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The Right Choice? Surgeons, confidence, and humility
It started as an offhand comment. The patient had been on the medicine service for over a week before developing acute appendicitis with an abscess requiring an emergency open appendectomy. He was a 68-year-old man who had longstanding medical issues that had given him many opportunities to interact with physicians in the prior few years.
On the second morning after surgery, a new team of surgical residents was rounding on him. The chief resident led the group of residents and students into the patient’s room and introduced himself as being part of the surgical team. The patient smiled and stated that he knew this was a group of surgeons. When asked why, the patient reported that he could always tell when surgeons enter the room. “You enter with an air of bravado and arrogance that the medical doctors do not exude.” The surgical residents commented on this fact to me later when I rounded on the patient, and it prompted discussion of the potential positives and negatives of confidence in surgical practice.
Most successful surgeons express a level of confidence in their abilities which often exceeds that of many other physicians. Such observations have led to the joke that “surgeons are often wrong, but never in doubt.” The question is whether the expression of confidence in one’s abilities as a surgeon is a requirement of a surgeon or simply a common characteristic for many people who choose to go into the field of surgery.
There is no doubt in my mind that in order to be willing to put a patient through an operation, surgeons must be confident in their skills. Surgery never achieves its benefit for patients without first causing the patient some harm. Any operation requires that the surgeon impose a violent act on the patient that, in any other context, would be illegal. To do such things to patients, surgeons must have a high degree of confidence.
Patients also appreciate a confident surgeon. Over the years, I have known many technically excellent surgeons who have never been as busy as they might have because of their inability to express confidence to their patients. The opposite, however, is also true. There are surgeons who become so overconfident in their abilities that they become reckless in recommending high-risk operations to patients.
Given that patients expect their surgeons to be confident and surgeons actually need to be confident to be successful, it might be surprising that the important attribute of self-confidence does not more frequently spill over into overbearing arrogance. Perhaps the most important temporizing of surgeon overconfidence is the unfortunate inevitable consequence of surgery that complications happen to even the best surgeons. We all know that the central question of the M & M conference is, “What could you have done differently?” Whether this question is answered publicly or only in the mind of the surgeon, the contemplation of the decisions made, and their consequences, is essential for each surgeon to consider in the face of every complication.
Much as the public should want surgeons to be confident, but not too confident, they should also want their surgeons to take complications seriously, but not too seriously. It is helpful for a surgeon to think about making a different choice in the future. But it would not be helpful if, in the face of a bad outcome, a surgeon decides that he or she can no longer perform surgery.
This balance between lack of confidence and overconfidence, and between thoughtful introspection and paralyzing fear of future complications, is challenging to teach to surgical residents and fellows. Part of the challenge is that often surgical faculty do not verbalize the challenges that we face in this realm. The perfect combination of confidence and humility is something that few of us have identified in our own lives, let alone are prepared to teach authoritatively to others. Nevertheless, teaching the next generation of surgeons to recognize the tension between confidence and humility is worthwhile. And like their elders, they may well discover that achieving the right balance is a lifelong pursuit.
Dr. Angelos is the Linda Kohler Anderson Professor of Surgery and Surgical Ethics; chief, endocrine surgery; and associate director of the MacLean Center for Clinical Medical Ethics at the University of Chicago.
It started as an offhand comment. The patient had been on the medicine service for over a week before developing acute appendicitis with an abscess requiring an emergency open appendectomy. He was a 68-year-old man who had longstanding medical issues that had given him many opportunities to interact with physicians in the prior few years.
On the second morning after surgery, a new team of surgical residents was rounding on him. The chief resident led the group of residents and students into the patient’s room and introduced himself as being part of the surgical team. The patient smiled and stated that he knew this was a group of surgeons. When asked why, the patient reported that he could always tell when surgeons enter the room. “You enter with an air of bravado and arrogance that the medical doctors do not exude.” The surgical residents commented on this fact to me later when I rounded on the patient, and it prompted discussion of the potential positives and negatives of confidence in surgical practice.
Most successful surgeons express a level of confidence in their abilities which often exceeds that of many other physicians. Such observations have led to the joke that “surgeons are often wrong, but never in doubt.” The question is whether the expression of confidence in one’s abilities as a surgeon is a requirement of a surgeon or simply a common characteristic for many people who choose to go into the field of surgery.
There is no doubt in my mind that in order to be willing to put a patient through an operation, surgeons must be confident in their skills. Surgery never achieves its benefit for patients without first causing the patient some harm. Any operation requires that the surgeon impose a violent act on the patient that, in any other context, would be illegal. To do such things to patients, surgeons must have a high degree of confidence.
Patients also appreciate a confident surgeon. Over the years, I have known many technically excellent surgeons who have never been as busy as they might have because of their inability to express confidence to their patients. The opposite, however, is also true. There are surgeons who become so overconfident in their abilities that they become reckless in recommending high-risk operations to patients.
Given that patients expect their surgeons to be confident and surgeons actually need to be confident to be successful, it might be surprising that the important attribute of self-confidence does not more frequently spill over into overbearing arrogance. Perhaps the most important temporizing of surgeon overconfidence is the unfortunate inevitable consequence of surgery that complications happen to even the best surgeons. We all know that the central question of the M & M conference is, “What could you have done differently?” Whether this question is answered publicly or only in the mind of the surgeon, the contemplation of the decisions made, and their consequences, is essential for each surgeon to consider in the face of every complication.
Much as the public should want surgeons to be confident, but not too confident, they should also want their surgeons to take complications seriously, but not too seriously. It is helpful for a surgeon to think about making a different choice in the future. But it would not be helpful if, in the face of a bad outcome, a surgeon decides that he or she can no longer perform surgery.
This balance between lack of confidence and overconfidence, and between thoughtful introspection and paralyzing fear of future complications, is challenging to teach to surgical residents and fellows. Part of the challenge is that often surgical faculty do not verbalize the challenges that we face in this realm. The perfect combination of confidence and humility is something that few of us have identified in our own lives, let alone are prepared to teach authoritatively to others. Nevertheless, teaching the next generation of surgeons to recognize the tension between confidence and humility is worthwhile. And like their elders, they may well discover that achieving the right balance is a lifelong pursuit.
Dr. Angelos is the Linda Kohler Anderson Professor of Surgery and Surgical Ethics; chief, endocrine surgery; and associate director of the MacLean Center for Clinical Medical Ethics at the University of Chicago.
It started as an offhand comment. The patient had been on the medicine service for over a week before developing acute appendicitis with an abscess requiring an emergency open appendectomy. He was a 68-year-old man who had longstanding medical issues that had given him many opportunities to interact with physicians in the prior few years.
On the second morning after surgery, a new team of surgical residents was rounding on him. The chief resident led the group of residents and students into the patient’s room and introduced himself as being part of the surgical team. The patient smiled and stated that he knew this was a group of surgeons. When asked why, the patient reported that he could always tell when surgeons enter the room. “You enter with an air of bravado and arrogance that the medical doctors do not exude.” The surgical residents commented on this fact to me later when I rounded on the patient, and it prompted discussion of the potential positives and negatives of confidence in surgical practice.
Most successful surgeons express a level of confidence in their abilities which often exceeds that of many other physicians. Such observations have led to the joke that “surgeons are often wrong, but never in doubt.” The question is whether the expression of confidence in one’s abilities as a surgeon is a requirement of a surgeon or simply a common characteristic for many people who choose to go into the field of surgery.
There is no doubt in my mind that in order to be willing to put a patient through an operation, surgeons must be confident in their skills. Surgery never achieves its benefit for patients without first causing the patient some harm. Any operation requires that the surgeon impose a violent act on the patient that, in any other context, would be illegal. To do such things to patients, surgeons must have a high degree of confidence.
Patients also appreciate a confident surgeon. Over the years, I have known many technically excellent surgeons who have never been as busy as they might have because of their inability to express confidence to their patients. The opposite, however, is also true. There are surgeons who become so overconfident in their abilities that they become reckless in recommending high-risk operations to patients.
Given that patients expect their surgeons to be confident and surgeons actually need to be confident to be successful, it might be surprising that the important attribute of self-confidence does not more frequently spill over into overbearing arrogance. Perhaps the most important temporizing of surgeon overconfidence is the unfortunate inevitable consequence of surgery that complications happen to even the best surgeons. We all know that the central question of the M & M conference is, “What could you have done differently?” Whether this question is answered publicly or only in the mind of the surgeon, the contemplation of the decisions made, and their consequences, is essential for each surgeon to consider in the face of every complication.
Much as the public should want surgeons to be confident, but not too confident, they should also want their surgeons to take complications seriously, but not too seriously. It is helpful for a surgeon to think about making a different choice in the future. But it would not be helpful if, in the face of a bad outcome, a surgeon decides that he or she can no longer perform surgery.
This balance between lack of confidence and overconfidence, and between thoughtful introspection and paralyzing fear of future complications, is challenging to teach to surgical residents and fellows. Part of the challenge is that often surgical faculty do not verbalize the challenges that we face in this realm. The perfect combination of confidence and humility is something that few of us have identified in our own lives, let alone are prepared to teach authoritatively to others. Nevertheless, teaching the next generation of surgeons to recognize the tension between confidence and humility is worthwhile. And like their elders, they may well discover that achieving the right balance is a lifelong pursuit.
Dr. Angelos is the Linda Kohler Anderson Professor of Surgery and Surgical Ethics; chief, endocrine surgery; and associate director of the MacLean Center for Clinical Medical Ethics at the University of Chicago.
A Message from the President: The ACS: Dedicated to Doing What’s Right for the Patient
Do what’s right for the patient. That statement is the bedrock on which the American College of Surgeons (ACS) stands.
Throughout its nearly 104-year history, the ACS has promoted surgical education and quality improvement. The College’s dedication to education and quality can be traced to the guiding principles of its founder, Franklin H. Martin, MD, FACS. In Dr. Martin’s era, the early 20th century, medical education was in a deplorable state, as documented in the well-known Flexner report of 1910.
To help improve surgical education and training, Dr. Martin first established Surgery, Gynecology & Obstetrics (SG&O, now the Journal of the American College of Surgeons) as a practical journal for practicing surgeons, edited by active surgeons. He published an editorial in the journal inviting surgeons to “learn by watching” and encouraged “every physician in the U.S. and Canada who was interested in surgery to observe the clinics in one of the large medical centers.” Approximately 1,300 physicians responded to Dr. Martin’s charge, resulting in the first Clinical Congress of Surgeons of North America (CCSNA), November 7-9, 1910, in Chicago, IL. After the third CCSNA meeting in 1912, Dr. Martin concluded that further change was necessary, which eventually led to the formation of the ACS in November 1913.
Standards
The importance of establishing standards for hospitals and surgical training cannot be emphasized enough. These programs fundamentally changed surgical practice and training. If the College had ceased to exist after that achievement, it would have more than fulfilled the expectations of Dr. Martin and other ACS leaders. But this did not happen. Instead, the College continued to inspire quality and to maintain the highest standards for better outcomes through establishment of programs aimed at improving care for cancer and trauma patients.
Committees
The ACS Committee on Cancer published a Standardized Method for Reporting Cancer End Results in 1953. In 1965, other organizations partnered with the College to transform this committee into the Commission on Cancer (CoC), which today uses strict criteria and a rigorous on-site evaluation process to accredit more than 1,530 U.S. cancer centers. This accreditation process is used not only for initial verification of achievement of program standards, but also for periodic review for compliance to maintain accreditation.
Early in its history, the College also established a Committee on the Treatment of Fractures, which evolved into what we now know as the Committee on Trauma (COT). The COT’s guidelines for hospitals to attain or maintain verification as trauma centers—Resources for Optimal Care of the Injured Patient—was first issued in 1976 and now is in its sixth edition.
Another seminal event in trauma took place in 1976—an airplane crash involving James K. Styner, MD, FACS, and his family, in rural Nebraska. His wife died on impact, and his children were severely injured. Angered by the delays his family experienced in receiving appropriate care, Dr. Styner called for the development of adequate facilities and standardized approaches to care for severely injured patients. He combined forces with Paul E. “Skip” Collicott, MD, FACS, and other Nebraska surgeons, to develop the Advanced Trauma Life Support® program, which introduces physicians and other health care professionals around the world to best practices for initial evaluation and management of trauma patients.
ACS Regent Lenworth M. Jacobs, Jr., MD, MPH, FACS, has led more recent COT initiatives, including development of the Advanced Trauma Operative Management® course and the Hartford ConsensusTM. This panel—composed of trauma care professionals and government officials—developed the Stop the Bleed program—an initiative aimed at enhancing survival from mass casualty and active shooter events.
Another important committee that the College established to ensure surgeons are prepared to do what’s right for the patient is the Committee on Emerging Surgical Technology and Education (CESTE). Launched in 1992 with the late C. James Carrico, MD, FACS, as the inaugural Chair, CESTE was charged with developing processes to evaluate emerging surgical technology for safety and effectiveness, creating standardized education programs, and measuring outcomes. Two of the College’s most important education and quality programs sprang from CESTE—the Accredited Education Institutes, under the leadership of Ajit K. Sachdeva, MD, FACS, Director, ACS Division of Education, and the Division of Research and Optimal Patient Care, first led by R. Scott Jones, MD, FACS, and now under the purview of Clifford Y. Ko, MD, MS, FACS.
The future is in your hands
Unquestionably, the ACS and its leaders have a rich history of doing what’s right for the patient. The future, however, belongs to you. I want to encourage you to participate in all the activities of your College at the local, state, and national levels. Establish personal relationships with leaders. Be an advocate for our education and quality programs. I am confident that there are those among you who will become the leaders who will continue the evolution of the College and inspire quality, maintain the highest standards, and ensure better outcomes.
Dr. Townsend is the Robertson-Poth Distinguished Chair in General Surgery, department of surgery, University of Texas Medical Branch (UTMB), Galveston; professor of surgery, department of surgery, professor of physician assistant studies, School of Allied Health Sciences; and graduate faculty in the cell biology program, UTMB. He is the 97th President of the ACS.
Do what’s right for the patient. That statement is the bedrock on which the American College of Surgeons (ACS) stands.
Throughout its nearly 104-year history, the ACS has promoted surgical education and quality improvement. The College’s dedication to education and quality can be traced to the guiding principles of its founder, Franklin H. Martin, MD, FACS. In Dr. Martin’s era, the early 20th century, medical education was in a deplorable state, as documented in the well-known Flexner report of 1910.
To help improve surgical education and training, Dr. Martin first established Surgery, Gynecology & Obstetrics (SG&O, now the Journal of the American College of Surgeons) as a practical journal for practicing surgeons, edited by active surgeons. He published an editorial in the journal inviting surgeons to “learn by watching” and encouraged “every physician in the U.S. and Canada who was interested in surgery to observe the clinics in one of the large medical centers.” Approximately 1,300 physicians responded to Dr. Martin’s charge, resulting in the first Clinical Congress of Surgeons of North America (CCSNA), November 7-9, 1910, in Chicago, IL. After the third CCSNA meeting in 1912, Dr. Martin concluded that further change was necessary, which eventually led to the formation of the ACS in November 1913.
Standards
The importance of establishing standards for hospitals and surgical training cannot be emphasized enough. These programs fundamentally changed surgical practice and training. If the College had ceased to exist after that achievement, it would have more than fulfilled the expectations of Dr. Martin and other ACS leaders. But this did not happen. Instead, the College continued to inspire quality and to maintain the highest standards for better outcomes through establishment of programs aimed at improving care for cancer and trauma patients.
Committees
The ACS Committee on Cancer published a Standardized Method for Reporting Cancer End Results in 1953. In 1965, other organizations partnered with the College to transform this committee into the Commission on Cancer (CoC), which today uses strict criteria and a rigorous on-site evaluation process to accredit more than 1,530 U.S. cancer centers. This accreditation process is used not only for initial verification of achievement of program standards, but also for periodic review for compliance to maintain accreditation.
Early in its history, the College also established a Committee on the Treatment of Fractures, which evolved into what we now know as the Committee on Trauma (COT). The COT’s guidelines for hospitals to attain or maintain verification as trauma centers—Resources for Optimal Care of the Injured Patient—was first issued in 1976 and now is in its sixth edition.
Another seminal event in trauma took place in 1976—an airplane crash involving James K. Styner, MD, FACS, and his family, in rural Nebraska. His wife died on impact, and his children were severely injured. Angered by the delays his family experienced in receiving appropriate care, Dr. Styner called for the development of adequate facilities and standardized approaches to care for severely injured patients. He combined forces with Paul E. “Skip” Collicott, MD, FACS, and other Nebraska surgeons, to develop the Advanced Trauma Life Support® program, which introduces physicians and other health care professionals around the world to best practices for initial evaluation and management of trauma patients.
ACS Regent Lenworth M. Jacobs, Jr., MD, MPH, FACS, has led more recent COT initiatives, including development of the Advanced Trauma Operative Management® course and the Hartford ConsensusTM. This panel—composed of trauma care professionals and government officials—developed the Stop the Bleed program—an initiative aimed at enhancing survival from mass casualty and active shooter events.
Another important committee that the College established to ensure surgeons are prepared to do what’s right for the patient is the Committee on Emerging Surgical Technology and Education (CESTE). Launched in 1992 with the late C. James Carrico, MD, FACS, as the inaugural Chair, CESTE was charged with developing processes to evaluate emerging surgical technology for safety and effectiveness, creating standardized education programs, and measuring outcomes. Two of the College’s most important education and quality programs sprang from CESTE—the Accredited Education Institutes, under the leadership of Ajit K. Sachdeva, MD, FACS, Director, ACS Division of Education, and the Division of Research and Optimal Patient Care, first led by R. Scott Jones, MD, FACS, and now under the purview of Clifford Y. Ko, MD, MS, FACS.
The future is in your hands
Unquestionably, the ACS and its leaders have a rich history of doing what’s right for the patient. The future, however, belongs to you. I want to encourage you to participate in all the activities of your College at the local, state, and national levels. Establish personal relationships with leaders. Be an advocate for our education and quality programs. I am confident that there are those among you who will become the leaders who will continue the evolution of the College and inspire quality, maintain the highest standards, and ensure better outcomes.
Dr. Townsend is the Robertson-Poth Distinguished Chair in General Surgery, department of surgery, University of Texas Medical Branch (UTMB), Galveston; professor of surgery, department of surgery, professor of physician assistant studies, School of Allied Health Sciences; and graduate faculty in the cell biology program, UTMB. He is the 97th President of the ACS.
Do what’s right for the patient. That statement is the bedrock on which the American College of Surgeons (ACS) stands.
Throughout its nearly 104-year history, the ACS has promoted surgical education and quality improvement. The College’s dedication to education and quality can be traced to the guiding principles of its founder, Franklin H. Martin, MD, FACS. In Dr. Martin’s era, the early 20th century, medical education was in a deplorable state, as documented in the well-known Flexner report of 1910.
To help improve surgical education and training, Dr. Martin first established Surgery, Gynecology & Obstetrics (SG&O, now the Journal of the American College of Surgeons) as a practical journal for practicing surgeons, edited by active surgeons. He published an editorial in the journal inviting surgeons to “learn by watching” and encouraged “every physician in the U.S. and Canada who was interested in surgery to observe the clinics in one of the large medical centers.” Approximately 1,300 physicians responded to Dr. Martin’s charge, resulting in the first Clinical Congress of Surgeons of North America (CCSNA), November 7-9, 1910, in Chicago, IL. After the third CCSNA meeting in 1912, Dr. Martin concluded that further change was necessary, which eventually led to the formation of the ACS in November 1913.
Standards
The importance of establishing standards for hospitals and surgical training cannot be emphasized enough. These programs fundamentally changed surgical practice and training. If the College had ceased to exist after that achievement, it would have more than fulfilled the expectations of Dr. Martin and other ACS leaders. But this did not happen. Instead, the College continued to inspire quality and to maintain the highest standards for better outcomes through establishment of programs aimed at improving care for cancer and trauma patients.
Committees
The ACS Committee on Cancer published a Standardized Method for Reporting Cancer End Results in 1953. In 1965, other organizations partnered with the College to transform this committee into the Commission on Cancer (CoC), which today uses strict criteria and a rigorous on-site evaluation process to accredit more than 1,530 U.S. cancer centers. This accreditation process is used not only for initial verification of achievement of program standards, but also for periodic review for compliance to maintain accreditation.
Early in its history, the College also established a Committee on the Treatment of Fractures, which evolved into what we now know as the Committee on Trauma (COT). The COT’s guidelines for hospitals to attain or maintain verification as trauma centers—Resources for Optimal Care of the Injured Patient—was first issued in 1976 and now is in its sixth edition.
Another seminal event in trauma took place in 1976—an airplane crash involving James K. Styner, MD, FACS, and his family, in rural Nebraska. His wife died on impact, and his children were severely injured. Angered by the delays his family experienced in receiving appropriate care, Dr. Styner called for the development of adequate facilities and standardized approaches to care for severely injured patients. He combined forces with Paul E. “Skip” Collicott, MD, FACS, and other Nebraska surgeons, to develop the Advanced Trauma Life Support® program, which introduces physicians and other health care professionals around the world to best practices for initial evaluation and management of trauma patients.
ACS Regent Lenworth M. Jacobs, Jr., MD, MPH, FACS, has led more recent COT initiatives, including development of the Advanced Trauma Operative Management® course and the Hartford ConsensusTM. This panel—composed of trauma care professionals and government officials—developed the Stop the Bleed program—an initiative aimed at enhancing survival from mass casualty and active shooter events.
Another important committee that the College established to ensure surgeons are prepared to do what’s right for the patient is the Committee on Emerging Surgical Technology and Education (CESTE). Launched in 1992 with the late C. James Carrico, MD, FACS, as the inaugural Chair, CESTE was charged with developing processes to evaluate emerging surgical technology for safety and effectiveness, creating standardized education programs, and measuring outcomes. Two of the College’s most important education and quality programs sprang from CESTE—the Accredited Education Institutes, under the leadership of Ajit K. Sachdeva, MD, FACS, Director, ACS Division of Education, and the Division of Research and Optimal Patient Care, first led by R. Scott Jones, MD, FACS, and now under the purview of Clifford Y. Ko, MD, MS, FACS.
The future is in your hands
Unquestionably, the ACS and its leaders have a rich history of doing what’s right for the patient. The future, however, belongs to you. I want to encourage you to participate in all the activities of your College at the local, state, and national levels. Establish personal relationships with leaders. Be an advocate for our education and quality programs. I am confident that there are those among you who will become the leaders who will continue the evolution of the College and inspire quality, maintain the highest standards, and ensure better outcomes.
Dr. Townsend is the Robertson-Poth Distinguished Chair in General Surgery, department of surgery, University of Texas Medical Branch (UTMB), Galveston; professor of surgery, department of surgery, professor of physician assistant studies, School of Allied Health Sciences; and graduate faculty in the cell biology program, UTMB. He is the 97th President of the ACS.
Seema Verma dodges questions on how to improve CMS
If confirmed as Centers for Medicare & Medicaid Services administrator, Seema Verma vowed to modernize CMS programs, improve Medicaid access, and leverage technology to drive better care, but she stopped short of explaining how she would do so during her confirmation hearing Feb. 16 before the Senate Finance Committee.
Legislators grilled Ms. Verma on Medicare improvements, the fate of the Affordable Care Act (ACA), Medicaid reform, and the execution of value-based care. At every turn. Ms. Verma pledged to review current processes and work toward enhancing programs, but she declined to support or oppose specific changes. Instead, she promised to help make health care more affordable and to allow patients more flexibility in making health insurance decisions.
Much of the committee’s questioning centered on Ms. Verma’s work on the Healthy Indiana Plan (HIP), Indiana’s Medicaid expansion under the ACA. The conservative plan requires patients to pay a small amount to receive health coverage and includes a lockout period if payments are missed. Legislators repeatedly asked if Ms. Verma planned to use HIP as a model to alter the Medicaid program.
Ms. Verma countered that each state has different needs and should be allowed to develop individualized Medicaid programs that provide flexibility.
“This is about putting states in a leadership role so that they can manage their programs better,” she said. “States are closer to the people that they serve and have a better understanding of what can work in their state than the federal government. I think states should have that flexibility.”
Legislators raised concerns about Ms. Verma’s past consulting agreements with states while working for Hewlett Packard (HP), a company that had financial interests in the health programs she designed. Ms. Verma’s company, SVC, advises clients on Medicaid waivers and state plan amendment development.
Ms. Verma argued that she never negotiated on behalf of Hewlett Packard, and that the work she conducted for the states did not overlap with work she completed for HP. Her company sought an ethics opinion to ensure the arrangement was not problematic, she said.
“I hold honesty and integrity and adherence to a high ethical standard as part of my personal philosophy. That’s for me, I demand that from my employees, and I set that example for my own children,” she said. “We were never in a position where we were negotiating on behalf of HP or any other contractor with the state that we had a relationship with. If there was the potential [for a conflict], we would recuse ourselves.”
Ms. Verma dodged many specific questions, including whether she supported block grants for Medicaid, how she might improve the problem of prescription drug prices, and whether she supported Medicare as a voucher program. When asked by Sen. Sherrod Campbell Brown (D-Ohio) whether she supported an extension of the current Children’s Health Insurance Program (CHIP) for another 8 years, Ms. Verma said she supported “the reauthorization of CHIP for as long as possible.”
When asked about the value-based reforms included in MACRA (the Medicare Access & CHIP Reauthorization Act of 2015), Ms. Verma said she applauded passage of the law, but she would not go into detail about potential changes to the statute.
“I think it’s an important step forward, not only to providing more stability for providers, but also moving us to better outcomes,” she said.
Sen. Wyden grew visibly frustrated with Ms. Verma’s vague answers, saying he was disappointed that, after many questions, the stances she took in many areas were still unclear.
“You’ve been asked a lot of questions and they were not ‘gotcha’ questions,” Sen. Wyden said during the hearing. “These were questions that were appropriate given the fact that if you’re confirmed, you’re going to head an agency that’s involved with a trillion [dollars] of spending in the health care of 100 million people. We’re not really getting much of a sense of how you’d approach [these issues]. I think this committee needs answers and I think the public needs answers.”
“It is critical that we get a strong, skilled leader as CMS administrator,” he said. “Here you are, somebody who has proven to be a tremendous leader in health care, not only to Indiana but as an example to the rest of the states. All I can say is you will be a strong, skilled leader as CMS administrator.”
A relative unknown before her nomination, Ms. Verma spent 20 years designing policy projects involving Medicaid, including HIP, the nation’s first consumer-directed Medicaid program under Indiana Governor Mitch Daniels and then-Gov. Mike Pence’s HIP 2.0 waiver proposal.
Prior to consulting, Ms. Verma served as vice president of planning for the Health and Hospital Corporation of Marion County (Ind.) and as a director with the Association of State and Territorial Health Officials in Washington.
Senators have asked that Ms. Verma submit written answers to their questions, which they will review before voting on her nomination.
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On Twitter @legal_med
If confirmed as Centers for Medicare & Medicaid Services administrator, Seema Verma vowed to modernize CMS programs, improve Medicaid access, and leverage technology to drive better care, but she stopped short of explaining how she would do so during her confirmation hearing Feb. 16 before the Senate Finance Committee.
Legislators grilled Ms. Verma on Medicare improvements, the fate of the Affordable Care Act (ACA), Medicaid reform, and the execution of value-based care. At every turn. Ms. Verma pledged to review current processes and work toward enhancing programs, but she declined to support or oppose specific changes. Instead, she promised to help make health care more affordable and to allow patients more flexibility in making health insurance decisions.
Much of the committee’s questioning centered on Ms. Verma’s work on the Healthy Indiana Plan (HIP), Indiana’s Medicaid expansion under the ACA. The conservative plan requires patients to pay a small amount to receive health coverage and includes a lockout period if payments are missed. Legislators repeatedly asked if Ms. Verma planned to use HIP as a model to alter the Medicaid program.
Ms. Verma countered that each state has different needs and should be allowed to develop individualized Medicaid programs that provide flexibility.
“This is about putting states in a leadership role so that they can manage their programs better,” she said. “States are closer to the people that they serve and have a better understanding of what can work in their state than the federal government. I think states should have that flexibility.”
Legislators raised concerns about Ms. Verma’s past consulting agreements with states while working for Hewlett Packard (HP), a company that had financial interests in the health programs she designed. Ms. Verma’s company, SVC, advises clients on Medicaid waivers and state plan amendment development.
Ms. Verma argued that she never negotiated on behalf of Hewlett Packard, and that the work she conducted for the states did not overlap with work she completed for HP. Her company sought an ethics opinion to ensure the arrangement was not problematic, she said.
“I hold honesty and integrity and adherence to a high ethical standard as part of my personal philosophy. That’s for me, I demand that from my employees, and I set that example for my own children,” she said. “We were never in a position where we were negotiating on behalf of HP or any other contractor with the state that we had a relationship with. If there was the potential [for a conflict], we would recuse ourselves.”
Ms. Verma dodged many specific questions, including whether she supported block grants for Medicaid, how she might improve the problem of prescription drug prices, and whether she supported Medicare as a voucher program. When asked by Sen. Sherrod Campbell Brown (D-Ohio) whether she supported an extension of the current Children’s Health Insurance Program (CHIP) for another 8 years, Ms. Verma said she supported “the reauthorization of CHIP for as long as possible.”
When asked about the value-based reforms included in MACRA (the Medicare Access & CHIP Reauthorization Act of 2015), Ms. Verma said she applauded passage of the law, but she would not go into detail about potential changes to the statute.
“I think it’s an important step forward, not only to providing more stability for providers, but also moving us to better outcomes,” she said.
Sen. Wyden grew visibly frustrated with Ms. Verma’s vague answers, saying he was disappointed that, after many questions, the stances she took in many areas were still unclear.
“You’ve been asked a lot of questions and they were not ‘gotcha’ questions,” Sen. Wyden said during the hearing. “These were questions that were appropriate given the fact that if you’re confirmed, you’re going to head an agency that’s involved with a trillion [dollars] of spending in the health care of 100 million people. We’re not really getting much of a sense of how you’d approach [these issues]. I think this committee needs answers and I think the public needs answers.”
“It is critical that we get a strong, skilled leader as CMS administrator,” he said. “Here you are, somebody who has proven to be a tremendous leader in health care, not only to Indiana but as an example to the rest of the states. All I can say is you will be a strong, skilled leader as CMS administrator.”
A relative unknown before her nomination, Ms. Verma spent 20 years designing policy projects involving Medicaid, including HIP, the nation’s first consumer-directed Medicaid program under Indiana Governor Mitch Daniels and then-Gov. Mike Pence’s HIP 2.0 waiver proposal.
Prior to consulting, Ms. Verma served as vice president of planning for the Health and Hospital Corporation of Marion County (Ind.) and as a director with the Association of State and Territorial Health Officials in Washington.
Senators have asked that Ms. Verma submit written answers to their questions, which they will review before voting on her nomination.
[email protected]
On Twitter @legal_med
If confirmed as Centers for Medicare & Medicaid Services administrator, Seema Verma vowed to modernize CMS programs, improve Medicaid access, and leverage technology to drive better care, but she stopped short of explaining how she would do so during her confirmation hearing Feb. 16 before the Senate Finance Committee.
Legislators grilled Ms. Verma on Medicare improvements, the fate of the Affordable Care Act (ACA), Medicaid reform, and the execution of value-based care. At every turn. Ms. Verma pledged to review current processes and work toward enhancing programs, but she declined to support or oppose specific changes. Instead, she promised to help make health care more affordable and to allow patients more flexibility in making health insurance decisions.
Much of the committee’s questioning centered on Ms. Verma’s work on the Healthy Indiana Plan (HIP), Indiana’s Medicaid expansion under the ACA. The conservative plan requires patients to pay a small amount to receive health coverage and includes a lockout period if payments are missed. Legislators repeatedly asked if Ms. Verma planned to use HIP as a model to alter the Medicaid program.
Ms. Verma countered that each state has different needs and should be allowed to develop individualized Medicaid programs that provide flexibility.
“This is about putting states in a leadership role so that they can manage their programs better,” she said. “States are closer to the people that they serve and have a better understanding of what can work in their state than the federal government. I think states should have that flexibility.”
Legislators raised concerns about Ms. Verma’s past consulting agreements with states while working for Hewlett Packard (HP), a company that had financial interests in the health programs she designed. Ms. Verma’s company, SVC, advises clients on Medicaid waivers and state plan amendment development.
Ms. Verma argued that she never negotiated on behalf of Hewlett Packard, and that the work she conducted for the states did not overlap with work she completed for HP. Her company sought an ethics opinion to ensure the arrangement was not problematic, she said.
“I hold honesty and integrity and adherence to a high ethical standard as part of my personal philosophy. That’s for me, I demand that from my employees, and I set that example for my own children,” she said. “We were never in a position where we were negotiating on behalf of HP or any other contractor with the state that we had a relationship with. If there was the potential [for a conflict], we would recuse ourselves.”
Ms. Verma dodged many specific questions, including whether she supported block grants for Medicaid, how she might improve the problem of prescription drug prices, and whether she supported Medicare as a voucher program. When asked by Sen. Sherrod Campbell Brown (D-Ohio) whether she supported an extension of the current Children’s Health Insurance Program (CHIP) for another 8 years, Ms. Verma said she supported “the reauthorization of CHIP for as long as possible.”
When asked about the value-based reforms included in MACRA (the Medicare Access & CHIP Reauthorization Act of 2015), Ms. Verma said she applauded passage of the law, but she would not go into detail about potential changes to the statute.
“I think it’s an important step forward, not only to providing more stability for providers, but also moving us to better outcomes,” she said.
Sen. Wyden grew visibly frustrated with Ms. Verma’s vague answers, saying he was disappointed that, after many questions, the stances she took in many areas were still unclear.
“You’ve been asked a lot of questions and they were not ‘gotcha’ questions,” Sen. Wyden said during the hearing. “These were questions that were appropriate given the fact that if you’re confirmed, you’re going to head an agency that’s involved with a trillion [dollars] of spending in the health care of 100 million people. We’re not really getting much of a sense of how you’d approach [these issues]. I think this committee needs answers and I think the public needs answers.”
“It is critical that we get a strong, skilled leader as CMS administrator,” he said. “Here you are, somebody who has proven to be a tremendous leader in health care, not only to Indiana but as an example to the rest of the states. All I can say is you will be a strong, skilled leader as CMS administrator.”
A relative unknown before her nomination, Ms. Verma spent 20 years designing policy projects involving Medicaid, including HIP, the nation’s first consumer-directed Medicaid program under Indiana Governor Mitch Daniels and then-Gov. Mike Pence’s HIP 2.0 waiver proposal.
Prior to consulting, Ms. Verma served as vice president of planning for the Health and Hospital Corporation of Marion County (Ind.) and as a director with the Association of State and Territorial Health Officials in Washington.
Senators have asked that Ms. Verma submit written answers to their questions, which they will review before voting on her nomination.
[email protected]
On Twitter @legal_med
Proximity to oil, gas wells linked to ALL
A pumpjack is used to lift
liquid from an oil well.
Photo by Eric Kounce
Living in an area of high-density oil and gas development may increase a young person’s risk of developing acute lymphoblastic leukemia (ALL), according to research published in PLOS ONE.
The study showed that children and young adults in Colorado who had been diagnosed with ALL were more likely than young people with non-hematologic cancers to live in areas of high-density oil and gas development.
However, there was no such association for young people with non-Hodgkin lymphoma (NHL).
“Over 378,000 Coloradans and millions of Americans currently live within a mile of at least one oil and gas well, and petroleum development continues to expand into residential areas,” said study author Lisa McKenzie, PhD, of the University of Colorado Anschutz Campus in Aurora.
“The findings from our registry-based, case-control study indicate that young Coloradans diagnosed with one type of childhood leukemia are more likely to live in the densest areas of oil and gas sites. More comprehensive research that can address our study’s limitations is needed to understand and explain these results.”
Dr McKenzie and her colleagues said they conducted this study because oil and gas development emits known hematological carcinogens, such as benzene, and increasingly occurs in residential areas.
The team wanted to determine whether living near areas of oil and gas development was associated with risk for hematologic cancers. So they analyzed data from the Colorado Central Cancer Registry and the Colorado Oil and Gas Information System.
The study included 743 subjects, ages 0 to 24, living in rural Colorado and diagnosed with cancer between 2001 and 2013. This included 87 ALL cases, 50 NHL cases, and 528 controls with non-hematologic cancers. (Other hematologic malignancies were not included in the analysis due to small numbers.)
Data analysis
The researchers used information from the Colorado Oil and Gas Information System to build a geocoded dataset with coordinates of all oil and gas wells in rural Colorado and determined dates for when each well was active.
Geocoded residential addresses of cancer patients at the time of diagnosis were linked to active well locations in the year of diagnosis and active well locations in each of the 10 years preceding the cancer diagnosis.
The researchers then took the inverse of each distance and summed the inverse distances to calculate inverse distance weighted (IDW) oil and gas well counts within a 16.1 km radius of each participant’s residence at cancer diagnosis for each of the 10 years prior to the date of diagnosis. (The IDW well count method gives greater weight to the wells nearer the home.)
The team used logistic regression to estimate associations for cancers across IDW well count tertiles. The first tertile had less than 4.9 wells per 1.6 km, the second had 4.9 to 33.6 wells per 1.6 km, and the third had more than 33.6 wells per 1.6 km.
Results
The researchers found an increase in the odds of living near oil and gas development at the time of ALL diagnosis, even after adjusting for age, race, gender, income, elevation, and year of cancer diagnosis.
ALL patients ages 0 to 24 were twice as likely as controls to live in the densest area of active oil and gas wells (highest IDW well count tertile).
ALL patients ages 5 to 24 were 4.6 times more likely than controls to live in areas included in the highest IDW well count tertile.
However, there was no significant association between ALL and proximity to oil and gas development in ALL patients ages 0 to 4. The adjusted odds ratio was 0.51 for the highest IDW well count tertile.
Likewise, there were no significant associations between density of oil and gas development and NHL. The adjusted odds ratio was 0.99 for the highest IDW well count tertile.
Limitations and next steps
The researchers said this study was limited by the low occurrence of ALL and NHL in rural Colorado, lack of specific age at cancer diagnosis, and the fact that all study participants had been diagnosed with cancer.
In addition, the study was limited by the lack of information on specific activities at the well sites, place of residence before cancer diagnosis, other sources of pollution around the residence, and individual characteristics such as common infections and family history of cancer.
The team said future research should incorporate information on oil and gas development activities and production levels, as well as levels of specific pollutants of interest such as benzene, near homes, schools, and day care centers.
They recommended that such research consider specific ages and residential histories, compare cases to controls without cancer, and address other potential confounders and and environmental stressors. 
A pumpjack is used to lift
liquid from an oil well.
Photo by Eric Kounce
Living in an area of high-density oil and gas development may increase a young person’s risk of developing acute lymphoblastic leukemia (ALL), according to research published in PLOS ONE.
The study showed that children and young adults in Colorado who had been diagnosed with ALL were more likely than young people with non-hematologic cancers to live in areas of high-density oil and gas development.
However, there was no such association for young people with non-Hodgkin lymphoma (NHL).
“Over 378,000 Coloradans and millions of Americans currently live within a mile of at least one oil and gas well, and petroleum development continues to expand into residential areas,” said study author Lisa McKenzie, PhD, of the University of Colorado Anschutz Campus in Aurora.
“The findings from our registry-based, case-control study indicate that young Coloradans diagnosed with one type of childhood leukemia are more likely to live in the densest areas of oil and gas sites. More comprehensive research that can address our study’s limitations is needed to understand and explain these results.”
Dr McKenzie and her colleagues said they conducted this study because oil and gas development emits known hematological carcinogens, such as benzene, and increasingly occurs in residential areas.
The team wanted to determine whether living near areas of oil and gas development was associated with risk for hematologic cancers. So they analyzed data from the Colorado Central Cancer Registry and the Colorado Oil and Gas Information System.
The study included 743 subjects, ages 0 to 24, living in rural Colorado and diagnosed with cancer between 2001 and 2013. This included 87 ALL cases, 50 NHL cases, and 528 controls with non-hematologic cancers. (Other hematologic malignancies were not included in the analysis due to small numbers.)
Data analysis
The researchers used information from the Colorado Oil and Gas Information System to build a geocoded dataset with coordinates of all oil and gas wells in rural Colorado and determined dates for when each well was active.
Geocoded residential addresses of cancer patients at the time of diagnosis were linked to active well locations in the year of diagnosis and active well locations in each of the 10 years preceding the cancer diagnosis.
The researchers then took the inverse of each distance and summed the inverse distances to calculate inverse distance weighted (IDW) oil and gas well counts within a 16.1 km radius of each participant’s residence at cancer diagnosis for each of the 10 years prior to the date of diagnosis. (The IDW well count method gives greater weight to the wells nearer the home.)
The team used logistic regression to estimate associations for cancers across IDW well count tertiles. The first tertile had less than 4.9 wells per 1.6 km, the second had 4.9 to 33.6 wells per 1.6 km, and the third had more than 33.6 wells per 1.6 km.
Results
The researchers found an increase in the odds of living near oil and gas development at the time of ALL diagnosis, even after adjusting for age, race, gender, income, elevation, and year of cancer diagnosis.
ALL patients ages 0 to 24 were twice as likely as controls to live in the densest area of active oil and gas wells (highest IDW well count tertile).
ALL patients ages 5 to 24 were 4.6 times more likely than controls to live in areas included in the highest IDW well count tertile.
However, there was no significant association between ALL and proximity to oil and gas development in ALL patients ages 0 to 4. The adjusted odds ratio was 0.51 for the highest IDW well count tertile.
Likewise, there were no significant associations between density of oil and gas development and NHL. The adjusted odds ratio was 0.99 for the highest IDW well count tertile.
Limitations and next steps
The researchers said this study was limited by the low occurrence of ALL and NHL in rural Colorado, lack of specific age at cancer diagnosis, and the fact that all study participants had been diagnosed with cancer.
In addition, the study was limited by the lack of information on specific activities at the well sites, place of residence before cancer diagnosis, other sources of pollution around the residence, and individual characteristics such as common infections and family history of cancer.
The team said future research should incorporate information on oil and gas development activities and production levels, as well as levels of specific pollutants of interest such as benzene, near homes, schools, and day care centers.
They recommended that such research consider specific ages and residential histories, compare cases to controls without cancer, and address other potential confounders and and environmental stressors.
A pumpjack is used to lift
liquid from an oil well.
Photo by Eric Kounce
Living in an area of high-density oil and gas development may increase a young person’s risk of developing acute lymphoblastic leukemia (ALL), according to research published in PLOS ONE.
The study showed that children and young adults in Colorado who had been diagnosed with ALL were more likely than young people with non-hematologic cancers to live in areas of high-density oil and gas development.
However, there was no such association for young people with non-Hodgkin lymphoma (NHL).
“Over 378,000 Coloradans and millions of Americans currently live within a mile of at least one oil and gas well, and petroleum development continues to expand into residential areas,” said study author Lisa McKenzie, PhD, of the University of Colorado Anschutz Campus in Aurora.
“The findings from our registry-based, case-control study indicate that young Coloradans diagnosed with one type of childhood leukemia are more likely to live in the densest areas of oil and gas sites. More comprehensive research that can address our study’s limitations is needed to understand and explain these results.”
Dr McKenzie and her colleagues said they conducted this study because oil and gas development emits known hematological carcinogens, such as benzene, and increasingly occurs in residential areas.
The team wanted to determine whether living near areas of oil and gas development was associated with risk for hematologic cancers. So they analyzed data from the Colorado Central Cancer Registry and the Colorado Oil and Gas Information System.
The study included 743 subjects, ages 0 to 24, living in rural Colorado and diagnosed with cancer between 2001 and 2013. This included 87 ALL cases, 50 NHL cases, and 528 controls with non-hematologic cancers. (Other hematologic malignancies were not included in the analysis due to small numbers.)
Data analysis
The researchers used information from the Colorado Oil and Gas Information System to build a geocoded dataset with coordinates of all oil and gas wells in rural Colorado and determined dates for when each well was active.
Geocoded residential addresses of cancer patients at the time of diagnosis were linked to active well locations in the year of diagnosis and active well locations in each of the 10 years preceding the cancer diagnosis.
The researchers then took the inverse of each distance and summed the inverse distances to calculate inverse distance weighted (IDW) oil and gas well counts within a 16.1 km radius of each participant’s residence at cancer diagnosis for each of the 10 years prior to the date of diagnosis. (The IDW well count method gives greater weight to the wells nearer the home.)
The team used logistic regression to estimate associations for cancers across IDW well count tertiles. The first tertile had less than 4.9 wells per 1.6 km, the second had 4.9 to 33.6 wells per 1.6 km, and the third had more than 33.6 wells per 1.6 km.
Results
The researchers found an increase in the odds of living near oil and gas development at the time of ALL diagnosis, even after adjusting for age, race, gender, income, elevation, and year of cancer diagnosis.
ALL patients ages 0 to 24 were twice as likely as controls to live in the densest area of active oil and gas wells (highest IDW well count tertile).
ALL patients ages 5 to 24 were 4.6 times more likely than controls to live in areas included in the highest IDW well count tertile.
However, there was no significant association between ALL and proximity to oil and gas development in ALL patients ages 0 to 4. The adjusted odds ratio was 0.51 for the highest IDW well count tertile.
Likewise, there were no significant associations between density of oil and gas development and NHL. The adjusted odds ratio was 0.99 for the highest IDW well count tertile.
Limitations and next steps
The researchers said this study was limited by the low occurrence of ALL and NHL in rural Colorado, lack of specific age at cancer diagnosis, and the fact that all study participants had been diagnosed with cancer.
In addition, the study was limited by the lack of information on specific activities at the well sites, place of residence before cancer diagnosis, other sources of pollution around the residence, and individual characteristics such as common infections and family history of cancer.
The team said future research should incorporate information on oil and gas development activities and production levels, as well as levels of specific pollutants of interest such as benzene, near homes, schools, and day care centers.
They recommended that such research consider specific ages and residential histories, compare cases to controls without cancer, and address other potential confounders and and environmental stressors.
High continuation rates for IUDs, implants at 2 years
The large majority of women who start using a long-acting reversible contraceptive (LARC) find it acceptable and cost effective enough to continue using the method for at least 2 years, findings from a retrospective cohort study suggest.
Investigators performed a chart review to assess continuation rates in a real-world, mixed-payer setting among 8,603 women aged 15-44 years who had a device inserted between 2004 and 2012 at the University of Utah Healthcare System.
At 2 years, the proportion of women still using the device they had received was 77.8% for the hormonal IUD users, 73.1% for the copper IUD users, and 75.9% for the implant users, according to study findings reported online (Am J Obstet Gynecol. 2017 Feb 8. doi: 10.1016/j.ajog.2017.02.003).
“These data demonstrate a high rate of 2-year continuation of contraceptive devices in a mixed-payer system suggesting user acceptability and confirming that a majority of users reach the point of cost neutrality as demonstrated previously,” Jessica N. Sanders, PhD, of the University of Utah, Salt Lake City, and her colleagues wrote.
In analyses adjusted for potential confounders, compared with copper IUD users, the levonorgestrel IUD users and the implant users had higher adjusted 2-year continuation rates (incidence risk ratio, 1.08 for each).
Additionally, women’s likelihood of continuing use of their contraceptive device for at least 2 years increased with their age at the time of insertion. And women were more likely to still be using their method at that time if they paid for care themselves (incidence risk ratio, 1.13) or were covered by public health insurance (1.04), as compared with those covered by private insurance. Hispanic ethnicity was also associated with 2-year continuation.
“Differences by method type and patient characteristics were small and consistent with previous studies that have demonstrated LARC acceptability across patient demographics,” Dr. Sanders and her coauthors wrote.
Study limitations included possible bias and residual confounding, potentially limited generalizability to other populations of women, and lack of information on pregnancy and obstetric history for the majority of the cohort. But one of the study’s strengths is that it represents actual use, which may differ from prospective studies where participants are reimbursed to continue participation.
Dr. Sanders reported having no relevant conflicts of interest; some of the coauthors are employees of, have affiliations with, and/or own stock in companies that manufacture IUDs and implants. The study was funded in part by Bayer Healthcare.
The large majority of women who start using a long-acting reversible contraceptive (LARC) find it acceptable and cost effective enough to continue using the method for at least 2 years, findings from a retrospective cohort study suggest.
Investigators performed a chart review to assess continuation rates in a real-world, mixed-payer setting among 8,603 women aged 15-44 years who had a device inserted between 2004 and 2012 at the University of Utah Healthcare System.
At 2 years, the proportion of women still using the device they had received was 77.8% for the hormonal IUD users, 73.1% for the copper IUD users, and 75.9% for the implant users, according to study findings reported online (Am J Obstet Gynecol. 2017 Feb 8. doi: 10.1016/j.ajog.2017.02.003).
“These data demonstrate a high rate of 2-year continuation of contraceptive devices in a mixed-payer system suggesting user acceptability and confirming that a majority of users reach the point of cost neutrality as demonstrated previously,” Jessica N. Sanders, PhD, of the University of Utah, Salt Lake City, and her colleagues wrote.
In analyses adjusted for potential confounders, compared with copper IUD users, the levonorgestrel IUD users and the implant users had higher adjusted 2-year continuation rates (incidence risk ratio, 1.08 for each).
Additionally, women’s likelihood of continuing use of their contraceptive device for at least 2 years increased with their age at the time of insertion. And women were more likely to still be using their method at that time if they paid for care themselves (incidence risk ratio, 1.13) or were covered by public health insurance (1.04), as compared with those covered by private insurance. Hispanic ethnicity was also associated with 2-year continuation.
“Differences by method type and patient characteristics were small and consistent with previous studies that have demonstrated LARC acceptability across patient demographics,” Dr. Sanders and her coauthors wrote.
Study limitations included possible bias and residual confounding, potentially limited generalizability to other populations of women, and lack of information on pregnancy and obstetric history for the majority of the cohort. But one of the study’s strengths is that it represents actual use, which may differ from prospective studies where participants are reimbursed to continue participation.
Dr. Sanders reported having no relevant conflicts of interest; some of the coauthors are employees of, have affiliations with, and/or own stock in companies that manufacture IUDs and implants. The study was funded in part by Bayer Healthcare.
The large majority of women who start using a long-acting reversible contraceptive (LARC) find it acceptable and cost effective enough to continue using the method for at least 2 years, findings from a retrospective cohort study suggest.
Investigators performed a chart review to assess continuation rates in a real-world, mixed-payer setting among 8,603 women aged 15-44 years who had a device inserted between 2004 and 2012 at the University of Utah Healthcare System.
At 2 years, the proportion of women still using the device they had received was 77.8% for the hormonal IUD users, 73.1% for the copper IUD users, and 75.9% for the implant users, according to study findings reported online (Am J Obstet Gynecol. 2017 Feb 8. doi: 10.1016/j.ajog.2017.02.003).
“These data demonstrate a high rate of 2-year continuation of contraceptive devices in a mixed-payer system suggesting user acceptability and confirming that a majority of users reach the point of cost neutrality as demonstrated previously,” Jessica N. Sanders, PhD, of the University of Utah, Salt Lake City, and her colleagues wrote.
In analyses adjusted for potential confounders, compared with copper IUD users, the levonorgestrel IUD users and the implant users had higher adjusted 2-year continuation rates (incidence risk ratio, 1.08 for each).
Additionally, women’s likelihood of continuing use of their contraceptive device for at least 2 years increased with their age at the time of insertion. And women were more likely to still be using their method at that time if they paid for care themselves (incidence risk ratio, 1.13) or were covered by public health insurance (1.04), as compared with those covered by private insurance. Hispanic ethnicity was also associated with 2-year continuation.
“Differences by method type and patient characteristics were small and consistent with previous studies that have demonstrated LARC acceptability across patient demographics,” Dr. Sanders and her coauthors wrote.
Study limitations included possible bias and residual confounding, potentially limited generalizability to other populations of women, and lack of information on pregnancy and obstetric history for the majority of the cohort. But one of the study’s strengths is that it represents actual use, which may differ from prospective studies where participants are reimbursed to continue participation.
Dr. Sanders reported having no relevant conflicts of interest; some of the coauthors are employees of, have affiliations with, and/or own stock in companies that manufacture IUDs and implants. The study was funded in part by Bayer Healthcare.
FROM THE AMERICAN JOURNAL OF OBSTETRICS & GYNECOLOGY
Key clinical point:
Major finding: The 2-year continuation rate was 77.8% for the levonorgestrel 52 mg IUD, 73.1% for the copper T380A IUD, and 75.9% for the 68 mg etonogestrel implant.
Data source: A single-center retrospective cohort study of 8,603 women who had an IUD or contraceptive implant inserted during a 9-year period.
Disclosures: Dr. Sanders reported having no relevant conflicts of interest; some of the coauthors are employees of, have affiliations with, and/or own stock in companies that manufacture IUDs and implants. The study was funded in part by Bayer Healthcare.
Quality group endorses new contraception measures
The National Quality Forum has endorsed – for the first time – a set of quality measures related to the prescribing of contraception.
The three new measures are intended to help reduce unintended pregnancies by ensuring that women aged 15-44 years are offered effective birth control options.
“[We] felt strongly that we needed to take a broader look at reproductive health and think about care even before someone was pregnant,” Helen Burstin, MD, the National Quality Forum’s (NQF) chief scientific officer, said in an interview. “That logically led us to thinking about what could come forward that would be useful, specifically around contraception. [We were] pleased to see this wider array of measures coming forward this round that weren’t as focused specifically on pregnancy and perinatal outcomes.”
Measure 2904 assesses the percentage of women aged 15-44 years at risk of an unintended pregnancy who receive a long-acting reversible contraceptive (LARC). The measure is intended to identify situations in which women do not have access to LARCs. The availability of LARCs varies depending on insurance coverage and availability of trained providers, according to NQF. “The measure encourages health systems to look at reporting units with very low rates of provision of LARC to identify unnecessary barriers to LARCs,” the report states. The measure does not include a target percentage for access to LARCs.
Measure 2902 is related to the postpartum period and assesses the percentage of women aged 15-44 years who have had a live birth and are provided a “most effective” or “moderately effective” method of contraception within 3 and 60 days of delivery, and the percentage of those provided with a LARC in the same time period after giving birth. “Contraceptive care for postpartum women is important to facilitate birth spacing, and this measure identifies women more clearly at risk for pregnancy,” the report states.
At the end of 2016, the NQF endorsed a total of 18 perinatal and reproductive health measures that also included measures related to chlamydia screening, labor and delivery, care of premature neonates, and postpartum care. NQF-endorsed measures are frequently used in federal public reporting and performance-based payment programs, including by Medicaid. They are also used in the private sector by hospitals and health plans.
The measures are a good foundation for understanding how women are accessing and using contraception, said Nikki Zite, MD, a professor and director of the obstetrics and gynecology residency program at the University of Tennessee, Knoxville.
“I think it was done in a very careful and thoughtful way, that they are going to track the percent of women of childbearing age using highly effective and moderately effective contraceptive options and they are going to separately track the percent of contracepting women using long-acting reversible methods,” Dr. Zite said. “We hope that if we educate women about contraceptive options, if they are trying to prevent pregnancies, they will choose the option that works best for them, and therefore it will be the most effective.”
Another selling point for the new measures is that they are patient-centered, Dr. Zite added. “The emphasis is on giving access for women who want access, removing barriers, but then also there is no goal amount, so we are not trying to say we want every woman to have LARC because that is not the right option for every woman.” Dr. Zite is an unpaid trainer for Nexplanon and serves on an international IUD advisory board for Bayer.
The American College of Obstetricians and Gynecologists voiced its support for the new measures. “All of these measures will help us advance understanding across the health care system in order to reduce unintended pregnancy,” said Sean Currigan, quality and safety officer at ACOG. “Specifically, the LARC measure will help us understand the unnecessary variation in access to LARC across providers and systems, especially outside of the Title X system; and the postpartum contraception measure will help us understand continuing barriers to contraception like nonpayment/coverage of immediate postpartum LARC.”
In 2016, ACOG withheld its endorsement from quality measures issued by the Core Quality Measures Collaborative (a group led by the Centers for Medicare & Medicaid Services and America’s Health Insurance Plans, with input from NQF, medical societies, employer groups, and consumer groups), because contraception measures were not included in the ob.gyn. measure set.
The National Quality Forum has endorsed – for the first time – a set of quality measures related to the prescribing of contraception.
The three new measures are intended to help reduce unintended pregnancies by ensuring that women aged 15-44 years are offered effective birth control options.
“[We] felt strongly that we needed to take a broader look at reproductive health and think about care even before someone was pregnant,” Helen Burstin, MD, the National Quality Forum’s (NQF) chief scientific officer, said in an interview. “That logically led us to thinking about what could come forward that would be useful, specifically around contraception. [We were] pleased to see this wider array of measures coming forward this round that weren’t as focused specifically on pregnancy and perinatal outcomes.”
Measure 2904 assesses the percentage of women aged 15-44 years at risk of an unintended pregnancy who receive a long-acting reversible contraceptive (LARC). The measure is intended to identify situations in which women do not have access to LARCs. The availability of LARCs varies depending on insurance coverage and availability of trained providers, according to NQF. “The measure encourages health systems to look at reporting units with very low rates of provision of LARC to identify unnecessary barriers to LARCs,” the report states. The measure does not include a target percentage for access to LARCs.
Measure 2902 is related to the postpartum period and assesses the percentage of women aged 15-44 years who have had a live birth and are provided a “most effective” or “moderately effective” method of contraception within 3 and 60 days of delivery, and the percentage of those provided with a LARC in the same time period after giving birth. “Contraceptive care for postpartum women is important to facilitate birth spacing, and this measure identifies women more clearly at risk for pregnancy,” the report states.
At the end of 2016, the NQF endorsed a total of 18 perinatal and reproductive health measures that also included measures related to chlamydia screening, labor and delivery, care of premature neonates, and postpartum care. NQF-endorsed measures are frequently used in federal public reporting and performance-based payment programs, including by Medicaid. They are also used in the private sector by hospitals and health plans.
The measures are a good foundation for understanding how women are accessing and using contraception, said Nikki Zite, MD, a professor and director of the obstetrics and gynecology residency program at the University of Tennessee, Knoxville.
“I think it was done in a very careful and thoughtful way, that they are going to track the percent of women of childbearing age using highly effective and moderately effective contraceptive options and they are going to separately track the percent of contracepting women using long-acting reversible methods,” Dr. Zite said. “We hope that if we educate women about contraceptive options, if they are trying to prevent pregnancies, they will choose the option that works best for them, and therefore it will be the most effective.”
Another selling point for the new measures is that they are patient-centered, Dr. Zite added. “The emphasis is on giving access for women who want access, removing barriers, but then also there is no goal amount, so we are not trying to say we want every woman to have LARC because that is not the right option for every woman.” Dr. Zite is an unpaid trainer for Nexplanon and serves on an international IUD advisory board for Bayer.
The American College of Obstetricians and Gynecologists voiced its support for the new measures. “All of these measures will help us advance understanding across the health care system in order to reduce unintended pregnancy,” said Sean Currigan, quality and safety officer at ACOG. “Specifically, the LARC measure will help us understand the unnecessary variation in access to LARC across providers and systems, especially outside of the Title X system; and the postpartum contraception measure will help us understand continuing barriers to contraception like nonpayment/coverage of immediate postpartum LARC.”
In 2016, ACOG withheld its endorsement from quality measures issued by the Core Quality Measures Collaborative (a group led by the Centers for Medicare & Medicaid Services and America’s Health Insurance Plans, with input from NQF, medical societies, employer groups, and consumer groups), because contraception measures were not included in the ob.gyn. measure set.
The National Quality Forum has endorsed – for the first time – a set of quality measures related to the prescribing of contraception.
The three new measures are intended to help reduce unintended pregnancies by ensuring that women aged 15-44 years are offered effective birth control options.
“[We] felt strongly that we needed to take a broader look at reproductive health and think about care even before someone was pregnant,” Helen Burstin, MD, the National Quality Forum’s (NQF) chief scientific officer, said in an interview. “That logically led us to thinking about what could come forward that would be useful, specifically around contraception. [We were] pleased to see this wider array of measures coming forward this round that weren’t as focused specifically on pregnancy and perinatal outcomes.”
Measure 2904 assesses the percentage of women aged 15-44 years at risk of an unintended pregnancy who receive a long-acting reversible contraceptive (LARC). The measure is intended to identify situations in which women do not have access to LARCs. The availability of LARCs varies depending on insurance coverage and availability of trained providers, according to NQF. “The measure encourages health systems to look at reporting units with very low rates of provision of LARC to identify unnecessary barriers to LARCs,” the report states. The measure does not include a target percentage for access to LARCs.
Measure 2902 is related to the postpartum period and assesses the percentage of women aged 15-44 years who have had a live birth and are provided a “most effective” or “moderately effective” method of contraception within 3 and 60 days of delivery, and the percentage of those provided with a LARC in the same time period after giving birth. “Contraceptive care for postpartum women is important to facilitate birth spacing, and this measure identifies women more clearly at risk for pregnancy,” the report states.
At the end of 2016, the NQF endorsed a total of 18 perinatal and reproductive health measures that also included measures related to chlamydia screening, labor and delivery, care of premature neonates, and postpartum care. NQF-endorsed measures are frequently used in federal public reporting and performance-based payment programs, including by Medicaid. They are also used in the private sector by hospitals and health plans.
The measures are a good foundation for understanding how women are accessing and using contraception, said Nikki Zite, MD, a professor and director of the obstetrics and gynecology residency program at the University of Tennessee, Knoxville.
“I think it was done in a very careful and thoughtful way, that they are going to track the percent of women of childbearing age using highly effective and moderately effective contraceptive options and they are going to separately track the percent of contracepting women using long-acting reversible methods,” Dr. Zite said. “We hope that if we educate women about contraceptive options, if they are trying to prevent pregnancies, they will choose the option that works best for them, and therefore it will be the most effective.”
Another selling point for the new measures is that they are patient-centered, Dr. Zite added. “The emphasis is on giving access for women who want access, removing barriers, but then also there is no goal amount, so we are not trying to say we want every woman to have LARC because that is not the right option for every woman.” Dr. Zite is an unpaid trainer for Nexplanon and serves on an international IUD advisory board for Bayer.
The American College of Obstetricians and Gynecologists voiced its support for the new measures. “All of these measures will help us advance understanding across the health care system in order to reduce unintended pregnancy,” said Sean Currigan, quality and safety officer at ACOG. “Specifically, the LARC measure will help us understand the unnecessary variation in access to LARC across providers and systems, especially outside of the Title X system; and the postpartum contraception measure will help us understand continuing barriers to contraception like nonpayment/coverage of immediate postpartum LARC.”
In 2016, ACOG withheld its endorsement from quality measures issued by the Core Quality Measures Collaborative (a group led by the Centers for Medicare & Medicaid Services and America’s Health Insurance Plans, with input from NQF, medical societies, employer groups, and consumer groups), because contraception measures were not included in the ob.gyn. measure set.
CDC: More preterm births after fertility treatments
Infants conceived through assisted reproductive technology (ART) represented less than 2% of all children born in the United States in 2014, but they experienced disproportionately large shares of adverse perinatal outcomes, according to the Centers for Disease Control and Prevention.
Of the 4.02 million children born in the United States in 2014, a total of 65,296 (1.6%) were conceived with ART procedures. ART-conceived children, however, represented 5.5% of all low-birth-weight infants (less than 2,500 g) and 5.6% of all very-low-birth-weight infants (less than 1,500 g). ART-conceived children also represented 4.7% of all preterm births (less than 37 weeks) in 2014 and 5.0% of all very preterm (less than 32 weeks) infants nationally, the CDC reported (MMWR Surveill Summ. 2017;66[SS-6]:1-24).
These poor outcomes are related, at least in part, to the effect of infertility treatment on multiple births. The percentage of triplets or higher-order infants among ART-conceived infants has decreased since 2000, but “the percentage of twin infants has remained persistently high,” the CDC noted. Multiple-birth infants represent 39.4% of all ART infants but only 3.5% of all infants, and ART-conceived multiple-birth infants represent 18.3% of all multiple-birth infants, the CDC said.
The multiple-birth effect varied considerably by state, however. In Hawaii, ART-conceived multiple-birth infants accounted for 37.3% of all multiple births in 2014, while Alaska and West Virginia both had rates of 5.5%. Poor outcomes also varied by state: In Massachusetts, ART infants represented 14.2% of all low-birth-weight infants, compared with 1.2% in West Virginia. Massachusetts had the highest rate of ART preterm infants to all infants, 13.4%, and Puerto Rico had the lowest, 1.2%, according to the CDC report, which was based on data from the National ART Surveillance System.
Puerto Rico’s rate of 364 ART procedures per 1 million women aged 15-44 years was the lowest in the country, and the highest rate belonged to Massachusetts at 6,726 per 1 million women aged 15-44 years.
Infants conceived through assisted reproductive technology (ART) represented less than 2% of all children born in the United States in 2014, but they experienced disproportionately large shares of adverse perinatal outcomes, according to the Centers for Disease Control and Prevention.
Of the 4.02 million children born in the United States in 2014, a total of 65,296 (1.6%) were conceived with ART procedures. ART-conceived children, however, represented 5.5% of all low-birth-weight infants (less than 2,500 g) and 5.6% of all very-low-birth-weight infants (less than 1,500 g). ART-conceived children also represented 4.7% of all preterm births (less than 37 weeks) in 2014 and 5.0% of all very preterm (less than 32 weeks) infants nationally, the CDC reported (MMWR Surveill Summ. 2017;66[SS-6]:1-24).
These poor outcomes are related, at least in part, to the effect of infertility treatment on multiple births. The percentage of triplets or higher-order infants among ART-conceived infants has decreased since 2000, but “the percentage of twin infants has remained persistently high,” the CDC noted. Multiple-birth infants represent 39.4% of all ART infants but only 3.5% of all infants, and ART-conceived multiple-birth infants represent 18.3% of all multiple-birth infants, the CDC said.
The multiple-birth effect varied considerably by state, however. In Hawaii, ART-conceived multiple-birth infants accounted for 37.3% of all multiple births in 2014, while Alaska and West Virginia both had rates of 5.5%. Poor outcomes also varied by state: In Massachusetts, ART infants represented 14.2% of all low-birth-weight infants, compared with 1.2% in West Virginia. Massachusetts had the highest rate of ART preterm infants to all infants, 13.4%, and Puerto Rico had the lowest, 1.2%, according to the CDC report, which was based on data from the National ART Surveillance System.
Puerto Rico’s rate of 364 ART procedures per 1 million women aged 15-44 years was the lowest in the country, and the highest rate belonged to Massachusetts at 6,726 per 1 million women aged 15-44 years.
Infants conceived through assisted reproductive technology (ART) represented less than 2% of all children born in the United States in 2014, but they experienced disproportionately large shares of adverse perinatal outcomes, according to the Centers for Disease Control and Prevention.
Of the 4.02 million children born in the United States in 2014, a total of 65,296 (1.6%) were conceived with ART procedures. ART-conceived children, however, represented 5.5% of all low-birth-weight infants (less than 2,500 g) and 5.6% of all very-low-birth-weight infants (less than 1,500 g). ART-conceived children also represented 4.7% of all preterm births (less than 37 weeks) in 2014 and 5.0% of all very preterm (less than 32 weeks) infants nationally, the CDC reported (MMWR Surveill Summ. 2017;66[SS-6]:1-24).
These poor outcomes are related, at least in part, to the effect of infertility treatment on multiple births. The percentage of triplets or higher-order infants among ART-conceived infants has decreased since 2000, but “the percentage of twin infants has remained persistently high,” the CDC noted. Multiple-birth infants represent 39.4% of all ART infants but only 3.5% of all infants, and ART-conceived multiple-birth infants represent 18.3% of all multiple-birth infants, the CDC said.
The multiple-birth effect varied considerably by state, however. In Hawaii, ART-conceived multiple-birth infants accounted for 37.3% of all multiple births in 2014, while Alaska and West Virginia both had rates of 5.5%. Poor outcomes also varied by state: In Massachusetts, ART infants represented 14.2% of all low-birth-weight infants, compared with 1.2% in West Virginia. Massachusetts had the highest rate of ART preterm infants to all infants, 13.4%, and Puerto Rico had the lowest, 1.2%, according to the CDC report, which was based on data from the National ART Surveillance System.
Puerto Rico’s rate of 364 ART procedures per 1 million women aged 15-44 years was the lowest in the country, and the highest rate belonged to Massachusetts at 6,726 per 1 million women aged 15-44 years.
FROM MMWR SURVEILLANCE SUMMARIES
Steroid use in adolescents
Anabolic androgenic steroid (AAS) use in athletes is not a new topic. In fact, many teens can relate a story involving a famous athlete and use of a performance-enhancing drug and the consequences associated with it. Although published data do not support a significant increase in use of performance-enhancing drugs among adolescents,1 more recent studies show that anabolic steroids are being found in nonprescription supplements, and their use among adolescents may be substantially underestimated.
Supplements are not regulated by the Food and Drug Administration, so many of these products are easily found on the Internet and sold in local stores.2,3 Some of these are marketed for increasing muscle mass, strength, and performance, which is appealing to the young athlete. Much of the marketing of these products minimize the side effects associated with their use and, therefore, most users are unaware of their harmful effects.
Approximately 5%-11% of teen athletes use AAS to improve physique and performance.3 Given its promotion for improved physique, many nonathletes also are turning to AAS for weight loss in both males and females. Side effects of steroid use are extrapolated from the data of therapeutic use, but most adolescents using steroids are not using under medical supervision. The dosing for building muscle mass uses a pyramid type dosing over a 6- to 12-week period and can be up to forty times the therapeutic dosing; therefore, the side effects can be greater than reported.4,5 Common side effects of AAS are hypogonadism, gynecomastia, decreased sperm count and infertility, acne, and aggressiveness. Liver tumors and psychosis have been reported, and increased depressed mood have been identified with discontinuation of use.4,6 Studies suggest that these side effects are reversible with discontinuation, but more studies are needed.4,6
Given that many of the side effects are not identifiable on physical exam, pediatricians must be proactive in questioning adolescents about their knowledge and use of AAS. Testing for steroid use is difficult and not very sensitive. Urine test for carbon isotopes 13/12 is the most common test, but if not done within hours of ingestion it will not be detected. T/E test (testosterone/epitestosterone glucuronide) is another test, but also limited by the timing of the test.6 Home screening also is available but the American Academy of Pediatrics 2014 guidelines warns against parents using these given the high false positive rate and risk of confrontation.7
Home and school screening may function more to deter athletes from using steroids to avoid consequences of being caught more than actually identifying use. If an athlete is suspected of using steroids, a test should be done. If negative, it should be repeated another time, as repeated testing is more likely to identify use. Studies have shown a correlation between steroid use and use of other illicit drugs so further screening should be done to identify if other drugs are being used.8
Widespread screening has not been shown to be cost effective and, therefore, should not be encouraged. Educating the patient on the risk of use and potential side effects along with healthy alternatives that improve performance and physique is much more effective.9 Being observant to signs and symptoms of AAS use helps to initiate conversation on the risk of using anabolic steroids.
References
1. Arch Pediatr Adolesc Med. 1997 Dec;151(12):1197-206.
2. Subst Use Misuse. 2012 Feb; 47(3):329-41.
3. Am J Clin Nutr. 2000 Feb;71(2):399-400.
4. J Sports Sci Med. 2006 Jun 1;5(2):182-93.
5. Br J Sports Med. 2006 Jul; 40(Suppl 1): i21-24.
6. J Athl Train. 1994 Mar; 29(1):60-4.
7. Pediatrics. 2014;133:e1798-1807.
8. Pediatrics. 1995 Jul;96(1 Pt 1):23-8.
9. Pediatrics. 1997 Jun;99(6):904-8.
Dr. Pearce is a pediatrician in Frankfort, Ill. She said she had no relevant financial disclosures. Email her at [email protected].
Anabolic androgenic steroid (AAS) use in athletes is not a new topic. In fact, many teens can relate a story involving a famous athlete and use of a performance-enhancing drug and the consequences associated with it. Although published data do not support a significant increase in use of performance-enhancing drugs among adolescents,1 more recent studies show that anabolic steroids are being found in nonprescription supplements, and their use among adolescents may be substantially underestimated.
Supplements are not regulated by the Food and Drug Administration, so many of these products are easily found on the Internet and sold in local stores.2,3 Some of these are marketed for increasing muscle mass, strength, and performance, which is appealing to the young athlete. Much of the marketing of these products minimize the side effects associated with their use and, therefore, most users are unaware of their harmful effects.
Approximately 5%-11% of teen athletes use AAS to improve physique and performance.3 Given its promotion for improved physique, many nonathletes also are turning to AAS for weight loss in both males and females. Side effects of steroid use are extrapolated from the data of therapeutic use, but most adolescents using steroids are not using under medical supervision. The dosing for building muscle mass uses a pyramid type dosing over a 6- to 12-week period and can be up to forty times the therapeutic dosing; therefore, the side effects can be greater than reported.4,5 Common side effects of AAS are hypogonadism, gynecomastia, decreased sperm count and infertility, acne, and aggressiveness. Liver tumors and psychosis have been reported, and increased depressed mood have been identified with discontinuation of use.4,6 Studies suggest that these side effects are reversible with discontinuation, but more studies are needed.4,6
Given that many of the side effects are not identifiable on physical exam, pediatricians must be proactive in questioning adolescents about their knowledge and use of AAS. Testing for steroid use is difficult and not very sensitive. Urine test for carbon isotopes 13/12 is the most common test, but if not done within hours of ingestion it will not be detected. T/E test (testosterone/epitestosterone glucuronide) is another test, but also limited by the timing of the test.6 Home screening also is available but the American Academy of Pediatrics 2014 guidelines warns against parents using these given the high false positive rate and risk of confrontation.7
Home and school screening may function more to deter athletes from using steroids to avoid consequences of being caught more than actually identifying use. If an athlete is suspected of using steroids, a test should be done. If negative, it should be repeated another time, as repeated testing is more likely to identify use. Studies have shown a correlation between steroid use and use of other illicit drugs so further screening should be done to identify if other drugs are being used.8
Widespread screening has not been shown to be cost effective and, therefore, should not be encouraged. Educating the patient on the risk of use and potential side effects along with healthy alternatives that improve performance and physique is much more effective.9 Being observant to signs and symptoms of AAS use helps to initiate conversation on the risk of using anabolic steroids.
References
1. Arch Pediatr Adolesc Med. 1997 Dec;151(12):1197-206.
2. Subst Use Misuse. 2012 Feb; 47(3):329-41.
3. Am J Clin Nutr. 2000 Feb;71(2):399-400.
4. J Sports Sci Med. 2006 Jun 1;5(2):182-93.
5. Br J Sports Med. 2006 Jul; 40(Suppl 1): i21-24.
6. J Athl Train. 1994 Mar; 29(1):60-4.
7. Pediatrics. 2014;133:e1798-1807.
8. Pediatrics. 1995 Jul;96(1 Pt 1):23-8.
9. Pediatrics. 1997 Jun;99(6):904-8.
Dr. Pearce is a pediatrician in Frankfort, Ill. She said she had no relevant financial disclosures. Email her at [email protected].
Anabolic androgenic steroid (AAS) use in athletes is not a new topic. In fact, many teens can relate a story involving a famous athlete and use of a performance-enhancing drug and the consequences associated with it. Although published data do not support a significant increase in use of performance-enhancing drugs among adolescents,1 more recent studies show that anabolic steroids are being found in nonprescription supplements, and their use among adolescents may be substantially underestimated.
Supplements are not regulated by the Food and Drug Administration, so many of these products are easily found on the Internet and sold in local stores.2,3 Some of these are marketed for increasing muscle mass, strength, and performance, which is appealing to the young athlete. Much of the marketing of these products minimize the side effects associated with their use and, therefore, most users are unaware of their harmful effects.
Approximately 5%-11% of teen athletes use AAS to improve physique and performance.3 Given its promotion for improved physique, many nonathletes also are turning to AAS for weight loss in both males and females. Side effects of steroid use are extrapolated from the data of therapeutic use, but most adolescents using steroids are not using under medical supervision. The dosing for building muscle mass uses a pyramid type dosing over a 6- to 12-week period and can be up to forty times the therapeutic dosing; therefore, the side effects can be greater than reported.4,5 Common side effects of AAS are hypogonadism, gynecomastia, decreased sperm count and infertility, acne, and aggressiveness. Liver tumors and psychosis have been reported, and increased depressed mood have been identified with discontinuation of use.4,6 Studies suggest that these side effects are reversible with discontinuation, but more studies are needed.4,6
Given that many of the side effects are not identifiable on physical exam, pediatricians must be proactive in questioning adolescents about their knowledge and use of AAS. Testing for steroid use is difficult and not very sensitive. Urine test for carbon isotopes 13/12 is the most common test, but if not done within hours of ingestion it will not be detected. T/E test (testosterone/epitestosterone glucuronide) is another test, but also limited by the timing of the test.6 Home screening also is available but the American Academy of Pediatrics 2014 guidelines warns against parents using these given the high false positive rate and risk of confrontation.7
Home and school screening may function more to deter athletes from using steroids to avoid consequences of being caught more than actually identifying use. If an athlete is suspected of using steroids, a test should be done. If negative, it should be repeated another time, as repeated testing is more likely to identify use. Studies have shown a correlation between steroid use and use of other illicit drugs so further screening should be done to identify if other drugs are being used.8
Widespread screening has not been shown to be cost effective and, therefore, should not be encouraged. Educating the patient on the risk of use and potential side effects along with healthy alternatives that improve performance and physique is much more effective.9 Being observant to signs and symptoms of AAS use helps to initiate conversation on the risk of using anabolic steroids.
References
1. Arch Pediatr Adolesc Med. 1997 Dec;151(12):1197-206.
2. Subst Use Misuse. 2012 Feb; 47(3):329-41.
3. Am J Clin Nutr. 2000 Feb;71(2):399-400.
4. J Sports Sci Med. 2006 Jun 1;5(2):182-93.
5. Br J Sports Med. 2006 Jul; 40(Suppl 1): i21-24.
6. J Athl Train. 1994 Mar; 29(1):60-4.
7. Pediatrics. 2014;133:e1798-1807.
8. Pediatrics. 1995 Jul;96(1 Pt 1):23-8.
9. Pediatrics. 1997 Jun;99(6):904-8.
Dr. Pearce is a pediatrician in Frankfort, Ill. She said she had no relevant financial disclosures. Email her at [email protected].
Sirolimus shows promise for pediatric refractory IBD treatment
Sirolimus may be an effective rescue treatment option for children with refractory inflammatory bowel disease, according to Dr. Mohamed Mutalib and his associates.
In a retrospective analysis of 11 ulcerative colitis (UC) and 3 Crohn’s disease patients treated with sirolimus, 5 of the UC patients and all of the Crohn’s disease patients achieved clinical remission. An additional 2 UC patients achieved clinical response. The remaining 4 UC patients did not respond to sirolimus treatment.
Mucosal healing was achieved in 5 of 11 UC patients and 2 of 3 Crohn’s patients. Clinical response to treatment occurred at least 2 weeks after treatment was started. The only significant side effect reported was minor gastrointestinal distress.
“Our data provide compelling evidence that sirolimus is effective as rescue therapy in a subgroup of children with severe [inflammatory bowel disease] refractory to conventional therapies by inducing both clinical remission and mucosal healing. However, randomized placebo-controlled studies are warranted to extend our encouraging initial findings,” the investigators concluded.
Find the full study in the Journal of Crohn’s and Colitis (doi: 10.1016/j.crohns.2014.08.014).
Sirolimus may be an effective rescue treatment option for children with refractory inflammatory bowel disease, according to Dr. Mohamed Mutalib and his associates.
In a retrospective analysis of 11 ulcerative colitis (UC) and 3 Crohn’s disease patients treated with sirolimus, 5 of the UC patients and all of the Crohn’s disease patients achieved clinical remission. An additional 2 UC patients achieved clinical response. The remaining 4 UC patients did not respond to sirolimus treatment.
Mucosal healing was achieved in 5 of 11 UC patients and 2 of 3 Crohn’s patients. Clinical response to treatment occurred at least 2 weeks after treatment was started. The only significant side effect reported was minor gastrointestinal distress.
“Our data provide compelling evidence that sirolimus is effective as rescue therapy in a subgroup of children with severe [inflammatory bowel disease] refractory to conventional therapies by inducing both clinical remission and mucosal healing. However, randomized placebo-controlled studies are warranted to extend our encouraging initial findings,” the investigators concluded.
Find the full study in the Journal of Crohn’s and Colitis (doi: 10.1016/j.crohns.2014.08.014).
Sirolimus may be an effective rescue treatment option for children with refractory inflammatory bowel disease, according to Dr. Mohamed Mutalib and his associates.
In a retrospective analysis of 11 ulcerative colitis (UC) and 3 Crohn’s disease patients treated with sirolimus, 5 of the UC patients and all of the Crohn’s disease patients achieved clinical remission. An additional 2 UC patients achieved clinical response. The remaining 4 UC patients did not respond to sirolimus treatment.
Mucosal healing was achieved in 5 of 11 UC patients and 2 of 3 Crohn’s patients. Clinical response to treatment occurred at least 2 weeks after treatment was started. The only significant side effect reported was minor gastrointestinal distress.
“Our data provide compelling evidence that sirolimus is effective as rescue therapy in a subgroup of children with severe [inflammatory bowel disease] refractory to conventional therapies by inducing both clinical remission and mucosal healing. However, randomized placebo-controlled studies are warranted to extend our encouraging initial findings,” the investigators concluded.
Find the full study in the Journal of Crohn’s and Colitis (doi: 10.1016/j.crohns.2014.08.014).
FROM THE JOURNAL OF CROHN'S AND COLITIS
Magnetic implant may offer new drug delivery method
A tiny magnetic implant could provide a new method of drug delivery, according to research published in Advanced Functional Materials.
The device is a silicone sponge with magnetic carbonyl iron particles wrapped in a round polymer layer. It measures 6 mm in diameter.
A drug is injected into the device, which is surgically implanted in the area being treated.
Passing a magnet over the implant activates the device by deforming the sponge and triggering the release of the drug into surrounding tissue through a tiny opening.
“Drug implants can be safe and effective for treating many conditions, and magnetically controlled implants are particularly interesting because you can adjust the dose after implantation by using different magnet strengths,” said study author Ali Shademani, a PhD student at the University of British Columbia (UBC) in Vancouver, British Columbia, Canada.
“This device lets you release the actual dose that the patient needs when they need it, and it’s sufficiently easy to use that patients could administer their own medication one day without having to go to a hospital,” added John K. Jackson, also of UBC.
The researchers tested the device on animal tissue in the lab using the prostate cancer drug docetaxel. The device was able to deliver the drug on demand even after repeated use.
The drug also produced an effect on cancer cells comparable to that of freshly administered docetaxel, suggesting that drugs stored in the device stay effective.
The researchers are now working on refining the device and narrowing down the conditions for its use.
“This could one day be used for administering painkillers, hormones, chemotherapy drugs, and other treatments for a wide range of health conditions,” said Mu Chiao, PhD, of UBC. “In the next few years, we hope to be able to test it for long-term use and for viability in living models.”
A tiny magnetic implant could provide a new method of drug delivery, according to research published in Advanced Functional Materials.
The device is a silicone sponge with magnetic carbonyl iron particles wrapped in a round polymer layer. It measures 6 mm in diameter.
A drug is injected into the device, which is surgically implanted in the area being treated.
Passing a magnet over the implant activates the device by deforming the sponge and triggering the release of the drug into surrounding tissue through a tiny opening.
“Drug implants can be safe and effective for treating many conditions, and magnetically controlled implants are particularly interesting because you can adjust the dose after implantation by using different magnet strengths,” said study author Ali Shademani, a PhD student at the University of British Columbia (UBC) in Vancouver, British Columbia, Canada.
“This device lets you release the actual dose that the patient needs when they need it, and it’s sufficiently easy to use that patients could administer their own medication one day without having to go to a hospital,” added John K. Jackson, also of UBC.
The researchers tested the device on animal tissue in the lab using the prostate cancer drug docetaxel. The device was able to deliver the drug on demand even after repeated use.
The drug also produced an effect on cancer cells comparable to that of freshly administered docetaxel, suggesting that drugs stored in the device stay effective.
The researchers are now working on refining the device and narrowing down the conditions for its use.
“This could one day be used for administering painkillers, hormones, chemotherapy drugs, and other treatments for a wide range of health conditions,” said Mu Chiao, PhD, of UBC. “In the next few years, we hope to be able to test it for long-term use and for viability in living models.”
A tiny magnetic implant could provide a new method of drug delivery, according to research published in Advanced Functional Materials.
The device is a silicone sponge with magnetic carbonyl iron particles wrapped in a round polymer layer. It measures 6 mm in diameter.
A drug is injected into the device, which is surgically implanted in the area being treated.
Passing a magnet over the implant activates the device by deforming the sponge and triggering the release of the drug into surrounding tissue through a tiny opening.
“Drug implants can be safe and effective for treating many conditions, and magnetically controlled implants are particularly interesting because you can adjust the dose after implantation by using different magnet strengths,” said study author Ali Shademani, a PhD student at the University of British Columbia (UBC) in Vancouver, British Columbia, Canada.
“This device lets you release the actual dose that the patient needs when they need it, and it’s sufficiently easy to use that patients could administer their own medication one day without having to go to a hospital,” added John K. Jackson, also of UBC.
The researchers tested the device on animal tissue in the lab using the prostate cancer drug docetaxel. The device was able to deliver the drug on demand even after repeated use.
The drug also produced an effect on cancer cells comparable to that of freshly administered docetaxel, suggesting that drugs stored in the device stay effective.
The researchers are now working on refining the device and narrowing down the conditions for its use.
“This could one day be used for administering painkillers, hormones, chemotherapy drugs, and other treatments for a wide range of health conditions,” said Mu Chiao, PhD, of UBC. “In the next few years, we hope to be able to test it for long-term use and for viability in living models.”