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Surviving ovarian cancer: Is there an association between hospital volume and quality of care?
The relationship between procedure volume and outcomes has long been recognized: studies have concluded that patients operated on by high-volume surgeons at high-volume hospitals have improved outcomes.1,2 This paradigm is also associated with ovarian cancer outcomes. But what affect does adherence to evidence-based guidelines have on these statistics?
Jason D. Wright, MD, and colleagues at the Columbia University College of Physicians and Surgeons, in New York City, sought to determine whether strict adherence to quality metrics by hospitals could explain the association between hospital volume and ovarian cancer survival.3
Details of the study
Using the National Cancer Database (NCD), the research team identified 100,725 patients at 1,268 hospitals who were treated for invasive epithelial ovarian cancer between 2004 and 2013. Hospitals were stratified by annual case volume into quintiles: low-volume (≤2 cases; n = 299 [23.6%]), low-intermediate–volume (2.01–5 cases; n = 465 [36.7%]), intermediate-volume (5.01–9 cases; n = 157 [12.4%]), high-intermediate–volume (9.01–19.9 cases; n = 194 [15.3%]), and high-volume (≥20 cases; n = 153 [12.1%]).3
To measure quality, the authors defined hospital-level rates of 5 metrics based on clinical guidelines3:
- lymph node dissection performed for patients with stage I–IIIB tumors
- performance of omentectomy or cytoreduction for patients with advanced stage tumors
- use of chemotherapy among patients with early-stage, high-risk tumors
- omission of chemotherapy for women with early-stage, low-risk tumors
- use of chemotherapy (either neoadjuvant or adjuvant) for women with advanced-stage disease.
For each metric, the authors determined the rate of hospital-level compliance for all study-eligible patients. Then a composite variable of overall quality was derived using all 5 metrics. Based on the overall quality metric, hospitals were stratified into quartiles: low-quality, medium-low–quality, medium-high–quality, and high-quality.3
Hospital-level adjusted 2- and 5-year survival rates were compared based on volume and adherence to quality metrics.3
Related article:
2017 Update on ovarian cancer
Trends and conclusions
Researchers found that compliance with quality metrics generally increased with hospital volume. Trends of increased compliance were observed with lymph node dissection for early-stage tumors, cytoreduction for advanced-stage tumors, and use of chemotherapy for advanced-stage tumors. No trends were evident for use of chemotherapy for high-risk, early-stage tumors. By contrast, a trend for higher-volume hospitals to administer chemotherapy for low-risk, early-stage tumors was discovered. Adherence with the composite overall quality metric was noted in 64.2% of low-volume centers and increased with each volume category to 82.2% at the highest-volume hospitals.3
Study results indicated that survival increased with increasing hospital volume and with adherence to the quality metrics. The association between volume and quality was then examined. For each volume category, survival increased with increasing adherence to the quality metrics. In the highest-volume group, 2-year adjusted survival rose from 75.5% (95% confidence interval [CI], 73.2%–77.8%) at the lowest-quality hospitals, to 78.6% (95% CI, 78.0%–79.1%) at the highest-quality hospitals. Similar trends were found for intermediate-volume hospitals and for 5-year survival. However, the relationship between adherence to quality metrics and survival was less consistent for the low-, low-intermediate–, and high-intermediate–volume hospitals.3
The authors concluded that both hospital volume and adherence to quality metrics are associated with survival for ovarian cancer. Even though survival rates are improved at low-volume hospitals that are highly adherent to quality metrics, their survival rates are still lower than high-volume hospitals.
Read about the pros and cons of regionalization for high-risk ovarian cancer surgery.
Study limitations
The authors cite several limitations to this study:
- chosen quality metrics focused on care during initial treatment. Women with ovarian cancer are often treated for many years.
- the NCD lacks information on aspects like hospital infrastructure and staffing; there are probably other confounders that influence treatment and outcomes
- although NCD data have been validated, misclassification of a small number of patients may exist. Also, some hospitals did not treat patients who might be eligible for a quality metric and therefore were not included in this analysis.
- some study participants (13.7%) received treatment at multiple hospitals
- the volume cutpoints chosen by the research team were based on prior studies; there could be outcome variation within a volume strata.
Should high-risk surgeries be regionalized?
The association between higher surgical volume and improved outcomes has led to efforts to regionalize the care for high-risk operations to high-volume centers, say the authors. They conclude that this may be a reasonable strategy for some procedures. However, they suggest that regionalization presents practical difficulties:
- patients prefer to receive local care and are often unwilling to or cannot travel
- regionalization can worsen inequalities in access to care and may adversely affect low-volume hospitals
- high-volume centers do not exist in some areas of the country. A recent report suggested that 9% of the US female population had geographic barriers to receiving care from a gynecologic oncologist.4
Can low-volume facilities attain the same outcomes as high-volume centers?
The authors pose an important question: Can lower-volume facilities that deliver high-quality care achieve the same outcomes as higher-volume centers? With the difficulties associated with regionalization, many advocates seek strategies to raise the quality of care at low-volume centers, they say. The authors note that, “although outcomes improve at low-volume centers that are highly compliant with the quality metrics examined, survival at these centers is still lower than at high-volume centers.”3 The authors suggest that there are factors other than adherence to guidelines that play a role in how hospital volume affects ovarian cancer outcomes.3
Practice considerations
“Because the best outcomes appear to be achieved at high-volume hospitals, efforts to promote volume-based referral for women with ovarian cancer are reasonable,” the authors conclude.3 However, in practicality, many women will not be able to receive care at high-volume centers, they concede. “For low-volume centers, targeted quality improvement efforts and strict adherence to quality guidelines may help to optimize outcomes for women with ovarian cancer.”3
Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.
- Birkmeyer JC, Siewers AE, Finlayson EV, et al. Hospital volume and surgical mortality in the United States. N Eng J Med. 2002;346(15):1128–1137.
- Birkmeyer JC, Stukel TA, Siewers AE, Goodney PP, Wennberg DE, Lucas FL. Surgeon volume and operative mortality in the United States. New Engl J Med. 2003;349(22):2117–2127.
- Wright JD, Chen L, Hou JY, et al. Association of hospital volume and quality of care with survival for ovarian cancer. Obstet Gynecol. 2017;130(3):545–553.
- Shalowitz DI, Vinograd AM, Giuntoli RL II. Geographic access to gynecologic cancer care in the United States. Gynecol Oncol. 2015;138(1):115–120.
The relationship between procedure volume and outcomes has long been recognized: studies have concluded that patients operated on by high-volume surgeons at high-volume hospitals have improved outcomes.1,2 This paradigm is also associated with ovarian cancer outcomes. But what affect does adherence to evidence-based guidelines have on these statistics?
Jason D. Wright, MD, and colleagues at the Columbia University College of Physicians and Surgeons, in New York City, sought to determine whether strict adherence to quality metrics by hospitals could explain the association between hospital volume and ovarian cancer survival.3
Details of the study
Using the National Cancer Database (NCD), the research team identified 100,725 patients at 1,268 hospitals who were treated for invasive epithelial ovarian cancer between 2004 and 2013. Hospitals were stratified by annual case volume into quintiles: low-volume (≤2 cases; n = 299 [23.6%]), low-intermediate–volume (2.01–5 cases; n = 465 [36.7%]), intermediate-volume (5.01–9 cases; n = 157 [12.4%]), high-intermediate–volume (9.01–19.9 cases; n = 194 [15.3%]), and high-volume (≥20 cases; n = 153 [12.1%]).3
To measure quality, the authors defined hospital-level rates of 5 metrics based on clinical guidelines3:
- lymph node dissection performed for patients with stage I–IIIB tumors
- performance of omentectomy or cytoreduction for patients with advanced stage tumors
- use of chemotherapy among patients with early-stage, high-risk tumors
- omission of chemotherapy for women with early-stage, low-risk tumors
- use of chemotherapy (either neoadjuvant or adjuvant) for women with advanced-stage disease.
For each metric, the authors determined the rate of hospital-level compliance for all study-eligible patients. Then a composite variable of overall quality was derived using all 5 metrics. Based on the overall quality metric, hospitals were stratified into quartiles: low-quality, medium-low–quality, medium-high–quality, and high-quality.3
Hospital-level adjusted 2- and 5-year survival rates were compared based on volume and adherence to quality metrics.3
Related article:
2017 Update on ovarian cancer
Trends and conclusions
Researchers found that compliance with quality metrics generally increased with hospital volume. Trends of increased compliance were observed with lymph node dissection for early-stage tumors, cytoreduction for advanced-stage tumors, and use of chemotherapy for advanced-stage tumors. No trends were evident for use of chemotherapy for high-risk, early-stage tumors. By contrast, a trend for higher-volume hospitals to administer chemotherapy for low-risk, early-stage tumors was discovered. Adherence with the composite overall quality metric was noted in 64.2% of low-volume centers and increased with each volume category to 82.2% at the highest-volume hospitals.3
Study results indicated that survival increased with increasing hospital volume and with adherence to the quality metrics. The association between volume and quality was then examined. For each volume category, survival increased with increasing adherence to the quality metrics. In the highest-volume group, 2-year adjusted survival rose from 75.5% (95% confidence interval [CI], 73.2%–77.8%) at the lowest-quality hospitals, to 78.6% (95% CI, 78.0%–79.1%) at the highest-quality hospitals. Similar trends were found for intermediate-volume hospitals and for 5-year survival. However, the relationship between adherence to quality metrics and survival was less consistent for the low-, low-intermediate–, and high-intermediate–volume hospitals.3
The authors concluded that both hospital volume and adherence to quality metrics are associated with survival for ovarian cancer. Even though survival rates are improved at low-volume hospitals that are highly adherent to quality metrics, their survival rates are still lower than high-volume hospitals.
Read about the pros and cons of regionalization for high-risk ovarian cancer surgery.
Study limitations
The authors cite several limitations to this study:
- chosen quality metrics focused on care during initial treatment. Women with ovarian cancer are often treated for many years.
- the NCD lacks information on aspects like hospital infrastructure and staffing; there are probably other confounders that influence treatment and outcomes
- although NCD data have been validated, misclassification of a small number of patients may exist. Also, some hospitals did not treat patients who might be eligible for a quality metric and therefore were not included in this analysis.
- some study participants (13.7%) received treatment at multiple hospitals
- the volume cutpoints chosen by the research team were based on prior studies; there could be outcome variation within a volume strata.
Should high-risk surgeries be regionalized?
The association between higher surgical volume and improved outcomes has led to efforts to regionalize the care for high-risk operations to high-volume centers, say the authors. They conclude that this may be a reasonable strategy for some procedures. However, they suggest that regionalization presents practical difficulties:
- patients prefer to receive local care and are often unwilling to or cannot travel
- regionalization can worsen inequalities in access to care and may adversely affect low-volume hospitals
- high-volume centers do not exist in some areas of the country. A recent report suggested that 9% of the US female population had geographic barriers to receiving care from a gynecologic oncologist.4
Can low-volume facilities attain the same outcomes as high-volume centers?
The authors pose an important question: Can lower-volume facilities that deliver high-quality care achieve the same outcomes as higher-volume centers? With the difficulties associated with regionalization, many advocates seek strategies to raise the quality of care at low-volume centers, they say. The authors note that, “although outcomes improve at low-volume centers that are highly compliant with the quality metrics examined, survival at these centers is still lower than at high-volume centers.”3 The authors suggest that there are factors other than adherence to guidelines that play a role in how hospital volume affects ovarian cancer outcomes.3
Practice considerations
“Because the best outcomes appear to be achieved at high-volume hospitals, efforts to promote volume-based referral for women with ovarian cancer are reasonable,” the authors conclude.3 However, in practicality, many women will not be able to receive care at high-volume centers, they concede. “For low-volume centers, targeted quality improvement efforts and strict adherence to quality guidelines may help to optimize outcomes for women with ovarian cancer.”3
Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.
The relationship between procedure volume and outcomes has long been recognized: studies have concluded that patients operated on by high-volume surgeons at high-volume hospitals have improved outcomes.1,2 This paradigm is also associated with ovarian cancer outcomes. But what affect does adherence to evidence-based guidelines have on these statistics?
Jason D. Wright, MD, and colleagues at the Columbia University College of Physicians and Surgeons, in New York City, sought to determine whether strict adherence to quality metrics by hospitals could explain the association between hospital volume and ovarian cancer survival.3
Details of the study
Using the National Cancer Database (NCD), the research team identified 100,725 patients at 1,268 hospitals who were treated for invasive epithelial ovarian cancer between 2004 and 2013. Hospitals were stratified by annual case volume into quintiles: low-volume (≤2 cases; n = 299 [23.6%]), low-intermediate–volume (2.01–5 cases; n = 465 [36.7%]), intermediate-volume (5.01–9 cases; n = 157 [12.4%]), high-intermediate–volume (9.01–19.9 cases; n = 194 [15.3%]), and high-volume (≥20 cases; n = 153 [12.1%]).3
To measure quality, the authors defined hospital-level rates of 5 metrics based on clinical guidelines3:
- lymph node dissection performed for patients with stage I–IIIB tumors
- performance of omentectomy or cytoreduction for patients with advanced stage tumors
- use of chemotherapy among patients with early-stage, high-risk tumors
- omission of chemotherapy for women with early-stage, low-risk tumors
- use of chemotherapy (either neoadjuvant or adjuvant) for women with advanced-stage disease.
For each metric, the authors determined the rate of hospital-level compliance for all study-eligible patients. Then a composite variable of overall quality was derived using all 5 metrics. Based on the overall quality metric, hospitals were stratified into quartiles: low-quality, medium-low–quality, medium-high–quality, and high-quality.3
Hospital-level adjusted 2- and 5-year survival rates were compared based on volume and adherence to quality metrics.3
Related article:
2017 Update on ovarian cancer
Trends and conclusions
Researchers found that compliance with quality metrics generally increased with hospital volume. Trends of increased compliance were observed with lymph node dissection for early-stage tumors, cytoreduction for advanced-stage tumors, and use of chemotherapy for advanced-stage tumors. No trends were evident for use of chemotherapy for high-risk, early-stage tumors. By contrast, a trend for higher-volume hospitals to administer chemotherapy for low-risk, early-stage tumors was discovered. Adherence with the composite overall quality metric was noted in 64.2% of low-volume centers and increased with each volume category to 82.2% at the highest-volume hospitals.3
Study results indicated that survival increased with increasing hospital volume and with adherence to the quality metrics. The association between volume and quality was then examined. For each volume category, survival increased with increasing adherence to the quality metrics. In the highest-volume group, 2-year adjusted survival rose from 75.5% (95% confidence interval [CI], 73.2%–77.8%) at the lowest-quality hospitals, to 78.6% (95% CI, 78.0%–79.1%) at the highest-quality hospitals. Similar trends were found for intermediate-volume hospitals and for 5-year survival. However, the relationship between adherence to quality metrics and survival was less consistent for the low-, low-intermediate–, and high-intermediate–volume hospitals.3
The authors concluded that both hospital volume and adherence to quality metrics are associated with survival for ovarian cancer. Even though survival rates are improved at low-volume hospitals that are highly adherent to quality metrics, their survival rates are still lower than high-volume hospitals.
Read about the pros and cons of regionalization for high-risk ovarian cancer surgery.
Study limitations
The authors cite several limitations to this study:
- chosen quality metrics focused on care during initial treatment. Women with ovarian cancer are often treated for many years.
- the NCD lacks information on aspects like hospital infrastructure and staffing; there are probably other confounders that influence treatment and outcomes
- although NCD data have been validated, misclassification of a small number of patients may exist. Also, some hospitals did not treat patients who might be eligible for a quality metric and therefore were not included in this analysis.
- some study participants (13.7%) received treatment at multiple hospitals
- the volume cutpoints chosen by the research team were based on prior studies; there could be outcome variation within a volume strata.
Should high-risk surgeries be regionalized?
The association between higher surgical volume and improved outcomes has led to efforts to regionalize the care for high-risk operations to high-volume centers, say the authors. They conclude that this may be a reasonable strategy for some procedures. However, they suggest that regionalization presents practical difficulties:
- patients prefer to receive local care and are often unwilling to or cannot travel
- regionalization can worsen inequalities in access to care and may adversely affect low-volume hospitals
- high-volume centers do not exist in some areas of the country. A recent report suggested that 9% of the US female population had geographic barriers to receiving care from a gynecologic oncologist.4
Can low-volume facilities attain the same outcomes as high-volume centers?
The authors pose an important question: Can lower-volume facilities that deliver high-quality care achieve the same outcomes as higher-volume centers? With the difficulties associated with regionalization, many advocates seek strategies to raise the quality of care at low-volume centers, they say. The authors note that, “although outcomes improve at low-volume centers that are highly compliant with the quality metrics examined, survival at these centers is still lower than at high-volume centers.”3 The authors suggest that there are factors other than adherence to guidelines that play a role in how hospital volume affects ovarian cancer outcomes.3
Practice considerations
“Because the best outcomes appear to be achieved at high-volume hospitals, efforts to promote volume-based referral for women with ovarian cancer are reasonable,” the authors conclude.3 However, in practicality, many women will not be able to receive care at high-volume centers, they concede. “For low-volume centers, targeted quality improvement efforts and strict adherence to quality guidelines may help to optimize outcomes for women with ovarian cancer.”3
Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.
- Birkmeyer JC, Siewers AE, Finlayson EV, et al. Hospital volume and surgical mortality in the United States. N Eng J Med. 2002;346(15):1128–1137.
- Birkmeyer JC, Stukel TA, Siewers AE, Goodney PP, Wennberg DE, Lucas FL. Surgeon volume and operative mortality in the United States. New Engl J Med. 2003;349(22):2117–2127.
- Wright JD, Chen L, Hou JY, et al. Association of hospital volume and quality of care with survival for ovarian cancer. Obstet Gynecol. 2017;130(3):545–553.
- Shalowitz DI, Vinograd AM, Giuntoli RL II. Geographic access to gynecologic cancer care in the United States. Gynecol Oncol. 2015;138(1):115–120.
- Birkmeyer JC, Siewers AE, Finlayson EV, et al. Hospital volume and surgical mortality in the United States. N Eng J Med. 2002;346(15):1128–1137.
- Birkmeyer JC, Stukel TA, Siewers AE, Goodney PP, Wennberg DE, Lucas FL. Surgeon volume and operative mortality in the United States. New Engl J Med. 2003;349(22):2117–2127.
- Wright JD, Chen L, Hou JY, et al. Association of hospital volume and quality of care with survival for ovarian cancer. Obstet Gynecol. 2017;130(3):545–553.
- Shalowitz DI, Vinograd AM, Giuntoli RL II. Geographic access to gynecologic cancer care in the United States. Gynecol Oncol. 2015;138(1):115–120.
Rapid genomic testing can diagnose critically ill infants
Rapid, targeted genomic sequencing shows promise in quickly diagnosing critically ill infants for whom standard clinical work-ups were unsuccessful, according to Cleo C. van Diemen, PhD, of the University of Groningen (the Netherlands), and associates.
Over the course of 1 year, 23 critically ill infants younger than 12 months who had no clear diagnosis after standard clinical work-ups underwent rapid, targeted genomics, with 7 receiving a genetic diagnosis. The median turnaround time was 12 days, falling from roughly 3 weeks at the beginning of the study to a maximum of 8 days by the end of the study.
Compound heterozygous mutations in the EPG5, RMND1, and EIF2B5 genes allowed for diagnoses of Vici syndrome, combined oxidative phosphorylation deficiency-11, and vanishing white matter, respectively. Homozygous mutations in the KLHL41, GFER, and GLB1 genes allowed for diagnoses of nemaline myopathy, progressive mitochondrial myopathy, and GM1-gangliosidosis, respectively. In addition, a 1p36.33p36.32 microdeletion was discovered in an infant with cardiomyopathy.
“The clinical relevance of rapid genome diagnostics lies in the fact that these results can be used in the clinical decisions made in caring for critically ill children in ICUs, in better genetic counseling of the parents, and in guiding their future reproductive choices,” the investigators noted.
Find the full study in Pediatrics (2017 Sep 22. doi: 10.1542/ peds.2016-2854).
Rapid, targeted genomic sequencing shows promise in quickly diagnosing critically ill infants for whom standard clinical work-ups were unsuccessful, according to Cleo C. van Diemen, PhD, of the University of Groningen (the Netherlands), and associates.
Over the course of 1 year, 23 critically ill infants younger than 12 months who had no clear diagnosis after standard clinical work-ups underwent rapid, targeted genomics, with 7 receiving a genetic diagnosis. The median turnaround time was 12 days, falling from roughly 3 weeks at the beginning of the study to a maximum of 8 days by the end of the study.
Compound heterozygous mutations in the EPG5, RMND1, and EIF2B5 genes allowed for diagnoses of Vici syndrome, combined oxidative phosphorylation deficiency-11, and vanishing white matter, respectively. Homozygous mutations in the KLHL41, GFER, and GLB1 genes allowed for diagnoses of nemaline myopathy, progressive mitochondrial myopathy, and GM1-gangliosidosis, respectively. In addition, a 1p36.33p36.32 microdeletion was discovered in an infant with cardiomyopathy.
“The clinical relevance of rapid genome diagnostics lies in the fact that these results can be used in the clinical decisions made in caring for critically ill children in ICUs, in better genetic counseling of the parents, and in guiding their future reproductive choices,” the investigators noted.
Find the full study in Pediatrics (2017 Sep 22. doi: 10.1542/ peds.2016-2854).
Rapid, targeted genomic sequencing shows promise in quickly diagnosing critically ill infants for whom standard clinical work-ups were unsuccessful, according to Cleo C. van Diemen, PhD, of the University of Groningen (the Netherlands), and associates.
Over the course of 1 year, 23 critically ill infants younger than 12 months who had no clear diagnosis after standard clinical work-ups underwent rapid, targeted genomics, with 7 receiving a genetic diagnosis. The median turnaround time was 12 days, falling from roughly 3 weeks at the beginning of the study to a maximum of 8 days by the end of the study.
Compound heterozygous mutations in the EPG5, RMND1, and EIF2B5 genes allowed for diagnoses of Vici syndrome, combined oxidative phosphorylation deficiency-11, and vanishing white matter, respectively. Homozygous mutations in the KLHL41, GFER, and GLB1 genes allowed for diagnoses of nemaline myopathy, progressive mitochondrial myopathy, and GM1-gangliosidosis, respectively. In addition, a 1p36.33p36.32 microdeletion was discovered in an infant with cardiomyopathy.
“The clinical relevance of rapid genome diagnostics lies in the fact that these results can be used in the clinical decisions made in caring for critically ill children in ICUs, in better genetic counseling of the parents, and in guiding their future reproductive choices,” the investigators noted.
Find the full study in Pediatrics (2017 Sep 22. doi: 10.1542/ peds.2016-2854).
FROM PEDIATRICS
Research mentors an invaluable resource to students
Editor’s Note: The Society of Hospital Medicine’s (SHM’s) Physician in Training Committee launched a scholarship program in 2015 for medical students to help transform health care and revolutionize patient care. The program has been expanded for the 2017-18 year, offering two options for students to receive funding and engage in scholarly work during their 1st, 2nd, and 3rd years of medical school. As a part of the program, recipients are required to write about their experience on a biweekly basis.
As a medical student, the summer is an excellent time to pursue extracurricular activities. While some people take these weeks to learn new skills in basic science laboratories or travel abroad for international electives, many will assume the role of a student researcher. But, with only 10 weeks of dedicated research time in the summer it can be challenging to see a project from start to finish.
The greatest challenge, however, is not in identifying a project that is possible to complete in 10 weeks. Instead, it has to do with the fact that as students we are inexperienced researchers, and such a short timeline leaves little room to troubleshoot problems when they inevitably arise. This, among other reasons, is why research mentors are an invaluable resource to students.
While my research mentor has helped tremendously in logistical tasks, such as helping me write a research proposal and navigate the IRB process, it’s his experience and knowledge of the research process that I’ve found to be most critical during this 10 week period. During the planning of the project he helped me identify pitfalls and weaknesses in our methods, which has helped me avoid major setbacks during the execution of the project. As a result, the project has been running smoothly and I have yet to run into any significant problems.
Reflecting on this fact has reminded me of the importance of planning ahead. We started outlining and planning this project about 6 months before my research period officially began, when we could both mull over the details without the pressure of time. Though unforeseen problems may still arise, I think this strategy has made all the difference and it’s a lesson I will take with me for future projects.
Cole Hirschfeld is originally from Phoenix. He received undergraduate degrees in finance and entrepreneurship from the University of Arizona and went on to work in the finance industry for 2 years before deciding to change careers and attend medical school. He is now a 4th year medical student at Cornell University, New York, and plans to apply for residency in internal medicine.
Editor’s Note: The Society of Hospital Medicine’s (SHM’s) Physician in Training Committee launched a scholarship program in 2015 for medical students to help transform health care and revolutionize patient care. The program has been expanded for the 2017-18 year, offering two options for students to receive funding and engage in scholarly work during their 1st, 2nd, and 3rd years of medical school. As a part of the program, recipients are required to write about their experience on a biweekly basis.
As a medical student, the summer is an excellent time to pursue extracurricular activities. While some people take these weeks to learn new skills in basic science laboratories or travel abroad for international electives, many will assume the role of a student researcher. But, with only 10 weeks of dedicated research time in the summer it can be challenging to see a project from start to finish.
The greatest challenge, however, is not in identifying a project that is possible to complete in 10 weeks. Instead, it has to do with the fact that as students we are inexperienced researchers, and such a short timeline leaves little room to troubleshoot problems when they inevitably arise. This, among other reasons, is why research mentors are an invaluable resource to students.
While my research mentor has helped tremendously in logistical tasks, such as helping me write a research proposal and navigate the IRB process, it’s his experience and knowledge of the research process that I’ve found to be most critical during this 10 week period. During the planning of the project he helped me identify pitfalls and weaknesses in our methods, which has helped me avoid major setbacks during the execution of the project. As a result, the project has been running smoothly and I have yet to run into any significant problems.
Reflecting on this fact has reminded me of the importance of planning ahead. We started outlining and planning this project about 6 months before my research period officially began, when we could both mull over the details without the pressure of time. Though unforeseen problems may still arise, I think this strategy has made all the difference and it’s a lesson I will take with me for future projects.
Cole Hirschfeld is originally from Phoenix. He received undergraduate degrees in finance and entrepreneurship from the University of Arizona and went on to work in the finance industry for 2 years before deciding to change careers and attend medical school. He is now a 4th year medical student at Cornell University, New York, and plans to apply for residency in internal medicine.
Editor’s Note: The Society of Hospital Medicine’s (SHM’s) Physician in Training Committee launched a scholarship program in 2015 for medical students to help transform health care and revolutionize patient care. The program has been expanded for the 2017-18 year, offering two options for students to receive funding and engage in scholarly work during their 1st, 2nd, and 3rd years of medical school. As a part of the program, recipients are required to write about their experience on a biweekly basis.
As a medical student, the summer is an excellent time to pursue extracurricular activities. While some people take these weeks to learn new skills in basic science laboratories or travel abroad for international electives, many will assume the role of a student researcher. But, with only 10 weeks of dedicated research time in the summer it can be challenging to see a project from start to finish.
The greatest challenge, however, is not in identifying a project that is possible to complete in 10 weeks. Instead, it has to do with the fact that as students we are inexperienced researchers, and such a short timeline leaves little room to troubleshoot problems when they inevitably arise. This, among other reasons, is why research mentors are an invaluable resource to students.
While my research mentor has helped tremendously in logistical tasks, such as helping me write a research proposal and navigate the IRB process, it’s his experience and knowledge of the research process that I’ve found to be most critical during this 10 week period. During the planning of the project he helped me identify pitfalls and weaknesses in our methods, which has helped me avoid major setbacks during the execution of the project. As a result, the project has been running smoothly and I have yet to run into any significant problems.
Reflecting on this fact has reminded me of the importance of planning ahead. We started outlining and planning this project about 6 months before my research period officially began, when we could both mull over the details without the pressure of time. Though unforeseen problems may still arise, I think this strategy has made all the difference and it’s a lesson I will take with me for future projects.
Cole Hirschfeld is originally from Phoenix. He received undergraduate degrees in finance and entrepreneurship from the University of Arizona and went on to work in the finance industry for 2 years before deciding to change careers and attend medical school. He is now a 4th year medical student at Cornell University, New York, and plans to apply for residency in internal medicine.
High rate of cannabis use among cancer patients
A survey has found that 24% of cancer patients at an ambulatory cancer center in Seattle report being active cannabis users.
Respondents said that the legalization of both medical and recreational marijuana increased the likelihood that they’d use the drug, and with most having a strong interest in learning about cannabis during treatment, according to findings published online Sept. 25 in Cancer (doi: 10.1002/cncr.30879).
A total of 926 of 2,737 possible patients – or 34% – filled out the survey.
Twenty-four percent had used cannabis in the last year, and 21% in the last month, with about half smoking cannabis and half consuming edibles.
About half of the respondents reported using cannabis for pain, the top physical symptom for use, with nausea a close second. About 30 to 50% of patients reported using cannabis for nonphysical symptoms such as depression and mood problems. But the researchers noted that the evidence of benefit is mixed at best for all of these symptoms.
“There is a need to better understand methods of cannabis use,” Dr. Pergam said, “to maximize benefit and limit risk because patients are already using a wide variety of products.”
Researchers reported receiving consulting fees from Merck Sharp & Dohme, Optimer/Cubist Pharmaceuticals, Gilead Sciences, and Quartet Health.
A survey has found that 24% of cancer patients at an ambulatory cancer center in Seattle report being active cannabis users.
Respondents said that the legalization of both medical and recreational marijuana increased the likelihood that they’d use the drug, and with most having a strong interest in learning about cannabis during treatment, according to findings published online Sept. 25 in Cancer (doi: 10.1002/cncr.30879).
A total of 926 of 2,737 possible patients – or 34% – filled out the survey.
Twenty-four percent had used cannabis in the last year, and 21% in the last month, with about half smoking cannabis and half consuming edibles.
About half of the respondents reported using cannabis for pain, the top physical symptom for use, with nausea a close second. About 30 to 50% of patients reported using cannabis for nonphysical symptoms such as depression and mood problems. But the researchers noted that the evidence of benefit is mixed at best for all of these symptoms.
“There is a need to better understand methods of cannabis use,” Dr. Pergam said, “to maximize benefit and limit risk because patients are already using a wide variety of products.”
Researchers reported receiving consulting fees from Merck Sharp & Dohme, Optimer/Cubist Pharmaceuticals, Gilead Sciences, and Quartet Health.
A survey has found that 24% of cancer patients at an ambulatory cancer center in Seattle report being active cannabis users.
Respondents said that the legalization of both medical and recreational marijuana increased the likelihood that they’d use the drug, and with most having a strong interest in learning about cannabis during treatment, according to findings published online Sept. 25 in Cancer (doi: 10.1002/cncr.30879).
A total of 926 of 2,737 possible patients – or 34% – filled out the survey.
Twenty-four percent had used cannabis in the last year, and 21% in the last month, with about half smoking cannabis and half consuming edibles.
About half of the respondents reported using cannabis for pain, the top physical symptom for use, with nausea a close second. About 30 to 50% of patients reported using cannabis for nonphysical symptoms such as depression and mood problems. But the researchers noted that the evidence of benefit is mixed at best for all of these symptoms.
“There is a need to better understand methods of cannabis use,” Dr. Pergam said, “to maximize benefit and limit risk because patients are already using a wide variety of products.”
Researchers reported receiving consulting fees from Merck Sharp & Dohme, Optimer/Cubist Pharmaceuticals, Gilead Sciences, and Quartet Health.
FROM CANCER
Key clinical point:
Major finding: Twenty-four percent of patients reported using cannabis in the past year, mostly for pain and nausea.
Data source: A survey of patients at an ambulatory cancer center in Seattle, where cannabis is legal for medical and recreational use.
Disclosures: Researchers reported receiving consulting fees from Merck Sharp & Dohme, Optimer/Cubist Pharmaceuticals, Gilead Sciences, and Quartet Health.
GEICAM/2006-10: Adjuvant fulvestrant/anastrozole role in early breast cancer uncertain
MADRID – Until funders pulled the financial rug out from under them, investigators in the GEICAM/2006-10 trial thought they were going to find out whether adding fulvestrant (Faslodex) to anastrozole (Femara) could improve disease-free survival for postmenopausal women with early-stage hormone receptor–positive/human epidermal growth factor receptor 2–negative (HR+/HER2–) breast cancer.
But, when the results of the FACT trial were published, showing no advantage for fulvestrant and anastrozole over anastrozole alone as first-line therapy for postmenopausal women with HR+ breast cancer, recruitment in the GEICAM 2006-10 trial was halted midstream after only 872 of the planned 2852 patients were enrolled.
“Fulvestrant at the current recommended dose of 500 mg merits further testing as adjuvant endocrine therapy, either alone, in sequence, or in combination with aromatase inhibitors,” he said.
Invited discussant Nadia Harbeck, MD, PhD, from the University of Munich, agreed.
“I just want to urge you that you don’t take this as [evidence of] nonefficacy of a SERD in the adjuvant setting, but it’s a trial with an underdosed drug, and there could be better development in future with a novel compound to come or even with fulvestrant at a better dose,” she said.
Approximately 15% of patients with HR+ breast cancer treated with endocrine therapy have a relapse within the first 5 years of therapy, which led investigators to speculate whether incomplete suppression of estrogen receptors could lead to resistance to aromatase inhibitors (AIs), such as anastrozole.
The GEICAM/2006-10 trial was designed to see whether achieving a complete estrogen blockade with an AI, minimizing serum estradiol levels, and using the SERD fulvestrant to prevent activation of tumor estrogen receptors could prove a more effective treatment strategy than endocrine therapy with an AI alone, Dr. Ruíz-Borrego explained.
The investigators enrolled postmenopausal women with early-stage breast cancer who had undergone surgery with or without neoadjuvant or adjuvant chemotherapy, and – after stratification for number of lymph nodes, for chemotherapy, and for hormone receptor status (positive for estrogen and/or progesterone receptors) – randomly assigned them to oral anastrozole 1 mg daily or oral anastrozole 1mg daily plus fulvestrant delivered intramuscularly 500 mg on the first day of treatment, 250 mg on days 14 and 28, then 250 mg every 28 days thereafter for 3 years.
As noted, only 872 of the initial target of 2,825 patients were enrolled and randomized to both fulvestrant and anastrozole (435 patients) or to anastrozole alone (437).
After 5 years of follow-up, there were no significant differences in either the primary endpoint of disease-free survival between patients treated with the combination and those treated with anastrozole alone (90.97% vs. 90.76%, respectively). Similarly, there were no differences in the secondary endpoints of breast cancer–specific survival (93.17% vs. 92.39%) or overall survival (94.81% vs. 95.34%).
The trial results “reflect on the checkered history of the development of this drug [fulvestrant], which probably missed out on a great potential for patients to get access to a drug like this in the early breast cancer setting,” Dr. Harbeck remarked. The trial results were muddied by the abrupt closure of accrual and by the use of a fulvestrant dose half that of the currently recommended dose, she noted, adding that there is preclinical evidence to suggest that fulvestrant and anastrozole combined may be less effective than if the drugs were used in sequence.
“So maybe, for the further development of SERDs, we may want to go into more sequencing than combination strategies,” she said.
The trial was funded by AstraZeneca, although funding was withdrawn before full recruitment was completed. Dr. Ruíz-Borrego and Dr. Harbeck reported having no relevant disclosures.
MADRID – Until funders pulled the financial rug out from under them, investigators in the GEICAM/2006-10 trial thought they were going to find out whether adding fulvestrant (Faslodex) to anastrozole (Femara) could improve disease-free survival for postmenopausal women with early-stage hormone receptor–positive/human epidermal growth factor receptor 2–negative (HR+/HER2–) breast cancer.
But, when the results of the FACT trial were published, showing no advantage for fulvestrant and anastrozole over anastrozole alone as first-line therapy for postmenopausal women with HR+ breast cancer, recruitment in the GEICAM 2006-10 trial was halted midstream after only 872 of the planned 2852 patients were enrolled.
“Fulvestrant at the current recommended dose of 500 mg merits further testing as adjuvant endocrine therapy, either alone, in sequence, or in combination with aromatase inhibitors,” he said.
Invited discussant Nadia Harbeck, MD, PhD, from the University of Munich, agreed.
“I just want to urge you that you don’t take this as [evidence of] nonefficacy of a SERD in the adjuvant setting, but it’s a trial with an underdosed drug, and there could be better development in future with a novel compound to come or even with fulvestrant at a better dose,” she said.
Approximately 15% of patients with HR+ breast cancer treated with endocrine therapy have a relapse within the first 5 years of therapy, which led investigators to speculate whether incomplete suppression of estrogen receptors could lead to resistance to aromatase inhibitors (AIs), such as anastrozole.
The GEICAM/2006-10 trial was designed to see whether achieving a complete estrogen blockade with an AI, minimizing serum estradiol levels, and using the SERD fulvestrant to prevent activation of tumor estrogen receptors could prove a more effective treatment strategy than endocrine therapy with an AI alone, Dr. Ruíz-Borrego explained.
The investigators enrolled postmenopausal women with early-stage breast cancer who had undergone surgery with or without neoadjuvant or adjuvant chemotherapy, and – after stratification for number of lymph nodes, for chemotherapy, and for hormone receptor status (positive for estrogen and/or progesterone receptors) – randomly assigned them to oral anastrozole 1 mg daily or oral anastrozole 1mg daily plus fulvestrant delivered intramuscularly 500 mg on the first day of treatment, 250 mg on days 14 and 28, then 250 mg every 28 days thereafter for 3 years.
As noted, only 872 of the initial target of 2,825 patients were enrolled and randomized to both fulvestrant and anastrozole (435 patients) or to anastrozole alone (437).
After 5 years of follow-up, there were no significant differences in either the primary endpoint of disease-free survival between patients treated with the combination and those treated with anastrozole alone (90.97% vs. 90.76%, respectively). Similarly, there were no differences in the secondary endpoints of breast cancer–specific survival (93.17% vs. 92.39%) or overall survival (94.81% vs. 95.34%).
The trial results “reflect on the checkered history of the development of this drug [fulvestrant], which probably missed out on a great potential for patients to get access to a drug like this in the early breast cancer setting,” Dr. Harbeck remarked. The trial results were muddied by the abrupt closure of accrual and by the use of a fulvestrant dose half that of the currently recommended dose, she noted, adding that there is preclinical evidence to suggest that fulvestrant and anastrozole combined may be less effective than if the drugs were used in sequence.
“So maybe, for the further development of SERDs, we may want to go into more sequencing than combination strategies,” she said.
The trial was funded by AstraZeneca, although funding was withdrawn before full recruitment was completed. Dr. Ruíz-Borrego and Dr. Harbeck reported having no relevant disclosures.
MADRID – Until funders pulled the financial rug out from under them, investigators in the GEICAM/2006-10 trial thought they were going to find out whether adding fulvestrant (Faslodex) to anastrozole (Femara) could improve disease-free survival for postmenopausal women with early-stage hormone receptor–positive/human epidermal growth factor receptor 2–negative (HR+/HER2–) breast cancer.
But, when the results of the FACT trial were published, showing no advantage for fulvestrant and anastrozole over anastrozole alone as first-line therapy for postmenopausal women with HR+ breast cancer, recruitment in the GEICAM 2006-10 trial was halted midstream after only 872 of the planned 2852 patients were enrolled.
“Fulvestrant at the current recommended dose of 500 mg merits further testing as adjuvant endocrine therapy, either alone, in sequence, or in combination with aromatase inhibitors,” he said.
Invited discussant Nadia Harbeck, MD, PhD, from the University of Munich, agreed.
“I just want to urge you that you don’t take this as [evidence of] nonefficacy of a SERD in the adjuvant setting, but it’s a trial with an underdosed drug, and there could be better development in future with a novel compound to come or even with fulvestrant at a better dose,” she said.
Approximately 15% of patients with HR+ breast cancer treated with endocrine therapy have a relapse within the first 5 years of therapy, which led investigators to speculate whether incomplete suppression of estrogen receptors could lead to resistance to aromatase inhibitors (AIs), such as anastrozole.
The GEICAM/2006-10 trial was designed to see whether achieving a complete estrogen blockade with an AI, minimizing serum estradiol levels, and using the SERD fulvestrant to prevent activation of tumor estrogen receptors could prove a more effective treatment strategy than endocrine therapy with an AI alone, Dr. Ruíz-Borrego explained.
The investigators enrolled postmenopausal women with early-stage breast cancer who had undergone surgery with or without neoadjuvant or adjuvant chemotherapy, and – after stratification for number of lymph nodes, for chemotherapy, and for hormone receptor status (positive for estrogen and/or progesterone receptors) – randomly assigned them to oral anastrozole 1 mg daily or oral anastrozole 1mg daily plus fulvestrant delivered intramuscularly 500 mg on the first day of treatment, 250 mg on days 14 and 28, then 250 mg every 28 days thereafter for 3 years.
As noted, only 872 of the initial target of 2,825 patients were enrolled and randomized to both fulvestrant and anastrozole (435 patients) or to anastrozole alone (437).
After 5 years of follow-up, there were no significant differences in either the primary endpoint of disease-free survival between patients treated with the combination and those treated with anastrozole alone (90.97% vs. 90.76%, respectively). Similarly, there were no differences in the secondary endpoints of breast cancer–specific survival (93.17% vs. 92.39%) or overall survival (94.81% vs. 95.34%).
The trial results “reflect on the checkered history of the development of this drug [fulvestrant], which probably missed out on a great potential for patients to get access to a drug like this in the early breast cancer setting,” Dr. Harbeck remarked. The trial results were muddied by the abrupt closure of accrual and by the use of a fulvestrant dose half that of the currently recommended dose, she noted, adding that there is preclinical evidence to suggest that fulvestrant and anastrozole combined may be less effective than if the drugs were used in sequence.
“So maybe, for the further development of SERDs, we may want to go into more sequencing than combination strategies,” she said.
The trial was funded by AstraZeneca, although funding was withdrawn before full recruitment was completed. Dr. Ruíz-Borrego and Dr. Harbeck reported having no relevant disclosures.
AT ESMO 2017
Key clinical point: Adding fulvestrant to anastrozole did not improve outcomes in women with HR+/HER2– early-stage breast cancer, but the trial was hampered by early closure.
Major finding: There were no significant differences in disease-free, breast cancer–specific, or overall survival with fulvestrant/anastrozole vs. anastrozole alone.
Data source: Randomized phase 3 trial in 872 of 2,582 planned patients.
Disclosures: The trial was funded by AstraZeneca, although funding was withdrawn before full recruitment was completed. Dr. Ruíz-Borrego and Dr. Harbeck reported having no relevant disclosures.
Hidradenitis Suppurativa: A New Indication for Adalimumab
Battling physician burnout delivers monetary benefits for health care organizations
The financial impact of physician burnout can provide a guide to help organizations address the problem, according to a special communication published online in JAMA Internal Medicine.
Approximately half of U.S. physicians experience some degree of professional burnout, but health care organizations have done little to respond, wrote Tait Shanafelt, MD, of Stanford (Calif.) University, and colleagues (JAMA Intern Med. 2017 Sep 25. doi: 10.1001/jamainternmed.2017.4340).
The researchers cited “a lack of awareness regarding the economic costs of physician burnout” and a lack of confidence that anything can be done as key factors in why the organizational response to burnout has been so limited.
The business end of physician burnout includes the costs associated with physician turnover and decreased productivity, as well as “financial risks to the organization’s long-term viability due to the relationship between burnout and lower quality of care, decreased patient satisfaction, and problems with patient safety,” the researchers said.
Organizations can combat physician burnout, the authors noted, and the effort is financially worthwhile, as well as morally and ethically important. “Burnout is primarily a system-level problem driven by excess job demands and inadequate resources and support, not an individual problem triggered by personal limitations,” they wrote.
The researchers developed a model outlining “Typical Steps in an Organization’s Journey Toward Expertise in Physician Well-being.” The steps begin with strategies that have a minor impact, including awareness of the problem of physician burnout and a focus on individual interventions such as mindfulness training, exercise, and nutrition.
However, the “transformative” changes in an organization include developing a “culture of wellness,” strategic investment in physician well-being, the presence of a “chief well-being officer” at the executive level, and accountability for physician wellness shared among organizational leaders.
The cost of such strategies varies among institutions, and the researchers provided worksheets to calculate the organizational cost of burnout and the return on investment if intervention steps are taken.
For example, an organization employing 450 physicians could potentially spend $1 million per year on an intervention to reduce physician burnout from 50% to 40%. The intervention investment could yield organizational cost savings of $1.125 million per year, with a 12.5% return on investment, as well as the potential financial benefits of improved patient satisfaction and quality of care.
“Understanding the business case to reduce burnout and promote engagement, as well as overcoming the misperception that nothing meaningful can be done, are key steps for organizations to begin to take action,” the researchers concluded.
“Improvement is possible, investment is justified, and return on investment measurable,” they said.
Dr. Shanafelt is a coinventor of the Physician Well-Being Index, Medical Student Well-Being Index, and Well-Being Index; copyright and licensing rights for these tools belong to the Mayo Clinic, and Dr. Shanafelt receives part of the royalties. The researchers had no other financial conflicts to disclose.
The financial impact of physician burnout can provide a guide to help organizations address the problem, according to a special communication published online in JAMA Internal Medicine.
Approximately half of U.S. physicians experience some degree of professional burnout, but health care organizations have done little to respond, wrote Tait Shanafelt, MD, of Stanford (Calif.) University, and colleagues (JAMA Intern Med. 2017 Sep 25. doi: 10.1001/jamainternmed.2017.4340).
The researchers cited “a lack of awareness regarding the economic costs of physician burnout” and a lack of confidence that anything can be done as key factors in why the organizational response to burnout has been so limited.
The business end of physician burnout includes the costs associated with physician turnover and decreased productivity, as well as “financial risks to the organization’s long-term viability due to the relationship between burnout and lower quality of care, decreased patient satisfaction, and problems with patient safety,” the researchers said.
Organizations can combat physician burnout, the authors noted, and the effort is financially worthwhile, as well as morally and ethically important. “Burnout is primarily a system-level problem driven by excess job demands and inadequate resources and support, not an individual problem triggered by personal limitations,” they wrote.
The researchers developed a model outlining “Typical Steps in an Organization’s Journey Toward Expertise in Physician Well-being.” The steps begin with strategies that have a minor impact, including awareness of the problem of physician burnout and a focus on individual interventions such as mindfulness training, exercise, and nutrition.
However, the “transformative” changes in an organization include developing a “culture of wellness,” strategic investment in physician well-being, the presence of a “chief well-being officer” at the executive level, and accountability for physician wellness shared among organizational leaders.
The cost of such strategies varies among institutions, and the researchers provided worksheets to calculate the organizational cost of burnout and the return on investment if intervention steps are taken.
For example, an organization employing 450 physicians could potentially spend $1 million per year on an intervention to reduce physician burnout from 50% to 40%. The intervention investment could yield organizational cost savings of $1.125 million per year, with a 12.5% return on investment, as well as the potential financial benefits of improved patient satisfaction and quality of care.
“Understanding the business case to reduce burnout and promote engagement, as well as overcoming the misperception that nothing meaningful can be done, are key steps for organizations to begin to take action,” the researchers concluded.
“Improvement is possible, investment is justified, and return on investment measurable,” they said.
Dr. Shanafelt is a coinventor of the Physician Well-Being Index, Medical Student Well-Being Index, and Well-Being Index; copyright and licensing rights for these tools belong to the Mayo Clinic, and Dr. Shanafelt receives part of the royalties. The researchers had no other financial conflicts to disclose.
The financial impact of physician burnout can provide a guide to help organizations address the problem, according to a special communication published online in JAMA Internal Medicine.
Approximately half of U.S. physicians experience some degree of professional burnout, but health care organizations have done little to respond, wrote Tait Shanafelt, MD, of Stanford (Calif.) University, and colleagues (JAMA Intern Med. 2017 Sep 25. doi: 10.1001/jamainternmed.2017.4340).
The researchers cited “a lack of awareness regarding the economic costs of physician burnout” and a lack of confidence that anything can be done as key factors in why the organizational response to burnout has been so limited.
The business end of physician burnout includes the costs associated with physician turnover and decreased productivity, as well as “financial risks to the organization’s long-term viability due to the relationship between burnout and lower quality of care, decreased patient satisfaction, and problems with patient safety,” the researchers said.
Organizations can combat physician burnout, the authors noted, and the effort is financially worthwhile, as well as morally and ethically important. “Burnout is primarily a system-level problem driven by excess job demands and inadequate resources and support, not an individual problem triggered by personal limitations,” they wrote.
The researchers developed a model outlining “Typical Steps in an Organization’s Journey Toward Expertise in Physician Well-being.” The steps begin with strategies that have a minor impact, including awareness of the problem of physician burnout and a focus on individual interventions such as mindfulness training, exercise, and nutrition.
However, the “transformative” changes in an organization include developing a “culture of wellness,” strategic investment in physician well-being, the presence of a “chief well-being officer” at the executive level, and accountability for physician wellness shared among organizational leaders.
The cost of such strategies varies among institutions, and the researchers provided worksheets to calculate the organizational cost of burnout and the return on investment if intervention steps are taken.
For example, an organization employing 450 physicians could potentially spend $1 million per year on an intervention to reduce physician burnout from 50% to 40%. The intervention investment could yield organizational cost savings of $1.125 million per year, with a 12.5% return on investment, as well as the potential financial benefits of improved patient satisfaction and quality of care.
“Understanding the business case to reduce burnout and promote engagement, as well as overcoming the misperception that nothing meaningful can be done, are key steps for organizations to begin to take action,” the researchers concluded.
“Improvement is possible, investment is justified, and return on investment measurable,” they said.
Dr. Shanafelt is a coinventor of the Physician Well-Being Index, Medical Student Well-Being Index, and Well-Being Index; copyright and licensing rights for these tools belong to the Mayo Clinic, and Dr. Shanafelt receives part of the royalties. The researchers had no other financial conflicts to disclose.
FROM JAMA INTERNAL MEDICINE
Early cognitive impairment associated with later Parkinson’s disease
Adults with early cognitive impairment are at greater risk for developing parkinsonism than those without cognitive impairment, based on data from 7,386 adults participating in the ongoing Rotterdam Study. The findings were published online Sept. 25 in JAMA Neurology.
“Between 15% and 43% of patients with newly diagnosed Parkinson disease (PD) are cognitively impaired,” wrote Sirwan K. L. Darweesh, MD, of Erasmus MC University Medical Center, Rotterdam, the Netherlands, and his colleagues. However, data on the predictive value of cognitive impairment for parkinsonism has not been well studied, they wrote (JAMA Neurol. 2017. doi: 10.1001/jamaneurol.2017.2248).
Over approximately 8 years’ follow-up, 1% of the participants were diagnosed with incident parkinsonism.
“Poor global cognition at baseline was associated with a higher risk of incident parkinsonism” with a hazard ratio of 1.79, the researchers said.
“To enable translation of our findings to clinical practice, we present likelihood ratios (LRs) for the baseline presence of isolated or combined cognitive dysfunction and subtle motor features for incident parkinsonism during follow-up,” they noted.
Approximately half of participants diagnosed with incident parkinsonism during the study period had subtle motor features, cognitive dysfunction, or both, at baseline. Baseline cognitive impairment alone showed a likelihood ratio of 1.76 for development of parkinsonism, but the likelihood ratio was greater when both cognitive impairment and subtle motor findings were present (2.66).
“In individuals who received a diagnosis of both incident dementia and incident parkinsonism, baseline cognitive dysfunction was not associated with incident dementia,” the researchers noted.
The researchers determined that the most likely explanation for the association between cognitive decline and increased Parkinson’s risk was that “low baseline cognitive scores may indicate ongoing cognitive decline in prediagnostic patients who probably will develop parkinsonism, most of whom have prediagnostic PD,” they said.
The study findings were limited by several factors including the potential misclassification of parkinsonism diagnosis, the researchers noted. However, the association between poor cognitive function and the risk of parkinsonism and probably Parkinson’s disease remained for the executive, attention, cognitive speed, and memory domains of cognition, they said. “Our findings suggest that poor cognitive functioning can be considered a prodromal sign of PD,” they concluded.
This study was supported in part by Stichting ParkinsonFonds. The researchers had no financial conflicts to disclose.
The long-term nature of the Rotterdam Study makes it an excellent source for examining the association between poor cognition and parkinsonism, wrote Ethan G. Brown, MD, and Caroline M. Tanner, MD, in an accompanying editorial.
“This study reiterates the presence of cognitive impairment very early in PD, emphasizing the need for therapeutic trials to target this symptom as an outcome. Although only some patients with cognitive impairment progress to PD, the study provides some clues on how to distinguish those most at risk. Progression to parkinsonism was more likely with baseline impairment of several individual cognitive tests, but only changes in semantic fluency predicted probable PD. Semantic fluency has been previously found to be specific for progression of cognitive impairment in PD, and this study again suggests the importance of this cognitive test early on,” they wrote.
“Yet the presence of cognitive impairment so early also gives rise to questions about the underlying pathology of PD progression. A commonly cited mechanism for progression of PD involves prion-like spread of synuclein pathology up through the dorsal nucleus of the vagus and substantia nigra. This spread presumably causes the autonomic, sleep, and motor dysfunction common in PD and supposedly leads to cognitive impairment only once Lewy bodies enter the neocortex. The current evidence that cognitive impairment can be evident in the prodromal stage challenges the universality of the model of vagal spread,” they noted.
However, recognizing the role of cognitive impairment as an early sign of PD can help clinicians plan screening and care, they said.
“This recognition can allow physicians to screen for falls or other nonmotor aspects of PD in these cases and provide early treatment for these symptoms. Physicians may recommend interventions, such as physical activity, that are helpful for motor and cognitive changes in PD,” they added (JAMA Neurol. 2017. doi: 10.1001/jamaneurol.2017.1474).
Dr. Brown and Dr. Tanner are affiliated with the Movement Disorders and Neuromodulation Center in the department of neurology at the University of California, San Francisco. Dr. Brown disclosed compensation for serving on the Fellowship Advisory Board for AbbVie. Dr. Tanner disclosed grants from a variety of nonprofit sources, as well as compensation for serving on Data Monitoring Committees for Biotie Therapeutics, Voyager Therapeutics, and Intec Pharma. Dr. Tanner also disclosed personal consulting fees from Neurocrine Biosciences, Adamas Therapeutics, and PhotoPharmics.
The long-term nature of the Rotterdam Study makes it an excellent source for examining the association between poor cognition and parkinsonism, wrote Ethan G. Brown, MD, and Caroline M. Tanner, MD, in an accompanying editorial.
“This study reiterates the presence of cognitive impairment very early in PD, emphasizing the need for therapeutic trials to target this symptom as an outcome. Although only some patients with cognitive impairment progress to PD, the study provides some clues on how to distinguish those most at risk. Progression to parkinsonism was more likely with baseline impairment of several individual cognitive tests, but only changes in semantic fluency predicted probable PD. Semantic fluency has been previously found to be specific for progression of cognitive impairment in PD, and this study again suggests the importance of this cognitive test early on,” they wrote.
“Yet the presence of cognitive impairment so early also gives rise to questions about the underlying pathology of PD progression. A commonly cited mechanism for progression of PD involves prion-like spread of synuclein pathology up through the dorsal nucleus of the vagus and substantia nigra. This spread presumably causes the autonomic, sleep, and motor dysfunction common in PD and supposedly leads to cognitive impairment only once Lewy bodies enter the neocortex. The current evidence that cognitive impairment can be evident in the prodromal stage challenges the universality of the model of vagal spread,” they noted.
However, recognizing the role of cognitive impairment as an early sign of PD can help clinicians plan screening and care, they said.
“This recognition can allow physicians to screen for falls or other nonmotor aspects of PD in these cases and provide early treatment for these symptoms. Physicians may recommend interventions, such as physical activity, that are helpful for motor and cognitive changes in PD,” they added (JAMA Neurol. 2017. doi: 10.1001/jamaneurol.2017.1474).
Dr. Brown and Dr. Tanner are affiliated with the Movement Disorders and Neuromodulation Center in the department of neurology at the University of California, San Francisco. Dr. Brown disclosed compensation for serving on the Fellowship Advisory Board for AbbVie. Dr. Tanner disclosed grants from a variety of nonprofit sources, as well as compensation for serving on Data Monitoring Committees for Biotie Therapeutics, Voyager Therapeutics, and Intec Pharma. Dr. Tanner also disclosed personal consulting fees from Neurocrine Biosciences, Adamas Therapeutics, and PhotoPharmics.
The long-term nature of the Rotterdam Study makes it an excellent source for examining the association between poor cognition and parkinsonism, wrote Ethan G. Brown, MD, and Caroline M. Tanner, MD, in an accompanying editorial.
“This study reiterates the presence of cognitive impairment very early in PD, emphasizing the need for therapeutic trials to target this symptom as an outcome. Although only some patients with cognitive impairment progress to PD, the study provides some clues on how to distinguish those most at risk. Progression to parkinsonism was more likely with baseline impairment of several individual cognitive tests, but only changes in semantic fluency predicted probable PD. Semantic fluency has been previously found to be specific for progression of cognitive impairment in PD, and this study again suggests the importance of this cognitive test early on,” they wrote.
“Yet the presence of cognitive impairment so early also gives rise to questions about the underlying pathology of PD progression. A commonly cited mechanism for progression of PD involves prion-like spread of synuclein pathology up through the dorsal nucleus of the vagus and substantia nigra. This spread presumably causes the autonomic, sleep, and motor dysfunction common in PD and supposedly leads to cognitive impairment only once Lewy bodies enter the neocortex. The current evidence that cognitive impairment can be evident in the prodromal stage challenges the universality of the model of vagal spread,” they noted.
However, recognizing the role of cognitive impairment as an early sign of PD can help clinicians plan screening and care, they said.
“This recognition can allow physicians to screen for falls or other nonmotor aspects of PD in these cases and provide early treatment for these symptoms. Physicians may recommend interventions, such as physical activity, that are helpful for motor and cognitive changes in PD,” they added (JAMA Neurol. 2017. doi: 10.1001/jamaneurol.2017.1474).
Dr. Brown and Dr. Tanner are affiliated with the Movement Disorders and Neuromodulation Center in the department of neurology at the University of California, San Francisco. Dr. Brown disclosed compensation for serving on the Fellowship Advisory Board for AbbVie. Dr. Tanner disclosed grants from a variety of nonprofit sources, as well as compensation for serving on Data Monitoring Committees for Biotie Therapeutics, Voyager Therapeutics, and Intec Pharma. Dr. Tanner also disclosed personal consulting fees from Neurocrine Biosciences, Adamas Therapeutics, and PhotoPharmics.
Adults with early cognitive impairment are at greater risk for developing parkinsonism than those without cognitive impairment, based on data from 7,386 adults participating in the ongoing Rotterdam Study. The findings were published online Sept. 25 in JAMA Neurology.
“Between 15% and 43% of patients with newly diagnosed Parkinson disease (PD) are cognitively impaired,” wrote Sirwan K. L. Darweesh, MD, of Erasmus MC University Medical Center, Rotterdam, the Netherlands, and his colleagues. However, data on the predictive value of cognitive impairment for parkinsonism has not been well studied, they wrote (JAMA Neurol. 2017. doi: 10.1001/jamaneurol.2017.2248).
Over approximately 8 years’ follow-up, 1% of the participants were diagnosed with incident parkinsonism.
“Poor global cognition at baseline was associated with a higher risk of incident parkinsonism” with a hazard ratio of 1.79, the researchers said.
“To enable translation of our findings to clinical practice, we present likelihood ratios (LRs) for the baseline presence of isolated or combined cognitive dysfunction and subtle motor features for incident parkinsonism during follow-up,” they noted.
Approximately half of participants diagnosed with incident parkinsonism during the study period had subtle motor features, cognitive dysfunction, or both, at baseline. Baseline cognitive impairment alone showed a likelihood ratio of 1.76 for development of parkinsonism, but the likelihood ratio was greater when both cognitive impairment and subtle motor findings were present (2.66).
“In individuals who received a diagnosis of both incident dementia and incident parkinsonism, baseline cognitive dysfunction was not associated with incident dementia,” the researchers noted.
The researchers determined that the most likely explanation for the association between cognitive decline and increased Parkinson’s risk was that “low baseline cognitive scores may indicate ongoing cognitive decline in prediagnostic patients who probably will develop parkinsonism, most of whom have prediagnostic PD,” they said.
The study findings were limited by several factors including the potential misclassification of parkinsonism diagnosis, the researchers noted. However, the association between poor cognitive function and the risk of parkinsonism and probably Parkinson’s disease remained for the executive, attention, cognitive speed, and memory domains of cognition, they said. “Our findings suggest that poor cognitive functioning can be considered a prodromal sign of PD,” they concluded.
This study was supported in part by Stichting ParkinsonFonds. The researchers had no financial conflicts to disclose.
Adults with early cognitive impairment are at greater risk for developing parkinsonism than those without cognitive impairment, based on data from 7,386 adults participating in the ongoing Rotterdam Study. The findings were published online Sept. 25 in JAMA Neurology.
“Between 15% and 43% of patients with newly diagnosed Parkinson disease (PD) are cognitively impaired,” wrote Sirwan K. L. Darweesh, MD, of Erasmus MC University Medical Center, Rotterdam, the Netherlands, and his colleagues. However, data on the predictive value of cognitive impairment for parkinsonism has not been well studied, they wrote (JAMA Neurol. 2017. doi: 10.1001/jamaneurol.2017.2248).
Over approximately 8 years’ follow-up, 1% of the participants were diagnosed with incident parkinsonism.
“Poor global cognition at baseline was associated with a higher risk of incident parkinsonism” with a hazard ratio of 1.79, the researchers said.
“To enable translation of our findings to clinical practice, we present likelihood ratios (LRs) for the baseline presence of isolated or combined cognitive dysfunction and subtle motor features for incident parkinsonism during follow-up,” they noted.
Approximately half of participants diagnosed with incident parkinsonism during the study period had subtle motor features, cognitive dysfunction, or both, at baseline. Baseline cognitive impairment alone showed a likelihood ratio of 1.76 for development of parkinsonism, but the likelihood ratio was greater when both cognitive impairment and subtle motor findings were present (2.66).
“In individuals who received a diagnosis of both incident dementia and incident parkinsonism, baseline cognitive dysfunction was not associated with incident dementia,” the researchers noted.
The researchers determined that the most likely explanation for the association between cognitive decline and increased Parkinson’s risk was that “low baseline cognitive scores may indicate ongoing cognitive decline in prediagnostic patients who probably will develop parkinsonism, most of whom have prediagnostic PD,” they said.
The study findings were limited by several factors including the potential misclassification of parkinsonism diagnosis, the researchers noted. However, the association between poor cognitive function and the risk of parkinsonism and probably Parkinson’s disease remained for the executive, attention, cognitive speed, and memory domains of cognition, they said. “Our findings suggest that poor cognitive functioning can be considered a prodromal sign of PD,” they concluded.
This study was supported in part by Stichting ParkinsonFonds. The researchers had no financial conflicts to disclose.
FROM JAMA NEUROLOGY
Key clinical point: Mild cognitive impairment may appear early in adults who go on to develop Parkinson’s disease.
Major finding: Poor global cognition at baseline was associated with a greater risk of incident parkinsonism (hazard ratio, 1.79) over approximately 8 years.
Data source: The data come from 7,386 adults in the population-based Rotterdam Study.
Disclosures: This study was supported in part by Stichting ParkinsonFonds. The researchers had no financial conflicts to disclose.
No reduction in preterm bronchopulmonary dysplasia with inhaled NO
Inhaled nitric oxide (NO) therapy does not appear to achieve reduction in the incidence of bronchopulmonary dysplasia in preterm infants, according to data published online Sept. 25 in JAMA Pediatrics.
Shabih U. Hasan, MD, from the Cumming School of Medicine at the University of Calgary, and his coauthors wrote that inhaled nitric oxide is currently approved for the treatment of hypoxic respiratory failure in infants with pulmonary hypertension. Animal studies have prompted interest in its potential to prevent bronchopulmonary dysplasia in preterm infants, but randomized trials so far have shown mixed results (JAMA Pediatr. 2017 Sep 25. doi: 10.1001/jamapediatrics.2017.2618).
The dosage selected was higher, and the treatment was given for a longer period and initiated later than in some previous studies, which the authors hypothesized might improve outcomes.
However, there was no significant difference between the placebo and inhaled NO groups in the primary outcome of survival to 36 weeks postmenstrual age without bronchopulmonary dysplasia (31.5% vs. 34.9%).
Similarly, the rate of severe bronchopulmonary dysplasia was similar for placebo and inhaled nitric oxide (26.6% vs. 20.5%), as was the rate of postnatal corticosteroid use (41.0% vs. 41.5%), mean days of positive pressure respiratory support (55 vs. 54), mean days of oxygen therapy (88 vs. 91) and mean days of hospitalization (105 vs. 108).
The subgroup analysis revealed that characteristics such as birth weight, gestational age, sex, postnatal age at study entry, maternal race or mode of respiratory support also did not influence the outcomes.
While the rates of severe bronchopulmonary dysplasia were similar between the placebo and inhaled nitric oxide groups, the inhaled NO group had a larger number of infants whose mothers were white and a higher rate of rupture of membranes for more than 7 days, compared with the placebo group.
The two groups had similar incidence of prematurity complications, such as sepsis, patent ductus arteriosus, necrotizing enterocolitis, retinopathy, intraventricular hemorrhage, and pulmonary air leak.
There were also no significant differences in neurodevelopmental or respiratory outcomes at 18-24 months postmenstrual age.
The authors commented that they had hoped their results would be similar to the earlier NO CLD trial, which hinted at a substantial increase in survival without bronchopulmonary dysplasia, compared with placebo in infants aged 7-14 days at the start of treatment.
“The NO CLD trial was not powered to assess the primary outcome in the subgroup enrolled between ages 7 and 14 days, whereas our study was powered specifically for that purpose and included twice as many infants in each treatment arm,” the authors wrote.
Despite this, and a lack of any obvious differences between the study populations, the authors could not identify a reason for the lack of efficacy seen in their own study, compared with this earlier study.
The authors noted that their findings of a lack of benefit from prophylactic but delayed NO on bronchopulmonary dysplasia were consistent with previous meta-analyses, and with a consensus statement from the National Institutes of Health.
The study was sponsored by Mallinckrodt Pharmaceuticals. Four authors declared honorarium, speaking engagements, advisory positions or consultancies with Mallinckrodt Pharmaceuticals. No other conflicts of interest were declared.
Inhaled nitric oxide (NO) therapy does not appear to achieve reduction in the incidence of bronchopulmonary dysplasia in preterm infants, according to data published online Sept. 25 in JAMA Pediatrics.
Shabih U. Hasan, MD, from the Cumming School of Medicine at the University of Calgary, and his coauthors wrote that inhaled nitric oxide is currently approved for the treatment of hypoxic respiratory failure in infants with pulmonary hypertension. Animal studies have prompted interest in its potential to prevent bronchopulmonary dysplasia in preterm infants, but randomized trials so far have shown mixed results (JAMA Pediatr. 2017 Sep 25. doi: 10.1001/jamapediatrics.2017.2618).
The dosage selected was higher, and the treatment was given for a longer period and initiated later than in some previous studies, which the authors hypothesized might improve outcomes.
However, there was no significant difference between the placebo and inhaled NO groups in the primary outcome of survival to 36 weeks postmenstrual age without bronchopulmonary dysplasia (31.5% vs. 34.9%).
Similarly, the rate of severe bronchopulmonary dysplasia was similar for placebo and inhaled nitric oxide (26.6% vs. 20.5%), as was the rate of postnatal corticosteroid use (41.0% vs. 41.5%), mean days of positive pressure respiratory support (55 vs. 54), mean days of oxygen therapy (88 vs. 91) and mean days of hospitalization (105 vs. 108).
The subgroup analysis revealed that characteristics such as birth weight, gestational age, sex, postnatal age at study entry, maternal race or mode of respiratory support also did not influence the outcomes.
While the rates of severe bronchopulmonary dysplasia were similar between the placebo and inhaled nitric oxide groups, the inhaled NO group had a larger number of infants whose mothers were white and a higher rate of rupture of membranes for more than 7 days, compared with the placebo group.
The two groups had similar incidence of prematurity complications, such as sepsis, patent ductus arteriosus, necrotizing enterocolitis, retinopathy, intraventricular hemorrhage, and pulmonary air leak.
There were also no significant differences in neurodevelopmental or respiratory outcomes at 18-24 months postmenstrual age.
The authors commented that they had hoped their results would be similar to the earlier NO CLD trial, which hinted at a substantial increase in survival without bronchopulmonary dysplasia, compared with placebo in infants aged 7-14 days at the start of treatment.
“The NO CLD trial was not powered to assess the primary outcome in the subgroup enrolled between ages 7 and 14 days, whereas our study was powered specifically for that purpose and included twice as many infants in each treatment arm,” the authors wrote.
Despite this, and a lack of any obvious differences between the study populations, the authors could not identify a reason for the lack of efficacy seen in their own study, compared with this earlier study.
The authors noted that their findings of a lack of benefit from prophylactic but delayed NO on bronchopulmonary dysplasia were consistent with previous meta-analyses, and with a consensus statement from the National Institutes of Health.
The study was sponsored by Mallinckrodt Pharmaceuticals. Four authors declared honorarium, speaking engagements, advisory positions or consultancies with Mallinckrodt Pharmaceuticals. No other conflicts of interest were declared.
Inhaled nitric oxide (NO) therapy does not appear to achieve reduction in the incidence of bronchopulmonary dysplasia in preterm infants, according to data published online Sept. 25 in JAMA Pediatrics.
Shabih U. Hasan, MD, from the Cumming School of Medicine at the University of Calgary, and his coauthors wrote that inhaled nitric oxide is currently approved for the treatment of hypoxic respiratory failure in infants with pulmonary hypertension. Animal studies have prompted interest in its potential to prevent bronchopulmonary dysplasia in preterm infants, but randomized trials so far have shown mixed results (JAMA Pediatr. 2017 Sep 25. doi: 10.1001/jamapediatrics.2017.2618).
The dosage selected was higher, and the treatment was given for a longer period and initiated later than in some previous studies, which the authors hypothesized might improve outcomes.
However, there was no significant difference between the placebo and inhaled NO groups in the primary outcome of survival to 36 weeks postmenstrual age without bronchopulmonary dysplasia (31.5% vs. 34.9%).
Similarly, the rate of severe bronchopulmonary dysplasia was similar for placebo and inhaled nitric oxide (26.6% vs. 20.5%), as was the rate of postnatal corticosteroid use (41.0% vs. 41.5%), mean days of positive pressure respiratory support (55 vs. 54), mean days of oxygen therapy (88 vs. 91) and mean days of hospitalization (105 vs. 108).
The subgroup analysis revealed that characteristics such as birth weight, gestational age, sex, postnatal age at study entry, maternal race or mode of respiratory support also did not influence the outcomes.
While the rates of severe bronchopulmonary dysplasia were similar between the placebo and inhaled nitric oxide groups, the inhaled NO group had a larger number of infants whose mothers were white and a higher rate of rupture of membranes for more than 7 days, compared with the placebo group.
The two groups had similar incidence of prematurity complications, such as sepsis, patent ductus arteriosus, necrotizing enterocolitis, retinopathy, intraventricular hemorrhage, and pulmonary air leak.
There were also no significant differences in neurodevelopmental or respiratory outcomes at 18-24 months postmenstrual age.
The authors commented that they had hoped their results would be similar to the earlier NO CLD trial, which hinted at a substantial increase in survival without bronchopulmonary dysplasia, compared with placebo in infants aged 7-14 days at the start of treatment.
“The NO CLD trial was not powered to assess the primary outcome in the subgroup enrolled between ages 7 and 14 days, whereas our study was powered specifically for that purpose and included twice as many infants in each treatment arm,” the authors wrote.
Despite this, and a lack of any obvious differences between the study populations, the authors could not identify a reason for the lack of efficacy seen in their own study, compared with this earlier study.
The authors noted that their findings of a lack of benefit from prophylactic but delayed NO on bronchopulmonary dysplasia were consistent with previous meta-analyses, and with a consensus statement from the National Institutes of Health.
The study was sponsored by Mallinckrodt Pharmaceuticals. Four authors declared honorarium, speaking engagements, advisory positions or consultancies with Mallinckrodt Pharmaceuticals. No other conflicts of interest were declared.
FROM JAMA PEDIATRICS
Key clinical point: Treatment with inhaled nitric oxide does not reduce the incidence of bronchopulmonary dysplasia in preterm infants.
Major finding: The incidence of bronchopulmonary dysplasia in preterm infants was not reduced with inhaled nitric oxide therapy.
Data source: Prospective randomized placebo-controlled trial in 451 preterm infants of less than 30 weeks gestation.
Disclosures: The study was sponsored by Mallinckrodt Pharmaceuticals. Four authors declared honorarium, speakers fees, advisory positions, or consultancies with Mallinckrodt Pharmaceuticals. No other conflicts of interest were declared.
Primary care deficient in cancer survivor care
Even advanced primary care practices are not providing comprehensive cancer survivorship care, with deficiencies in how cancer survivors are categorized, how they’re transitioned to primary care, and in the information systems used in their care, according to a new study published online September 25 in JAMA Internal Medicine.
The analysis came from data gathered by investigators at Rutgers Robert Wood Johnson Medical School, New Brunswick, N.J., who performed case studies on 12 advanced primary care centers across a variety of practice types and geographic settings. The centers were chosen using a national registry of “workforce innovators” compiled by the Robert Wood Johnson Foundation in 2011 and 2012. All but three of the centers were designated patient-centered medical homes (JAMA Intern Med. 2017. doi: 10.1001/jamainternmed.2017.4747).
Researchers noted the tremendous importance of primary care to cancer survivors. Only about a third of cancer survivors continue to be seen by a cancer specialist 5 years after their diagnosis, but 75% are seen in primary care. The importance of preventive screening, surveillance for recurrence, interventions for long-term effects, and care coordination between specialty and primary care were noted in an Institute of Medicine report in 2006.
Researchers found that the primary care clinicians don’t treat cancer survivors as a distinct population; they get limited information or follow-up guidance on cancer care; and information systems aren’t good at supporting survivorship care.
“Codifying survivorship as a distinct clinical category that belongs on problem lists with payment-linked – fee, value-based, or capitated – care services is a critical first step toward bringing comprehensive cancer survivorship services to primary care,” Dr. Rubinstein said.
Researchers described what they called “cancer exceptionalism,” in which a cancer diagnosis follows a different clinical norm and patients are referred to oncology and then become disengaged with primary care.
On transition of care, one primary care physician told an interviewer that it seems that patients’ cancer treatment “kind of happens in a black box” and that they feel “a little intimidated” in providing the needed follow-up care.
Another said that while a patient’s cancer history could be seen “at a glance” in old paper charts, their electronic health record requires searching multiple screens and “sometimes it’s a needle in a haystack.”
“Despite the push from national organizations to enhance cancer survivorship care capacity in primary care,” Dr. Rubinstein said, “findings from this study suggest that cancer survivorship care does not integrate easily into advanced primary care.”
The researchers reported no conflicts of interest.
Even advanced primary care practices are not providing comprehensive cancer survivorship care, with deficiencies in how cancer survivors are categorized, how they’re transitioned to primary care, and in the information systems used in their care, according to a new study published online September 25 in JAMA Internal Medicine.
The analysis came from data gathered by investigators at Rutgers Robert Wood Johnson Medical School, New Brunswick, N.J., who performed case studies on 12 advanced primary care centers across a variety of practice types and geographic settings. The centers were chosen using a national registry of “workforce innovators” compiled by the Robert Wood Johnson Foundation in 2011 and 2012. All but three of the centers were designated patient-centered medical homes (JAMA Intern Med. 2017. doi: 10.1001/jamainternmed.2017.4747).
Researchers noted the tremendous importance of primary care to cancer survivors. Only about a third of cancer survivors continue to be seen by a cancer specialist 5 years after their diagnosis, but 75% are seen in primary care. The importance of preventive screening, surveillance for recurrence, interventions for long-term effects, and care coordination between specialty and primary care were noted in an Institute of Medicine report in 2006.
Researchers found that the primary care clinicians don’t treat cancer survivors as a distinct population; they get limited information or follow-up guidance on cancer care; and information systems aren’t good at supporting survivorship care.
“Codifying survivorship as a distinct clinical category that belongs on problem lists with payment-linked – fee, value-based, or capitated – care services is a critical first step toward bringing comprehensive cancer survivorship services to primary care,” Dr. Rubinstein said.
Researchers described what they called “cancer exceptionalism,” in which a cancer diagnosis follows a different clinical norm and patients are referred to oncology and then become disengaged with primary care.
On transition of care, one primary care physician told an interviewer that it seems that patients’ cancer treatment “kind of happens in a black box” and that they feel “a little intimidated” in providing the needed follow-up care.
Another said that while a patient’s cancer history could be seen “at a glance” in old paper charts, their electronic health record requires searching multiple screens and “sometimes it’s a needle in a haystack.”
“Despite the push from national organizations to enhance cancer survivorship care capacity in primary care,” Dr. Rubinstein said, “findings from this study suggest that cancer survivorship care does not integrate easily into advanced primary care.”
The researchers reported no conflicts of interest.
Even advanced primary care practices are not providing comprehensive cancer survivorship care, with deficiencies in how cancer survivors are categorized, how they’re transitioned to primary care, and in the information systems used in their care, according to a new study published online September 25 in JAMA Internal Medicine.
The analysis came from data gathered by investigators at Rutgers Robert Wood Johnson Medical School, New Brunswick, N.J., who performed case studies on 12 advanced primary care centers across a variety of practice types and geographic settings. The centers were chosen using a national registry of “workforce innovators” compiled by the Robert Wood Johnson Foundation in 2011 and 2012. All but three of the centers were designated patient-centered medical homes (JAMA Intern Med. 2017. doi: 10.1001/jamainternmed.2017.4747).
Researchers noted the tremendous importance of primary care to cancer survivors. Only about a third of cancer survivors continue to be seen by a cancer specialist 5 years after their diagnosis, but 75% are seen in primary care. The importance of preventive screening, surveillance for recurrence, interventions for long-term effects, and care coordination between specialty and primary care were noted in an Institute of Medicine report in 2006.
Researchers found that the primary care clinicians don’t treat cancer survivors as a distinct population; they get limited information or follow-up guidance on cancer care; and information systems aren’t good at supporting survivorship care.
“Codifying survivorship as a distinct clinical category that belongs on problem lists with payment-linked – fee, value-based, or capitated – care services is a critical first step toward bringing comprehensive cancer survivorship services to primary care,” Dr. Rubinstein said.
Researchers described what they called “cancer exceptionalism,” in which a cancer diagnosis follows a different clinical norm and patients are referred to oncology and then become disengaged with primary care.
On transition of care, one primary care physician told an interviewer that it seems that patients’ cancer treatment “kind of happens in a black box” and that they feel “a little intimidated” in providing the needed follow-up care.
Another said that while a patient’s cancer history could be seen “at a glance” in old paper charts, their electronic health record requires searching multiple screens and “sometimes it’s a needle in a haystack.”
“Despite the push from national organizations to enhance cancer survivorship care capacity in primary care,” Dr. Rubinstein said, “findings from this study suggest that cancer survivorship care does not integrate easily into advanced primary care.”
The researchers reported no conflicts of interest.
FROM JAMA INTERNAL MEDICINE
Key clinical point: Advanced primary care practices are not providing comprehensive cancer survivorship care.
Major finding: Primary care clinicians don’t treat cancer survivors as a distinct population; they get limited information or follow-up guidance on cancer care; and information systems aren’t good at supporting survivorship care.
Data source: A comparative case study of 12 primary care practices compiled using a national registry of “workforce innovators.”
Disclosures: None reported.