to the signs and symptoms in patients, and the structural progression,” said Dr. Elewaut, who spoke at the annual Perspectives in Rheumatic Diseases held by Global Academy for Medical Education. “ ”
One key reason why the early TNF inhibition trials showed no effect of treatment on structural progression stemmed from inadequate study design. “The original studies were underpowered, and the patients used NSAIDs,” he said. “We also know that the anti-inflammatory effect [of TNF inhibition] is not 100%. So you have a clear drop in inflammation with biologics, but it’s not completely stopped. This led to a lot of speculation as to whether inflammation and ankyloses are coupled or not.”
More recently, researchers have honed in on the transition from acute inflammatory lesions visible on MRI by bone marrow edema to so-called fatty lesions, which are also visible on MRI. They have observed that fatty lesions are associated with new bone formation. “Lesions containing more fat are thought to be more difficult to modulate by biological therapy,” Dr. Elewaut said. “Once you have a fatty lesion, you have some kind of metabolic disease of the bone, and it’s a one-way road to the development of new syndesmophytes. So in other words, it is essential to assess the relationship between inflammation and new bone formation with both the STIR [short tau inversion recovery images] and T1-weighted MRI.”
A working hypothesis among AS researchers is that the effect of anti-TNF therapy on radiologic progression depends on the relative number of acute and mature inflammatory lesions that individual patients have. “Early diagnosis is a prerequisite for advances in disease modification,” he said. At least three “windows of opportunity” for disease modification exist, Dr. Elewaut continued. One is that the link between inflammation as measured by clinical parameters and new bone formation will be more evident in early AS. The second is that early treatment of patients with axial AS and spinal inflammation with anti-TNF agents will prevent new bone formation. The third is that reduction of new bone formation in established AS will be observed only with long-term anti-TNF therapy after mature lesions have resolved/repaired, and no new inflammatory lesions are being formed. One study found that patients with a delay of more than 10 years starting anti-TNF therapy were more likely to progress, compared with patients who received therapy earlier (odds ratio, 2.4; P = .03; see Arthritis Rheum. 2013;65:645-54). “The message here is quite clear,” Dr. Elewaut said. “The earlier we treat intensively, the better impact you have on structural outcomes.”
In a trial known as CRESPA (Clinical Remission in peripheral SPondyloArthritis), researchers including Dr. Elewaut evaluated the efficacy and safety of golimumab (Simponi) to induce clinical remission in patients with early, active peripheral AS (Ann Rheum Dis. 2017;76:1389-95). In all, 60 patients were randomized to golimumab or placebo for 24 weeks. At week 24, a significantly higher percentage of patients receiving golimumab achieved clinical remission, compared with placebo (75% vs. 20%, respectively; P less than .001). At week 12, similar results were observed (70% vs. 15%; P less than .001).
“These were very striking results in this early disease population,” Dr. Elewaut said. In a follow-up analysis, the researchers withdrew therapy in patients who reached clinical remission, to see what would happen. “At 1.5 years of follow-up, 57% of patients are in drug-free remission,” Dr. Elewaut said. “This is interesting and suggests that at least in a fraction of those patients, you can actually achieve a drug-free remission.” Predictors for relapse included pre-existing psoriasis and having more than five swollen joints.
Dr. Elewaut disclosed that he is a member of the speakers bureau for AbbVie, Novartis, Pfizer, and UCB. Global Academy for Medical Education and this news organization are owned by the same parent company.
Structural damage in axial and peripheral ankylosing spondylitis is the result of a combination of destruction and new bone formation, which can be halted if treated early and for long enough, according to Dirk Elewaut, MD, PhD.
“There is a longstanding paradox in the field of ankylosing spondylitis, as to whether there is a strict relationship between the inflammation that leads to the signs and symptoms in patients, and the structural progression,” said Dr. Elewaut, who spoke at the annual Perspectives in Rheumatic Diseases held by Global Academy for Medical Education. “ ”
One key reason why the early TNF inhibition trials showed no effect of treatment on structural progression stemmed from inadequate study design. “The original studies were underpowered, and the patients used NSAIDs,” he said. “We also know that the anti-inflammatory effect [of TNF inhibition] is not 100%. So you have a clear drop in inflammation with biologics, but it’s not completely stopped. This led to a lot of speculation as to whether inflammation and ankyloses are coupled or not.”
More recently, researchers have honed in on the transition from acute inflammatory lesions visible on MRI by bone marrow edema to so-called fatty lesions, which are also visible on MRI. They have observed that fatty lesions are associated with new bone formation. “Lesions containing more fat are thought to be more difficult to modulate by biological therapy,” Dr. Elewaut said. “Once you have a fatty lesion, you have some kind of metabolic disease of the bone, and it’s a one-way road to the development of new syndesmophytes. So in other words, it is essential to assess the relationship between inflammation and new bone formation with both the STIR [short tau inversion recovery images] and T1-weighted MRI.”
A working hypothesis among AS researchers is that the effect of anti-TNF therapy on radiologic progression depends on the relative number of acute and mature inflammatory lesions that individual patients have. “Early diagnosis is a prerequisite for advances in disease modification,” he said. At least three “windows of opportunity” for disease modification exist, Dr. Elewaut continued. One is that the link between inflammation as measured by clinical parameters and new bone formation will be more evident in early AS. The second is that early treatment of patients with axial AS and spinal inflammation with anti-TNF agents will prevent new bone formation. The third is that reduction of new bone formation in established AS will be observed only with long-term anti-TNF therapy after mature lesions have resolved/repaired, and no new inflammatory lesions are being formed. One study found that patients with a delay of more than 10 years starting anti-TNF therapy were more likely to progress, compared with patients who received therapy earlier (odds ratio, 2.4; P = .03; see Arthritis Rheum. 2013;65:645-54). “The message here is quite clear,” Dr. Elewaut said. “The earlier we treat intensively, the better impact you have on structural outcomes.”
In a trial known as CRESPA (Clinical Remission in peripheral SPondyloArthritis), researchers including Dr. Elewaut evaluated the efficacy and safety of golimumab (Simponi) to induce clinical remission in patients with early, active peripheral AS (Ann Rheum Dis. 2017;76:1389-95). In all, 60 patients were randomized to golimumab or placebo for 24 weeks. At week 24, a significantly higher percentage of patients receiving golimumab achieved clinical remission, compared with placebo (75% vs. 20%, respectively; P less than .001). At week 12, similar results were observed (70% vs. 15%; P less than .001).
“These were very striking results in this early disease population,” Dr. Elewaut said. In a follow-up analysis, the researchers withdrew therapy in patients who reached clinical remission, to see what would happen. “At 1.5 years of follow-up, 57% of patients are in drug-free remission,” Dr. Elewaut said. “This is interesting and suggests that at least in a fraction of those patients, you can actually achieve a drug-free remission.” Predictors for relapse included pre-existing psoriasis and having more than five swollen joints.
Dr. Elewaut disclosed that he is a member of the speakers bureau for AbbVie, Novartis, Pfizer, and UCB. Global Academy for Medical Education and this news organization are owned by the same parent company.
EXPERT ANALYSIS FROM ANNUAL PERSPECTIVES IN RHEUMATIC DISEASES
Impact of elder program on delirium and LOS for abdominal surgery patients
Clinical question: Can a modified Hospital Elder Life Program (mHELP) reduce delirium and hospital LOS in older patients undergoing abdominal surgery?
Background: Development of delirium in the hospitalized patient, especially postsurgical patients, can have detrimental effects on the clinical recovery and LOS. Delirium occurs in 13%-50% of patients undergoing noncardiac surgery, and older surgical patients are at a higher risk.
Study design: Cluster randomized clinical trial.
Synopsis: There were 377 older patients (65 years of age or older) who were admitted for elective abdominal surgery (gastrectomy, pancreaticoduodenectomy, or colectomy) with an expected LOS greater than 6 days enrolled and randomly assigned to mHELP group (197 patients) or control group (180 patients). The mHELP intervention consisted of three core nursing protocols that occurred daily by a trained nurse: orienting communication, oral and nutritional assistance, and early mobilization. Delirium developed in 13 cases (6.6%) in the mHELP group and in 27 cases (15.1%) in the control group. This is a risk reduction of 56% indicating the need to treat 11.8 patients to prevent one case of delirium. The mHELP group had a 2-day hospital LOS reduction, compared with the control group. The effect of mHELP could be underestimated as crossover effects were not accounted for in the study. Data were not collected on postoperative complications which can have a significant effect on delirium occurrence.
Bottom line: The three nursing protocols of mHELP reduced rates of delirium and hospital LOS in older adults undergoing abdominal surgeries and could be a quick intervention to reduce the most common surgical complication in older patients.
Citation: Chen CC, Li HC, Liang JT, et al. Effect of a modified hospital elder life program on delirium and length of hospital stay in patients undergoing abdominal surgery. JAMA Surg. Published online May 24, 2017. doi: 10.1001/jamasurg.2017.1083.
Dr. Newsom is a hospitalist at Ochsner Health System, New Orleans.
Clinical question: Can a modified Hospital Elder Life Program (mHELP) reduce delirium and hospital LOS in older patients undergoing abdominal surgery?
Background: Development of delirium in the hospitalized patient, especially postsurgical patients, can have detrimental effects on the clinical recovery and LOS. Delirium occurs in 13%-50% of patients undergoing noncardiac surgery, and older surgical patients are at a higher risk.
Study design: Cluster randomized clinical trial.
Synopsis: There were 377 older patients (65 years of age or older) who were admitted for elective abdominal surgery (gastrectomy, pancreaticoduodenectomy, or colectomy) with an expected LOS greater than 6 days enrolled and randomly assigned to mHELP group (197 patients) or control group (180 patients). The mHELP intervention consisted of three core nursing protocols that occurred daily by a trained nurse: orienting communication, oral and nutritional assistance, and early mobilization. Delirium developed in 13 cases (6.6%) in the mHELP group and in 27 cases (15.1%) in the control group. This is a risk reduction of 56% indicating the need to treat 11.8 patients to prevent one case of delirium. The mHELP group had a 2-day hospital LOS reduction, compared with the control group. The effect of mHELP could be underestimated as crossover effects were not accounted for in the study. Data were not collected on postoperative complications which can have a significant effect on delirium occurrence.
Bottom line: The three nursing protocols of mHELP reduced rates of delirium and hospital LOS in older adults undergoing abdominal surgeries and could be a quick intervention to reduce the most common surgical complication in older patients.
Citation: Chen CC, Li HC, Liang JT, et al. Effect of a modified hospital elder life program on delirium and length of hospital stay in patients undergoing abdominal surgery. JAMA Surg. Published online May 24, 2017. doi: 10.1001/jamasurg.2017.1083.
Dr. Newsom is a hospitalist at Ochsner Health System, New Orleans.
Clinical question: Can a modified Hospital Elder Life Program (mHELP) reduce delirium and hospital LOS in older patients undergoing abdominal surgery?
Background: Development of delirium in the hospitalized patient, especially postsurgical patients, can have detrimental effects on the clinical recovery and LOS. Delirium occurs in 13%-50% of patients undergoing noncardiac surgery, and older surgical patients are at a higher risk.
Study design: Cluster randomized clinical trial.
Synopsis: There were 377 older patients (65 years of age or older) who were admitted for elective abdominal surgery (gastrectomy, pancreaticoduodenectomy, or colectomy) with an expected LOS greater than 6 days enrolled and randomly assigned to mHELP group (197 patients) or control group (180 patients). The mHELP intervention consisted of three core nursing protocols that occurred daily by a trained nurse: orienting communication, oral and nutritional assistance, and early mobilization. Delirium developed in 13 cases (6.6%) in the mHELP group and in 27 cases (15.1%) in the control group. This is a risk reduction of 56% indicating the need to treat 11.8 patients to prevent one case of delirium. The mHELP group had a 2-day hospital LOS reduction, compared with the control group. The effect of mHELP could be underestimated as crossover effects were not accounted for in the study. Data were not collected on postoperative complications which can have a significant effect on delirium occurrence.
Bottom line: The three nursing protocols of mHELP reduced rates of delirium and hospital LOS in older adults undergoing abdominal surgeries and could be a quick intervention to reduce the most common surgical complication in older patients.
Citation: Chen CC, Li HC, Liang JT, et al. Effect of a modified hospital elder life program on delirium and length of hospital stay in patients undergoing abdominal surgery. JAMA Surg. Published online May 24, 2017. doi: 10.1001/jamasurg.2017.1083.
Dr. Newsom is a hospitalist at Ochsner Health System, New Orleans.
ECHO rheumatology programs increase access, improve care
As in many places throughout the country, rheumatologists are in short supply in southern Arizona. Patients frequently wait up to 6 months to visit a rheumatologist at Banner University Medical Center (BUMC) in Tucson, and many drive between 3 and 4 hours for the appointment, said Dominick G. Sudano, MD, a rheumatologist at BUMC, which is affiliated with the University of Arizona.
[polldaddy:9823712]
The high demand for rheumatologists and lack of timely access led the University of Arizona to develop a program that will train primary care providers at remote sites to treat rheumatic diseases. The program, a partnership between the university’s Arizona Telemedicine Program and the University of Arizona Center for Rural Health, will use the popular ECHO (Extension for Community Healthcare Outcomes) model, founded by the University of New Mexico in Albuquerque, which aims to increase workforce capacity by sharing medical knowledge.
A unique model of care
As part of the program, set to launch this month, Dr. Sudano will hold rheumatology training sessions via telemedicine for primary care physicians and other nonphysicians at four remote sites around Arizona. Participating sites include Canyonlands Healthcare, North County Healthcare, and Northern Arizona Healthcare – all located in the northern part of the state – and Copper Queen Community Hospital in southern Arizona.
The virtual sessions will include both educational topics and the opportunity for local doctors and health professionals to present patient cases to Dr. Sudano for guidance. The local doctors and health professionals will eventually treat rheumatic cases in their communities, while cases identified as severe will still be referred to rheumatologists.
The university’s Arizona Telemedicine Program was fortunate to receive a $17,700 grant from Lilly to launch the 1-year rheumatology ECHO pilot program, Dr. Sudano noted. The grant will enable the program to get off the ground, while administrators search for additional funding sources to become sustainable, he said.
Dr. Sudano credits the assistance and support of the University of New Mexico and its ECHO leaders for helping the University of Arizona build its ECHO rheumatology program and helping administrators address the details of setting up the program.
“[The University of New Mexico] was immensely helpful,” he said. “They have immersion sessions about once a month and you spend [time] working with their team. They work with you to get the logistics ironed out.”
A spreading movement
The University of New Mexico (UNM) has good reason to assist other health and academic medical centers in launching their own ECHO programs. UNM’s mission is to continue building the ECHO movement and accomplish its goal of “touching 1 billion lives” by 2025, said Sanjeev Arora, MD, a gastroenterologist at UNM and founder/director of the university’s Project ECHO.
“There was a great shortage of specialists to treat hepatitis C so I came up with this idea of ECHO to bring access to care to everyone in New Mexico who needed care,” he said. “The second part of the idea was, if we could do that for hepatitis C, we could do that for a lot of other problems like rheumatoid arthritis, like addiction, like diabetes.”
Project ECHO has now spread to medical centers and hospitals across the country, with programs that center on asthma, HIV infection, cardiac risk reduction, chronic pain management, geriatrics, palliative care, substance abuse, and obesity, among others. The model is now in 139 academic hubs in 24 countries with more than 65 health conditions targeted, according to Dr. Arora. Replication sites focus on four key principles of ECHO: technology used to leverage scarce health care expertise and resources; best practices shared to standardize care across disparate health care delivery systems; case-based learning used as the primary modality to build knowledge, confidence, and expertise; and evaluations conducted to monitor outcomes.
Data show the care patients receive via the ECHO model is equal to that of care provided by university-based specialists. A 2011 report published in the New England Journal of Medicine, for example, found that a sustained viral response to treatment for hepatitis C was achieved in 58% of patients managed at the university and by 58% of patients managed by primary care physicians at rural and prison sites who participated in Project ECHO (N Engl J Med. 2011;364:2199-2207). Response rates to different subtypes of hepatitis C also did not differ significantly between the two groups.
The ECHO model has also greatly improved access and outcomes for hepatitis C patients in Northern Arizona, said Colleen Hopkins, telehealth coordinator at North Country Healthcare in Flagstaff. North Country Healthcare has participated in a hepatitis C ECHO program since 2012, linking its chain of 14 community health centers with a hepatologist-educator at St. Joseph’s Hospital and Medical Center in Phoenix, 140 miles to the south.
“In 2011, more than 950 patients in the health system’s network had a hepatitis C diagnosis, but the majority did not have access to care,” Ms. Hopkins said in an interview.
“To date, over 500 patients have received care for their liver disease in rural Northern Arizona,” she said. “These numbers continue to climb as our awareness has caused an increase in screening and various outreach efforts ... Overall, our providers and patients are empowered by having access to specialty care; they are living longer healthier lives as well as keeping money in our communities.”
Rheumatology and the ECHO model
The volume of rheumatic conditions encountered by primary care physicians and the shortage of specialists make rheumatology a logical fit for the ECHO model, Dr. Arora said. Rheumatoid arthritis, osteoarthritis, osteoporosis, fibromyalgia, and joint pain account for as many as one in five visits to primary care doctors, he noted.
“Osteoporosis and rheumatoid arthritis produce massive disability in the world,” he said. “Treatment exists, but it’s not getting to patients. ECHO can fundamentally transform the field of rheumatology if it’s adopted widely.”
However, compared with other specialty ECHO models, there are not many rheumatology ECHO programs in operation. Dr. Arora is hopeful that as word spreads about how well rheumatology fits into the ECHO structure, more programs will develop, he said.
“We have found over the years that with our training these providers – both physicians and nonphysician – are able to function as well as a specially trained [rheumatologist],” Dr. Bankhurst said. “We help them as needed by our weekly teleconference where they present cases to us and those cases which appear to be most difficult, we see immediately in our clinics.”
The program has led to decreased referrals to the university from outlying areas and more care access for patients in rural areas, Dr. Bankhurst said. A university study is underway to analyze clinical outcomes for rheumatoid arthritis as conducted by distant provider sites compared with treatment at the university clinic.
“It’s my perspective, based on 12 years of experience, that they’ll be identical,” he said.
Setting up such ECHO programs is not without challenges. Financial support for telecommunication equipment in all needed areas can be difficult, Dr. Bankhurst said. Recruiting individuals who are well motivated to participate in the program can also be a challenge.
“It needs a commitment by the administration,” he said. “It does take time from other activities. It requires dedicated time away from a busy clinic.”
[email protected]
On Twitter @legal_med
As in many places throughout the country, rheumatologists are in short supply in southern Arizona. Patients frequently wait up to 6 months to visit a rheumatologist at Banner University Medical Center (BUMC) in Tucson, and many drive between 3 and 4 hours for the appointment, said Dominick G. Sudano, MD, a rheumatologist at BUMC, which is affiliated with the University of Arizona.
[polldaddy:9823712]
The high demand for rheumatologists and lack of timely access led the University of Arizona to develop a program that will train primary care providers at remote sites to treat rheumatic diseases. The program, a partnership between the university’s Arizona Telemedicine Program and the University of Arizona Center for Rural Health, will use the popular ECHO (Extension for Community Healthcare Outcomes) model, founded by the University of New Mexico in Albuquerque, which aims to increase workforce capacity by sharing medical knowledge.
A unique model of care
As part of the program, set to launch this month, Dr. Sudano will hold rheumatology training sessions via telemedicine for primary care physicians and other nonphysicians at four remote sites around Arizona. Participating sites include Canyonlands Healthcare, North County Healthcare, and Northern Arizona Healthcare – all located in the northern part of the state – and Copper Queen Community Hospital in southern Arizona.
The virtual sessions will include both educational topics and the opportunity for local doctors and health professionals to present patient cases to Dr. Sudano for guidance. The local doctors and health professionals will eventually treat rheumatic cases in their communities, while cases identified as severe will still be referred to rheumatologists.
The university’s Arizona Telemedicine Program was fortunate to receive a $17,700 grant from Lilly to launch the 1-year rheumatology ECHO pilot program, Dr. Sudano noted. The grant will enable the program to get off the ground, while administrators search for additional funding sources to become sustainable, he said.
Dr. Sudano credits the assistance and support of the University of New Mexico and its ECHO leaders for helping the University of Arizona build its ECHO rheumatology program and helping administrators address the details of setting up the program.
“[The University of New Mexico] was immensely helpful,” he said. “They have immersion sessions about once a month and you spend [time] working with their team. They work with you to get the logistics ironed out.”
A spreading movement
The University of New Mexico (UNM) has good reason to assist other health and academic medical centers in launching their own ECHO programs. UNM’s mission is to continue building the ECHO movement and accomplish its goal of “touching 1 billion lives” by 2025, said Sanjeev Arora, MD, a gastroenterologist at UNM and founder/director of the university’s Project ECHO.
“There was a great shortage of specialists to treat hepatitis C so I came up with this idea of ECHO to bring access to care to everyone in New Mexico who needed care,” he said. “The second part of the idea was, if we could do that for hepatitis C, we could do that for a lot of other problems like rheumatoid arthritis, like addiction, like diabetes.”
Project ECHO has now spread to medical centers and hospitals across the country, with programs that center on asthma, HIV infection, cardiac risk reduction, chronic pain management, geriatrics, palliative care, substance abuse, and obesity, among others. The model is now in 139 academic hubs in 24 countries with more than 65 health conditions targeted, according to Dr. Arora. Replication sites focus on four key principles of ECHO: technology used to leverage scarce health care expertise and resources; best practices shared to standardize care across disparate health care delivery systems; case-based learning used as the primary modality to build knowledge, confidence, and expertise; and evaluations conducted to monitor outcomes.
Data show the care patients receive via the ECHO model is equal to that of care provided by university-based specialists. A 2011 report published in the New England Journal of Medicine, for example, found that a sustained viral response to treatment for hepatitis C was achieved in 58% of patients managed at the university and by 58% of patients managed by primary care physicians at rural and prison sites who participated in Project ECHO (N Engl J Med. 2011;364:2199-2207). Response rates to different subtypes of hepatitis C also did not differ significantly between the two groups.
The ECHO model has also greatly improved access and outcomes for hepatitis C patients in Northern Arizona, said Colleen Hopkins, telehealth coordinator at North Country Healthcare in Flagstaff. North Country Healthcare has participated in a hepatitis C ECHO program since 2012, linking its chain of 14 community health centers with a hepatologist-educator at St. Joseph’s Hospital and Medical Center in Phoenix, 140 miles to the south.
“In 2011, more than 950 patients in the health system’s network had a hepatitis C diagnosis, but the majority did not have access to care,” Ms. Hopkins said in an interview.
“To date, over 500 patients have received care for their liver disease in rural Northern Arizona,” she said. “These numbers continue to climb as our awareness has caused an increase in screening and various outreach efforts ... Overall, our providers and patients are empowered by having access to specialty care; they are living longer healthier lives as well as keeping money in our communities.”
Rheumatology and the ECHO model
The volume of rheumatic conditions encountered by primary care physicians and the shortage of specialists make rheumatology a logical fit for the ECHO model, Dr. Arora said. Rheumatoid arthritis, osteoarthritis, osteoporosis, fibromyalgia, and joint pain account for as many as one in five visits to primary care doctors, he noted.
“Osteoporosis and rheumatoid arthritis produce massive disability in the world,” he said. “Treatment exists, but it’s not getting to patients. ECHO can fundamentally transform the field of rheumatology if it’s adopted widely.”
However, compared with other specialty ECHO models, there are not many rheumatology ECHO programs in operation. Dr. Arora is hopeful that as word spreads about how well rheumatology fits into the ECHO structure, more programs will develop, he said.
“We have found over the years that with our training these providers – both physicians and nonphysician – are able to function as well as a specially trained [rheumatologist],” Dr. Bankhurst said. “We help them as needed by our weekly teleconference where they present cases to us and those cases which appear to be most difficult, we see immediately in our clinics.”
The program has led to decreased referrals to the university from outlying areas and more care access for patients in rural areas, Dr. Bankhurst said. A university study is underway to analyze clinical outcomes for rheumatoid arthritis as conducted by distant provider sites compared with treatment at the university clinic.
“It’s my perspective, based on 12 years of experience, that they’ll be identical,” he said.
Setting up such ECHO programs is not without challenges. Financial support for telecommunication equipment in all needed areas can be difficult, Dr. Bankhurst said. Recruiting individuals who are well motivated to participate in the program can also be a challenge.
“It needs a commitment by the administration,” he said. “It does take time from other activities. It requires dedicated time away from a busy clinic.”
[email protected]
On Twitter @legal_med
As in many places throughout the country, rheumatologists are in short supply in southern Arizona. Patients frequently wait up to 6 months to visit a rheumatologist at Banner University Medical Center (BUMC) in Tucson, and many drive between 3 and 4 hours for the appointment, said Dominick G. Sudano, MD, a rheumatologist at BUMC, which is affiliated with the University of Arizona.
[polldaddy:9823712]
The high demand for rheumatologists and lack of timely access led the University of Arizona to develop a program that will train primary care providers at remote sites to treat rheumatic diseases. The program, a partnership between the university’s Arizona Telemedicine Program and the University of Arizona Center for Rural Health, will use the popular ECHO (Extension for Community Healthcare Outcomes) model, founded by the University of New Mexico in Albuquerque, which aims to increase workforce capacity by sharing medical knowledge.
A unique model of care
As part of the program, set to launch this month, Dr. Sudano will hold rheumatology training sessions via telemedicine for primary care physicians and other nonphysicians at four remote sites around Arizona. Participating sites include Canyonlands Healthcare, North County Healthcare, and Northern Arizona Healthcare – all located in the northern part of the state – and Copper Queen Community Hospital in southern Arizona.
The virtual sessions will include both educational topics and the opportunity for local doctors and health professionals to present patient cases to Dr. Sudano for guidance. The local doctors and health professionals will eventually treat rheumatic cases in their communities, while cases identified as severe will still be referred to rheumatologists.
The university’s Arizona Telemedicine Program was fortunate to receive a $17,700 grant from Lilly to launch the 1-year rheumatology ECHO pilot program, Dr. Sudano noted. The grant will enable the program to get off the ground, while administrators search for additional funding sources to become sustainable, he said.
Dr. Sudano credits the assistance and support of the University of New Mexico and its ECHO leaders for helping the University of Arizona build its ECHO rheumatology program and helping administrators address the details of setting up the program.
“[The University of New Mexico] was immensely helpful,” he said. “They have immersion sessions about once a month and you spend [time] working with their team. They work with you to get the logistics ironed out.”
A spreading movement
The University of New Mexico (UNM) has good reason to assist other health and academic medical centers in launching their own ECHO programs. UNM’s mission is to continue building the ECHO movement and accomplish its goal of “touching 1 billion lives” by 2025, said Sanjeev Arora, MD, a gastroenterologist at UNM and founder/director of the university’s Project ECHO.
“There was a great shortage of specialists to treat hepatitis C so I came up with this idea of ECHO to bring access to care to everyone in New Mexico who needed care,” he said. “The second part of the idea was, if we could do that for hepatitis C, we could do that for a lot of other problems like rheumatoid arthritis, like addiction, like diabetes.”
Project ECHO has now spread to medical centers and hospitals across the country, with programs that center on asthma, HIV infection, cardiac risk reduction, chronic pain management, geriatrics, palliative care, substance abuse, and obesity, among others. The model is now in 139 academic hubs in 24 countries with more than 65 health conditions targeted, according to Dr. Arora. Replication sites focus on four key principles of ECHO: technology used to leverage scarce health care expertise and resources; best practices shared to standardize care across disparate health care delivery systems; case-based learning used as the primary modality to build knowledge, confidence, and expertise; and evaluations conducted to monitor outcomes.
Data show the care patients receive via the ECHO model is equal to that of care provided by university-based specialists. A 2011 report published in the New England Journal of Medicine, for example, found that a sustained viral response to treatment for hepatitis C was achieved in 58% of patients managed at the university and by 58% of patients managed by primary care physicians at rural and prison sites who participated in Project ECHO (N Engl J Med. 2011;364:2199-2207). Response rates to different subtypes of hepatitis C also did not differ significantly between the two groups.
The ECHO model has also greatly improved access and outcomes for hepatitis C patients in Northern Arizona, said Colleen Hopkins, telehealth coordinator at North Country Healthcare in Flagstaff. North Country Healthcare has participated in a hepatitis C ECHO program since 2012, linking its chain of 14 community health centers with a hepatologist-educator at St. Joseph’s Hospital and Medical Center in Phoenix, 140 miles to the south.
“In 2011, more than 950 patients in the health system’s network had a hepatitis C diagnosis, but the majority did not have access to care,” Ms. Hopkins said in an interview.
“To date, over 500 patients have received care for their liver disease in rural Northern Arizona,” she said. “These numbers continue to climb as our awareness has caused an increase in screening and various outreach efforts ... Overall, our providers and patients are empowered by having access to specialty care; they are living longer healthier lives as well as keeping money in our communities.”
Rheumatology and the ECHO model
The volume of rheumatic conditions encountered by primary care physicians and the shortage of specialists make rheumatology a logical fit for the ECHO model, Dr. Arora said. Rheumatoid arthritis, osteoarthritis, osteoporosis, fibromyalgia, and joint pain account for as many as one in five visits to primary care doctors, he noted.
“Osteoporosis and rheumatoid arthritis produce massive disability in the world,” he said. “Treatment exists, but it’s not getting to patients. ECHO can fundamentally transform the field of rheumatology if it’s adopted widely.”
However, compared with other specialty ECHO models, there are not many rheumatology ECHO programs in operation. Dr. Arora is hopeful that as word spreads about how well rheumatology fits into the ECHO structure, more programs will develop, he said.
“We have found over the years that with our training these providers – both physicians and nonphysician – are able to function as well as a specially trained [rheumatologist],” Dr. Bankhurst said. “We help them as needed by our weekly teleconference where they present cases to us and those cases which appear to be most difficult, we see immediately in our clinics.”
The program has led to decreased referrals to the university from outlying areas and more care access for patients in rural areas, Dr. Bankhurst said. A university study is underway to analyze clinical outcomes for rheumatoid arthritis as conducted by distant provider sites compared with treatment at the university clinic.
“It’s my perspective, based on 12 years of experience, that they’ll be identical,” he said.
Setting up such ECHO programs is not without challenges. Financial support for telecommunication equipment in all needed areas can be difficult, Dr. Bankhurst said. Recruiting individuals who are well motivated to participate in the program can also be a challenge.
“It needs a commitment by the administration,” he said. “It does take time from other activities. It requires dedicated time away from a busy clinic.”
[email protected]
On Twitter @legal_med
The 3 Reasons Patients With Diabetes Don’t Get Eye Care
As diabetes becomes more prevalent, so do eye diseases. The good news is that many patients are aware of the risk. However, they may think that they do not need regular eye checkups. Patient awareness of the value of prevention is a key message in a study by researchers from the University of Lausanne in Switzerland.
In their study of 323 patients, 41% of patients with type 1 diabetes (T1DM) and 10% of those with type 2 diabetes (T2DM) had diabetic retinopathy. One-third of patients had myopia, astigmatism, and other common visual defects, 36% had cataract, and 13% had glaucoma. The patients with T1DM were about 5 times more likely to have more than 3 eye diseases than were those with type 2.
But all patients with T1DM and 95% of those with T2DM knew that diabetes could damage the eyes. Further, the “vast majority” of all the patients knew the benefit of maintaining good glycemic control and getting regular eye examinations by an ophthalmologist. About 91% of patients with T1DM and 85% of patients with T2DM knew that controlling blood pressure and lipids also was important. But one-quarter of the participants thought nothing could be done to prevent diabetic eye diseases—that they were the result of bad luck.
About 71% of the participants were examined by an ophthalmologist in the previous year. Exploring the reasons, the researchers found 3 main barriers: Patients said they had no visual symptoms, they felt they didn’t need an exam because their diabetes was well controlled, or they did not get recommendations from their family physician or diabetologist. The researchers say diabetic retinopathy may be underestimated because some patients are not getting eye exams.
Conversely, the 3 main reasons for regular eye exams, according to patient reports, were that health care professionals recommended them, patients were aware of the importance of regular controls, and they knew the risks of diabetes-related retinal problems.
The researchers say physicians can help by emphasizing that preventive care includes regular eye exams. They also suggest that it may be time to “broaden the diabetes education perspective” and include all significant diabetic eye diseases instead of focusing on diabetic retinopathy.
Source:
Konstantinidis L, Carron T, de Ancos E, et al. BMC Endocr Disord. 2017;17(1):56.
doi: 10.1186/s12902-017-0206-2.
As diabetes becomes more prevalent, so do eye diseases. The good news is that many patients are aware of the risk. However, they may think that they do not need regular eye checkups. Patient awareness of the value of prevention is a key message in a study by researchers from the University of Lausanne in Switzerland.
In their study of 323 patients, 41% of patients with type 1 diabetes (T1DM) and 10% of those with type 2 diabetes (T2DM) had diabetic retinopathy. One-third of patients had myopia, astigmatism, and other common visual defects, 36% had cataract, and 13% had glaucoma. The patients with T1DM were about 5 times more likely to have more than 3 eye diseases than were those with type 2.
But all patients with T1DM and 95% of those with T2DM knew that diabetes could damage the eyes. Further, the “vast majority” of all the patients knew the benefit of maintaining good glycemic control and getting regular eye examinations by an ophthalmologist. About 91% of patients with T1DM and 85% of patients with T2DM knew that controlling blood pressure and lipids also was important. But one-quarter of the participants thought nothing could be done to prevent diabetic eye diseases—that they were the result of bad luck.
About 71% of the participants were examined by an ophthalmologist in the previous year. Exploring the reasons, the researchers found 3 main barriers: Patients said they had no visual symptoms, they felt they didn’t need an exam because their diabetes was well controlled, or they did not get recommendations from their family physician or diabetologist. The researchers say diabetic retinopathy may be underestimated because some patients are not getting eye exams.
Conversely, the 3 main reasons for regular eye exams, according to patient reports, were that health care professionals recommended them, patients were aware of the importance of regular controls, and they knew the risks of diabetes-related retinal problems.
The researchers say physicians can help by emphasizing that preventive care includes regular eye exams. They also suggest that it may be time to “broaden the diabetes education perspective” and include all significant diabetic eye diseases instead of focusing on diabetic retinopathy.
Source:
Konstantinidis L, Carron T, de Ancos E, et al. BMC Endocr Disord. 2017;17(1):56.
doi: 10.1186/s12902-017-0206-2.
As diabetes becomes more prevalent, so do eye diseases. The good news is that many patients are aware of the risk. However, they may think that they do not need regular eye checkups. Patient awareness of the value of prevention is a key message in a study by researchers from the University of Lausanne in Switzerland.
In their study of 323 patients, 41% of patients with type 1 diabetes (T1DM) and 10% of those with type 2 diabetes (T2DM) had diabetic retinopathy. One-third of patients had myopia, astigmatism, and other common visual defects, 36% had cataract, and 13% had glaucoma. The patients with T1DM were about 5 times more likely to have more than 3 eye diseases than were those with type 2.
But all patients with T1DM and 95% of those with T2DM knew that diabetes could damage the eyes. Further, the “vast majority” of all the patients knew the benefit of maintaining good glycemic control and getting regular eye examinations by an ophthalmologist. About 91% of patients with T1DM and 85% of patients with T2DM knew that controlling blood pressure and lipids also was important. But one-quarter of the participants thought nothing could be done to prevent diabetic eye diseases—that they were the result of bad luck.
About 71% of the participants were examined by an ophthalmologist in the previous year. Exploring the reasons, the researchers found 3 main barriers: Patients said they had no visual symptoms, they felt they didn’t need an exam because their diabetes was well controlled, or they did not get recommendations from their family physician or diabetologist. The researchers say diabetic retinopathy may be underestimated because some patients are not getting eye exams.
Conversely, the 3 main reasons for regular eye exams, according to patient reports, were that health care professionals recommended them, patients were aware of the importance of regular controls, and they knew the risks of diabetes-related retinal problems.
The researchers say physicians can help by emphasizing that preventive care includes regular eye exams. They also suggest that it may be time to “broaden the diabetes education perspective” and include all significant diabetic eye diseases instead of focusing on diabetic retinopathy.
Source:
Konstantinidis L, Carron T, de Ancos E, et al. BMC Endocr Disord. 2017;17(1):56.
doi: 10.1186/s12902-017-0206-2.