LOS ANGELES – Acutely hospitalized patients who have been on mechanical ventilation for more than 24 hours, are at high risk for extubation failure, and have passed a spontaneous breathing trial should be extubated to noninvasive ventilation.

The recommendation comes from new clinical practice guidelines from the American College of Chest Physicians and the American Thoracic Society. Moderate-quality evidence suggests that early extubation and a switch to noninvasive ventilation reduces ventilator-related and ICU-related complications, including infections and injury to the lungs and other organs. Extubation also cuts costs by reducing ICU stays.

We suggest that the initial spontaneous breathing trial be conducted with inspiratory pressure augmentation rather than T-piece or continuous positive airway pressure. The committee wrote that conducting the initial spontaneous breathing trial with pressure augmentation was more likely to be successful, produced a higher rate of extubation success, and was associated with a trend towards lower intensive care unit mortality.

We suggest protocols attempting to minimize sedation. The committee found that sedation protocols reduced ICU length of stay. However, the protocols did not appear to decrease time on the ventilator or reduce short-term mortality. The authors could not recommend one protocol over another but said the burden of providing sedation by any of the protocols was “very low.”

We suggest protocolized rehabilitation directed toward early mobilization. The committee wrote that patients receiving the intervention spent less time on the ventilator and were more likely to be able to walk when they left the hospital. However, their mortality rate appeared unchanged. The authors noted the exercises created additional work for ICU staff that might have come at the expense of other care priorities.

We suggest managing patients with a ventilator liberation protocol. The committee said that patients managed by protocol spent on average 25 fewer hours on mechanical ventilation and were discharged from the ICU a day early. However, their mortality rate appeared unchanged.

We suggest performing a cuff leak test in patients who meet extubation criteria and are deemed at high risk for postextubation stridor. The committee suggested that the test should be used only in patients with a high risk of stridor (abnormal breathing caused by blockage of windpipe) after extubation. Although patients passing the test had lower stridor and reintubation rates, the authors wrote that a high percentage of patients who failed the test could be successfully extubated.

For patients who failed the cuff leak test but are otherwise ready for extubation, we suggest administering systemic steroids at least 4 hours before extubation. The committee said that clinical judgment should take priority over test results, and systemic steroids should be administered to these patients at least 4 hours before extubation. The authors added that the short duration of the steroid therapy was likely to improve success rates without resulting in adverse events.

In a prepared statement, Timothy Girard, MD, of the department of medicine at the University of Pittsburgh and a lead author of the guidelines said the committee hoped the guidelines would help reduce variations in practice that do not benefit patients. “We are not prescribing a specific approach to care for every patient every time,” he said. “But we are trying to summarize the available evidence in as clear and succinct a way as possible so that clinicians know how it applies to most patients.”

Dr. Ouellette disclosed that he has received a research grant from Cardeas Pharma for health care–associated pneumonia.

[email protected]

LOS ANGELES – Acutely hospitalized patients who have been on mechanical ventilation for more than 24 hours, are at high risk for extubation failure, and have passed a spontaneous breathing trial should be extubated to noninvasive ventilation.

The recommendation comes from new clinical practice guidelines from the American College of Chest Physicians and the American Thoracic Society. Moderate-quality evidence suggests that early extubation and a switch to noninvasive ventilation reduces ventilator-related and ICU-related complications, including infections and injury to the lungs and other organs. Extubation also cuts costs by reducing ICU stays.

We suggest that the initial spontaneous breathing trial be conducted with inspiratory pressure augmentation rather than T-piece or continuous positive airway pressure. The committee wrote that conducting the initial spontaneous breathing trial with pressure augmentation was more likely to be successful, produced a higher rate of extubation success, and was associated with a trend towards lower intensive care unit mortality.

We suggest protocols attempting to minimize sedation. The committee found that sedation protocols reduced ICU length of stay. However, the protocols did not appear to decrease time on the ventilator or reduce short-term mortality. The authors could not recommend one protocol over another but said the burden of providing sedation by any of the protocols was “very low.”

We suggest protocolized rehabilitation directed toward early mobilization. The committee wrote that patients receiving the intervention spent less time on the ventilator and were more likely to be able to walk when they left the hospital. However, their mortality rate appeared unchanged. The authors noted the exercises created additional work for ICU staff that might have come at the expense of other care priorities.

We suggest managing patients with a ventilator liberation protocol. The committee said that patients managed by protocol spent on average 25 fewer hours on mechanical ventilation and were discharged from the ICU a day early. However, their mortality rate appeared unchanged.

We suggest performing a cuff leak test in patients who meet extubation criteria and are deemed at high risk for postextubation stridor. The committee suggested that the test should be used only in patients with a high risk of stridor (abnormal breathing caused by blockage of windpipe) after extubation. Although patients passing the test had lower stridor and reintubation rates, the authors wrote that a high percentage of patients who failed the test could be successfully extubated.

For patients who failed the cuff leak test but are otherwise ready for extubation, we suggest administering systemic steroids at least 4 hours before extubation. The committee said that clinical judgment should take priority over test results, and systemic steroids should be administered to these patients at least 4 hours before extubation. The authors added that the short duration of the steroid therapy was likely to improve success rates without resulting in adverse events.

In a prepared statement, Timothy Girard, MD, of the department of medicine at the University of Pittsburgh and a lead author of the guidelines said the committee hoped the guidelines would help reduce variations in practice that do not benefit patients. “We are not prescribing a specific approach to care for every patient every time,” he said. “But we are trying to summarize the available evidence in as clear and succinct a way as possible so that clinicians know how it applies to most patients.”

Dr. Ouellette disclosed that he has received a research grant from Cardeas Pharma for health care–associated pneumonia.

[email protected]

LOS ANGELES – Acutely hospitalized patients who have been on mechanical ventilation for more than 24 hours, are at high risk for extubation failure, and have passed a spontaneous breathing trial should be extubated to noninvasive ventilation.

The recommendation comes from new clinical practice guidelines from the American College of Chest Physicians and the American Thoracic Society. Moderate-quality evidence suggests that early extubation and a switch to noninvasive ventilation reduces ventilator-related and ICU-related complications, including infections and injury to the lungs and other organs. Extubation also cuts costs by reducing ICU stays.

We suggest that the initial spontaneous breathing trial be conducted with inspiratory pressure augmentation rather than T-piece or continuous positive airway pressure. The committee wrote that conducting the initial spontaneous breathing trial with pressure augmentation was more likely to be successful, produced a higher rate of extubation success, and was associated with a trend towards lower intensive care unit mortality.

We suggest protocols attempting to minimize sedation. The committee found that sedation protocols reduced ICU length of stay. However, the protocols did not appear to decrease time on the ventilator or reduce short-term mortality. The authors could not recommend one protocol over another but said the burden of providing sedation by any of the protocols was “very low.”

We suggest protocolized rehabilitation directed toward early mobilization. The committee wrote that patients receiving the intervention spent less time on the ventilator and were more likely to be able to walk when they left the hospital. However, their mortality rate appeared unchanged. The authors noted the exercises created additional work for ICU staff that might have come at the expense of other care priorities.

We suggest managing patients with a ventilator liberation protocol. The committee said that patients managed by protocol spent on average 25 fewer hours on mechanical ventilation and were discharged from the ICU a day early. However, their mortality rate appeared unchanged.

We suggest performing a cuff leak test in patients who meet extubation criteria and are deemed at high risk for postextubation stridor. The committee suggested that the test should be used only in patients with a high risk of stridor (abnormal breathing caused by blockage of windpipe) after extubation. Although patients passing the test had lower stridor and reintubation rates, the authors wrote that a high percentage of patients who failed the test could be successfully extubated.

For patients who failed the cuff leak test but are otherwise ready for extubation, we suggest administering systemic steroids at least 4 hours before extubation. The committee said that clinical judgment should take priority over test results, and systemic steroids should be administered to these patients at least 4 hours before extubation. The authors added that the short duration of the steroid therapy was likely to improve success rates without resulting in adverse events.

In a prepared statement, Timothy Girard, MD, of the department of medicine at the University of Pittsburgh and a lead author of the guidelines said the committee hoped the guidelines would help reduce variations in practice that do not benefit patients. “We are not prescribing a specific approach to care for every patient every time,” he said. “But we are trying to summarize the available evidence in as clear and succinct a way as possible so that clinicians know how it applies to most patients.”

Dr. Ouellette disclosed that he has received a research grant from Cardeas Pharma for health care–associated pneumonia.

[email protected]

Physicians will have several options to choose from when it comes to advanced alternative payment models (APMs) in 2017.

In an Oct. 25 release, the Centers for Medicare & Medicaid Services announced seven models that will be considered advanced APMs in 2017, including the new Oncology Care Model with two-sided risk. Other advanced APM choices will include:

• Comprehensive Primary Care Plus (CPC+).

• Comprehensive ESRD Care Model (Large Dialysis Organization [LDO] arrangement).

• Comprehensive ESRD Care Model (non-LDO arrangement).

• Medicare Shared Savings Program Accountable Care Organizations (ACOs) – Track 2.

• Medicare Shared Savings Program ACOs – Track 3.

• Next Generation ACO Model.

• ACO – Track 1+.

• New voluntary bundled payment model.

• Comprehensive Care for Joint Replacement Payment Model (Certified Electronic Health Record Technology [CEHRT] track).

• Advancing Care Coordination through Episode Payment Models – Track 1 (CEHRT).

For performance years 2017 and 2018, participation requirements will apply only to Medicare payments and physicians who treat Medicare patients. Starting in 2019, clinicians may also meet an alternative standard for advanced APMs that will include non-Medicare payments and patients.

“With these new opportunities, CMS expects that by the 2018 performance period, 25% of clinicians in the Quality Payment Program will earn incentive payments by being a part of these advanced models,” Patrick Conway, MD, CMS deputy administrator said in a statement. “Thanks to MACRA and the Innovation Center, we’re striving to see more Medicare patients benefit from better care when they visit their doctor for a knee replacement, receive cancer treatment, or have a coordinated care team manage their complex conditions.”

CMS is accepting feedback from physicians on the Quality Payment Program final rule until Dec. 17. Doctors can submit their comments and suggestions electronically through the CMS e-Regulation website.

[email protected]

On Twitter @legal_med

Physicians will have several options to choose from when it comes to advanced alternative payment models (APMs) in 2017.

In an Oct. 25 release, the Centers for Medicare & Medicaid Services announced seven models that will be considered advanced APMs in 2017, including the new Oncology Care Model with two-sided risk. Other advanced APM choices will include:

• Comprehensive Primary Care Plus (CPC+).

• Comprehensive ESRD Care Model (Large Dialysis Organization [LDO] arrangement).

• Comprehensive ESRD Care Model (non-LDO arrangement).

• Medicare Shared Savings Program Accountable Care Organizations (ACOs) – Track 2.

• Medicare Shared Savings Program ACOs – Track 3.

• Next Generation ACO Model.

• ACO – Track 1+.

• New voluntary bundled payment model.

• Comprehensive Care for Joint Replacement Payment Model (Certified Electronic Health Record Technology [CEHRT] track).

• Advancing Care Coordination through Episode Payment Models – Track 1 (CEHRT).

For performance years 2017 and 2018, participation requirements will apply only to Medicare payments and physicians who treat Medicare patients. Starting in 2019, clinicians may also meet an alternative standard for advanced APMs that will include non-Medicare payments and patients.

“With these new opportunities, CMS expects that by the 2018 performance period, 25% of clinicians in the Quality Payment Program will earn incentive payments by being a part of these advanced models,” Patrick Conway, MD, CMS deputy administrator said in a statement. “Thanks to MACRA and the Innovation Center, we’re striving to see more Medicare patients benefit from better care when they visit their doctor for a knee replacement, receive cancer treatment, or have a coordinated care team manage their complex conditions.”

CMS is accepting feedback from physicians on the Quality Payment Program final rule until Dec. 17. Doctors can submit their comments and suggestions electronically through the CMS e-Regulation website.

[email protected]

On Twitter @legal_med

Physicians will have several options to choose from when it comes to advanced alternative payment models (APMs) in 2017.

In an Oct. 25 release, the Centers for Medicare & Medicaid Services announced seven models that will be considered advanced APMs in 2017, including the new Oncology Care Model with two-sided risk. Other advanced APM choices will include:

• Comprehensive Primary Care Plus (CPC+).

• Comprehensive ESRD Care Model (Large Dialysis Organization [LDO] arrangement).

• Comprehensive ESRD Care Model (non-LDO arrangement).

• Medicare Shared Savings Program Accountable Care Organizations (ACOs) – Track 2.

• Medicare Shared Savings Program ACOs – Track 3.

• Next Generation ACO Model.

• ACO – Track 1+.

• New voluntary bundled payment model.

• Comprehensive Care for Joint Replacement Payment Model (Certified Electronic Health Record Technology [CEHRT] track).

• Advancing Care Coordination through Episode Payment Models – Track 1 (CEHRT).

For performance years 2017 and 2018, participation requirements will apply only to Medicare payments and physicians who treat Medicare patients. Starting in 2019, clinicians may also meet an alternative standard for advanced APMs that will include non-Medicare payments and patients.

“With these new opportunities, CMS expects that by the 2018 performance period, 25% of clinicians in the Quality Payment Program will earn incentive payments by being a part of these advanced models,” Patrick Conway, MD, CMS deputy administrator said in a statement. “Thanks to MACRA and the Innovation Center, we’re striving to see more Medicare patients benefit from better care when they visit their doctor for a knee replacement, receive cancer treatment, or have a coordinated care team manage their complex conditions.”

CMS is accepting feedback from physicians on the Quality Payment Program final rule until Dec. 17. Doctors can submit their comments and suggestions electronically through the CMS e-Regulation website.

[email protected]

On Twitter @legal_med

A Web-based risk test endorsed by the American Medical Association, the American Diabetes Association, and the Centers for Disease Control and Prevention would label 59%-81% of adults as prediabetic if it were applied to the general U.S. population, according to a Research Letter to the Editor published online Oct. 3 in JAMA Internal Medicine.

The test is intended to evaluate the risk for prediabetes of any adult patient, and it advises those it identifies as prediabetic to see their physicians for confirmatory blood glucose testing. But given the results of their study, labeling this many people as prediabetic constitutes overmedicalization and could have the unintended consequence of diluting access to health care for people who actually have type 2 diabetes and other chronic conditions, said Saeid Shahraz, MD, PhD, of the Predictive Analytics and Comparative Effectiveness Center, Tufts Medical Center, Boston, and his associates.

The investigators assessed how many people this test would classify as prediabetic by analyzing data for a nationally representative sample of 10,175 adults who participated in the National Health and Nutrition Examination Survey in 2013-2014. They extracted the same information from participant responses to the NHANES survey that is elicited by the Web-based test: age, sex, history of gestational diabetes, first-degree relatives with diabetes, hypertension, physical activity level, and weight.

Among Americans aged 40 years and older, this test would classify an estimated 73.3 million, or 58.7%, as prediabetic; among those aged 60 years and older, it would classify 80.8% as prediabetic. The test also would advise all those people to see their physicians and undergo blood glucose testing for confirmation, Dr. Shahraz and his associates said (JAMA Intern Med. 2016 Oct 3. doi: 10.1001/jamainternmed.2016.5919).

This would be “premature” for many reasons. Intensive lifestyle modifications are not known to be beneficial for such patients, even those who are found to have impaired glucose tolerance. And there is no direct evidence that preventing type 2 diabetes actually reduces the risk for diabetes-related complications. Moreover, the natural progression from prediabetes to type 2 diabetes is likely to be slow, which calls into question the need for any intervention, particularly for older patients likely to die from competing causes, the researchers noted.

“A valid method to examine for prediabetes should avoid unnecessary medicalization by labeling a disease predecessor as a medical condition and seek to concentrate on people at highest risk to allow for efficient distribution of limited health care resources,” they added.

A Web-based risk test endorsed by the American Medical Association, the American Diabetes Association, and the Centers for Disease Control and Prevention would label 59%-81% of adults as prediabetic if it were applied to the general U.S. population, according to a Research Letter to the Editor published online Oct. 3 in JAMA Internal Medicine.

The test is intended to evaluate the risk for prediabetes of any adult patient, and it advises those it identifies as prediabetic to see their physicians for confirmatory blood glucose testing. But given the results of their study, labeling this many people as prediabetic constitutes overmedicalization and could have the unintended consequence of diluting access to health care for people who actually have type 2 diabetes and other chronic conditions, said Saeid Shahraz, MD, PhD, of the Predictive Analytics and Comparative Effectiveness Center, Tufts Medical Center, Boston, and his associates.

The investigators assessed how many people this test would classify as prediabetic by analyzing data for a nationally representative sample of 10,175 adults who participated in the National Health and Nutrition Examination Survey in 2013-2014. They extracted the same information from participant responses to the NHANES survey that is elicited by the Web-based test: age, sex, history of gestational diabetes, first-degree relatives with diabetes, hypertension, physical activity level, and weight.

Among Americans aged 40 years and older, this test would classify an estimated 73.3 million, or 58.7%, as prediabetic; among those aged 60 years and older, it would classify 80.8% as prediabetic. The test also would advise all those people to see their physicians and undergo blood glucose testing for confirmation, Dr. Shahraz and his associates said (JAMA Intern Med. 2016 Oct 3. doi: 10.1001/jamainternmed.2016.5919).

This would be “premature” for many reasons. Intensive lifestyle modifications are not known to be beneficial for such patients, even those who are found to have impaired glucose tolerance. And there is no direct evidence that preventing type 2 diabetes actually reduces the risk for diabetes-related complications. Moreover, the natural progression from prediabetes to type 2 diabetes is likely to be slow, which calls into question the need for any intervention, particularly for older patients likely to die from competing causes, the researchers noted.

“A valid method to examine for prediabetes should avoid unnecessary medicalization by labeling a disease predecessor as a medical condition and seek to concentrate on people at highest risk to allow for efficient distribution of limited health care resources,” they added.

A Web-based risk test endorsed by the American Medical Association, the American Diabetes Association, and the Centers for Disease Control and Prevention would label 59%-81% of adults as prediabetic if it were applied to the general U.S. population, according to a Research Letter to the Editor published online Oct. 3 in JAMA Internal Medicine.

The test is intended to evaluate the risk for prediabetes of any adult patient, and it advises those it identifies as prediabetic to see their physicians for confirmatory blood glucose testing. But given the results of their study, labeling this many people as prediabetic constitutes overmedicalization and could have the unintended consequence of diluting access to health care for people who actually have type 2 diabetes and other chronic conditions, said Saeid Shahraz, MD, PhD, of the Predictive Analytics and Comparative Effectiveness Center, Tufts Medical Center, Boston, and his associates.

The investigators assessed how many people this test would classify as prediabetic by analyzing data for a nationally representative sample of 10,175 adults who participated in the National Health and Nutrition Examination Survey in 2013-2014. They extracted the same information from participant responses to the NHANES survey that is elicited by the Web-based test: age, sex, history of gestational diabetes, first-degree relatives with diabetes, hypertension, physical activity level, and weight.

Among Americans aged 40 years and older, this test would classify an estimated 73.3 million, or 58.7%, as prediabetic; among those aged 60 years and older, it would classify 80.8% as prediabetic. The test also would advise all those people to see their physicians and undergo blood glucose testing for confirmation, Dr. Shahraz and his associates said (JAMA Intern Med. 2016 Oct 3. doi: 10.1001/jamainternmed.2016.5919).

This would be “premature” for many reasons. Intensive lifestyle modifications are not known to be beneficial for such patients, even those who are found to have impaired glucose tolerance. And there is no direct evidence that preventing type 2 diabetes actually reduces the risk for diabetes-related complications. Moreover, the natural progression from prediabetes to type 2 diabetes is likely to be slow, which calls into question the need for any intervention, particularly for older patients likely to die from competing causes, the researchers noted.

“A valid method to examine for prediabetes should avoid unnecessary medicalization by labeling a disease predecessor as a medical condition and seek to concentrate on people at highest risk to allow for efficient distribution of limited health care resources,” they added.

Fusobacterium nucleatum, a component of the human microbiome, appears to be associated with shorter survival in esophageal cancer, according to new findings.

F. nucleatum, generally found in the oral cavity and associated with periodontal disease, may have a potential role as a prognostic biomarker, and it might also contribute to aggressive tumor behavior via activation of chemokines, the study authors suggest (Clin Cancer Res. 2016 Oct. doi: 10.1158/1078-0432.CCR-16-1786).

Eraxion/Thinkstock.com

*This article was updated 10/26/2016.

Fusobacterium nucleatum, a component of the human microbiome, appears to be associated with shorter survival in esophageal cancer, according to new findings.

F. nucleatum, generally found in the oral cavity and associated with periodontal disease, may have a potential role as a prognostic biomarker, and it might also contribute to aggressive tumor behavior via activation of chemokines, the study authors suggest (Clin Cancer Res. 2016 Oct. doi: 10.1158/1078-0432.CCR-16-1786).

Eraxion/Thinkstock.com

*This article was updated 10/26/2016.

Fusobacterium nucleatum, a component of the human microbiome, appears to be associated with shorter survival in esophageal cancer, according to new findings.

F. nucleatum, generally found in the oral cavity and associated with periodontal disease, may have a potential role as a prognostic biomarker, and it might also contribute to aggressive tumor behavior via activation of chemokines, the study authors suggest (Clin Cancer Res. 2016 Oct. doi: 10.1158/1078-0432.CCR-16-1786).

Eraxion/Thinkstock.com

*This article was updated 10/26/2016.

How do we increase patient adherence to therapy? This question fascinates me. As dermatologists, we will see thousands of patients over the course of our careers, most with treatable conditions that will improve with therapy and others with chronic or genetic conditions that will at least be made more tolerable with therapy. Only 50% of patients with a chronic condition are adherent to therapy.¹ Why some patients adhere to treatment and others do not can be difficult to understand. The emotional makeup, culture, family background, socioeconomic status, and motivation of each person is unique, which leads to complexity. This column is not meant to answer a question that is both complex and broad; rather, it is meant to survey and summarize the literature on this topic.  

Education

Health literacy is defined as cognitive and social skills that determine the motivation and ability of individuals to gain access to, understand, and use information in ways that promote and maintain good health.² Greater health literacy leads to improved compliance and health outcomes.^3,4 When we take the time to educate patients about their condition, it improves health literacy, treatment compliance, and patient safety and satisfaction, factors that ultimately are linked to better health outcomes.^3-8

There are many practical ways of educating patients. Interestingly, one meta-analysis found that no single strategy is more effective than another.⁶ This analysis found that "[c]omprehensive interventions combining cognitive, behavioral, and affective components were more effective than single-focus interventions."⁶ The Centers for Disease Control and Prevention (CDC) website is an excellent source of information on how to educate patients and increase patient treatment compliance.² The CDC website offers a free tool kit on how to design educational information to your target audience, resources for children, a database of health-related educational images, an electronic textbook on teaching patients with low literacy skills, a summary of evidence-based ideas on how to improve patient adherence to medications used long-term, and more.²

Facilitating Adherence

The World Health Organization (WHO) emphasizes 5 dimensions of patient adherence: health system, socioeconomic, condition-related, therapy-related, and patient-related factors.⁹ Becker and Maiman⁵ summarized it eloquently when they wrote that we must take "clinically appropriate steps to reduce the cost, complexity, duration, and amount of behavioral change required by the regimen and increasing the regimen's convenience through 'tailoring' and other approaches." It is a broad ultimatum that will require creativity and persistence on the part of the dermatology community.

Some common patient-related factors associated with nonadherence to treatment are lack of information and skills as they pertain to self-management, difficulty with motivation and self-efficacy, and lack of support for behavioral changes.⁹ It is interesting that low socioeconomic status has not been consistently shown to portend low treatment adherence. It has been shown that children, especially adolescents, and elderly patients tend to be the least adherent.^9-11

Dermatologists Take Action

As dermatologists, the WHO encourages us (physicians) to promote optimism, provide enthusiasm, and encourage maintenance of healthy behaviors.⁹ Comprehensive interventions that have had a positive impact on patient adherence to therapy for diseases such as diabetes mellitus, asthma, and hypertension may serve as motivating examples.⁹ Some specific dermatologic conditions that will benefit from increased patient adherence include acne, vesiculobullous disease, psoriasis, and atopic dermatitis. We can lend support to efforts to reduce the cost of dermatologic medications and be aware of the populations most at risk for low adherence to treatment.^9-12

Final Thoughts

As we work to increase patient adherence to therapy in dermatology, we will help improve health literacy, patient safety, and patient satisfaction. These factors are ultimately linked to better health outcomes. The CDC and WHO websites are excellent sources of information on practical methods for doing so.^2,9

How do we increase patient adherence to therapy? This question fascinates me. As dermatologists, we will see thousands of patients over the course of our careers, most with treatable conditions that will improve with therapy and others with chronic or genetic conditions that will at least be made more tolerable with therapy. Only 50% of patients with a chronic condition are adherent to therapy.¹ Why some patients adhere to treatment and others do not can be difficult to understand. The emotional makeup, culture, family background, socioeconomic status, and motivation of each person is unique, which leads to complexity. This column is not meant to answer a question that is both complex and broad; rather, it is meant to survey and summarize the literature on this topic.  

Education

Health literacy is defined as cognitive and social skills that determine the motivation and ability of individuals to gain access to, understand, and use information in ways that promote and maintain good health.² Greater health literacy leads to improved compliance and health outcomes.^3,4 When we take the time to educate patients about their condition, it improves health literacy, treatment compliance, and patient safety and satisfaction, factors that ultimately are linked to better health outcomes.^3-8

There are many practical ways of educating patients. Interestingly, one meta-analysis found that no single strategy is more effective than another.⁶ This analysis found that "[c]omprehensive interventions combining cognitive, behavioral, and affective components were more effective than single-focus interventions."⁶ The Centers for Disease Control and Prevention (CDC) website is an excellent source of information on how to educate patients and increase patient treatment compliance.² The CDC website offers a free tool kit on how to design educational information to your target audience, resources for children, a database of health-related educational images, an electronic textbook on teaching patients with low literacy skills, a summary of evidence-based ideas on how to improve patient adherence to medications used long-term, and more.²

Facilitating Adherence

The World Health Organization (WHO) emphasizes 5 dimensions of patient adherence: health system, socioeconomic, condition-related, therapy-related, and patient-related factors.⁹ Becker and Maiman⁵ summarized it eloquently when they wrote that we must take "clinically appropriate steps to reduce the cost, complexity, duration, and amount of behavioral change required by the regimen and increasing the regimen's convenience through 'tailoring' and other approaches." It is a broad ultimatum that will require creativity and persistence on the part of the dermatology community.

Some common patient-related factors associated with nonadherence to treatment are lack of information and skills as they pertain to self-management, difficulty with motivation and self-efficacy, and lack of support for behavioral changes.⁹ It is interesting that low socioeconomic status has not been consistently shown to portend low treatment adherence. It has been shown that children, especially adolescents, and elderly patients tend to be the least adherent.^9-11

Dermatologists Take Action

As dermatologists, the WHO encourages us (physicians) to promote optimism, provide enthusiasm, and encourage maintenance of healthy behaviors.⁹ Comprehensive interventions that have had a positive impact on patient adherence to therapy for diseases such as diabetes mellitus, asthma, and hypertension may serve as motivating examples.⁹ Some specific dermatologic conditions that will benefit from increased patient adherence include acne, vesiculobullous disease, psoriasis, and atopic dermatitis. We can lend support to efforts to reduce the cost of dermatologic medications and be aware of the populations most at risk for low adherence to treatment.^9-12

Final Thoughts

As we work to increase patient adherence to therapy in dermatology, we will help improve health literacy, patient safety, and patient satisfaction. These factors are ultimately linked to better health outcomes. The CDC and WHO websites are excellent sources of information on practical methods for doing so.^2,9

How do we increase patient adherence to therapy? This question fascinates me. As dermatologists, we will see thousands of patients over the course of our careers, most with treatable conditions that will improve with therapy and others with chronic or genetic conditions that will at least be made more tolerable with therapy. Only 50% of patients with a chronic condition are adherent to therapy.¹ Why some patients adhere to treatment and others do not can be difficult to understand. The emotional makeup, culture, family background, socioeconomic status, and motivation of each person is unique, which leads to complexity. This column is not meant to answer a question that is both complex and broad; rather, it is meant to survey and summarize the literature on this topic.  

Education

Health literacy is defined as cognitive and social skills that determine the motivation and ability of individuals to gain access to, understand, and use information in ways that promote and maintain good health.² Greater health literacy leads to improved compliance and health outcomes.^3,4 When we take the time to educate patients about their condition, it improves health literacy, treatment compliance, and patient safety and satisfaction, factors that ultimately are linked to better health outcomes.^3-8

There are many practical ways of educating patients. Interestingly, one meta-analysis found that no single strategy is more effective than another.⁶ This analysis found that "[c]omprehensive interventions combining cognitive, behavioral, and affective components were more effective than single-focus interventions."⁶ The Centers for Disease Control and Prevention (CDC) website is an excellent source of information on how to educate patients and increase patient treatment compliance.² The CDC website offers a free tool kit on how to design educational information to your target audience, resources for children, a database of health-related educational images, an electronic textbook on teaching patients with low literacy skills, a summary of evidence-based ideas on how to improve patient adherence to medications used long-term, and more.²

Facilitating Adherence

The World Health Organization (WHO) emphasizes 5 dimensions of patient adherence: health system, socioeconomic, condition-related, therapy-related, and patient-related factors.⁹ Becker and Maiman⁵ summarized it eloquently when they wrote that we must take "clinically appropriate steps to reduce the cost, complexity, duration, and amount of behavioral change required by the regimen and increasing the regimen's convenience through 'tailoring' and other approaches." It is a broad ultimatum that will require creativity and persistence on the part of the dermatology community.

Some common patient-related factors associated with nonadherence to treatment are lack of information and skills as they pertain to self-management, difficulty with motivation and self-efficacy, and lack of support for behavioral changes.⁹ It is interesting that low socioeconomic status has not been consistently shown to portend low treatment adherence. It has been shown that children, especially adolescents, and elderly patients tend to be the least adherent.^9-11

Dermatologists Take Action

As dermatologists, the WHO encourages us (physicians) to promote optimism, provide enthusiasm, and encourage maintenance of healthy behaviors.⁹ Comprehensive interventions that have had a positive impact on patient adherence to therapy for diseases such as diabetes mellitus, asthma, and hypertension may serve as motivating examples.⁹ Some specific dermatologic conditions that will benefit from increased patient adherence include acne, vesiculobullous disease, psoriasis, and atopic dermatitis. We can lend support to efforts to reduce the cost of dermatologic medications and be aware of the populations most at risk for low adherence to treatment.^9-12

Final Thoughts

As we work to increase patient adherence to therapy in dermatology, we will help improve health literacy, patient safety, and patient satisfaction. These factors are ultimately linked to better health outcomes. The CDC and WHO websites are excellent sources of information on practical methods for doing so.^2,9

VIENNA – Antipsychotic-naive children and adolescents are at greater risk for clinically significant weight gain during their first 6 months on a second-generation antipsychotic agent than adults, Covadonga M. Diaz-Caneja, MD, reported at the annual congress of the European College of Neuropsychopharmacology.

She presented what she believes to be the first prospective observational study comparing weight gain between antipsychotic-naive children and adults during their first 6 months on second-generation antipsychotics. Weight gains were significantly greater with olanzapine (Zyprexa) than risperidone (Risperdal) or quetiapine (Seroquel) in both age groups, but the magnitude and trajectory of olanzapine-related weight gain was significantly more impressive in the pediatric patients.

Bruce Jancin/Frontline Medical News

[email protected]

VIENNA – Antipsychotic-naive children and adolescents are at greater risk for clinically significant weight gain during their first 6 months on a second-generation antipsychotic agent than adults, Covadonga M. Diaz-Caneja, MD, reported at the annual congress of the European College of Neuropsychopharmacology.

She presented what she believes to be the first prospective observational study comparing weight gain between antipsychotic-naive children and adults during their first 6 months on second-generation antipsychotics. Weight gains were significantly greater with olanzapine (Zyprexa) than risperidone (Risperdal) or quetiapine (Seroquel) in both age groups, but the magnitude and trajectory of olanzapine-related weight gain was significantly more impressive in the pediatric patients.

Bruce Jancin/Frontline Medical News

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VIENNA – Antipsychotic-naive children and adolescents are at greater risk for clinically significant weight gain during their first 6 months on a second-generation antipsychotic agent than adults, Covadonga M. Diaz-Caneja, MD, reported at the annual congress of the European College of Neuropsychopharmacology.

She presented what she believes to be the first prospective observational study comparing weight gain between antipsychotic-naive children and adults during their first 6 months on second-generation antipsychotics. Weight gains were significantly greater with olanzapine (Zyprexa) than risperidone (Risperdal) or quetiapine (Seroquel) in both age groups, but the magnitude and trajectory of olanzapine-related weight gain was significantly more impressive in the pediatric patients.

Bruce Jancin/Frontline Medical News

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VIENNA – Psychiatrists have received a welcome gift in the form of CEQUEL, a randomized trial that offers much needed guidance on how to proceed when quetiapine for bipolar depression isn’t achieving sufficient response, Eduard Vieta, MD, said at the annual congress of the European College of Neuropsychopharmacology.

The answer provided by CEQUEL is to add lamotrigine.

“Quetiapine is indicated for treatment of symptoms of bipolar depression, but many clinicians – including myself – are a bit underwhelmed about the practical results. In the clinical trials, quetiapine looks great, but when we use it in practice we’re not so happy with the results. The trials are consistently positive with a large effect size, whereas in clinical practice many patients respond only partially to quetiapine. The question has been what to do next,” observed Dr. Vieta, professor of psychiatry and head of the bipolar disorders program at the University of Barcelona.

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VIENNA – Psychiatrists have received a welcome gift in the form of CEQUEL, a randomized trial that offers much needed guidance on how to proceed when quetiapine for bipolar depression isn’t achieving sufficient response, Eduard Vieta, MD, said at the annual congress of the European College of Neuropsychopharmacology.

The answer provided by CEQUEL is to add lamotrigine.

“Quetiapine is indicated for treatment of symptoms of bipolar depression, but many clinicians – including myself – are a bit underwhelmed about the practical results. In the clinical trials, quetiapine looks great, but when we use it in practice we’re not so happy with the results. The trials are consistently positive with a large effect size, whereas in clinical practice many patients respond only partially to quetiapine. The question has been what to do next,” observed Dr. Vieta, professor of psychiatry and head of the bipolar disorders program at the University of Barcelona.

[email protected]

VIENNA – Psychiatrists have received a welcome gift in the form of CEQUEL, a randomized trial that offers much needed guidance on how to proceed when quetiapine for bipolar depression isn’t achieving sufficient response, Eduard Vieta, MD, said at the annual congress of the European College of Neuropsychopharmacology.

The answer provided by CEQUEL is to add lamotrigine.

“Quetiapine is indicated for treatment of symptoms of bipolar depression, but many clinicians – including myself – are a bit underwhelmed about the practical results. In the clinical trials, quetiapine looks great, but when we use it in practice we’re not so happy with the results. The trials are consistently positive with a large effect size, whereas in clinical practice many patients respond only partially to quetiapine. The question has been what to do next,” observed Dr. Vieta, professor of psychiatry and head of the bipolar disorders program at the University of Barcelona.

[email protected]

LAS VEGAS – In fluid derived from pancreatic cysts, methylated DNA markers predict the presence of high-grade dysplasia (HGD) or cancer, and could help physicians decide whether to surgically remove cysts – a procedure that often has serious complications.

If validated in larger studies, the biomarkers have the potential to supplant the Fukuoka criteria that is currently used. “The markers could cause a paradigm shift in how we approach these lesions in our clinical practice,” Shounak Majumder, MD, a fellow at the Mayo Clinic in Rochester, Minn., said in an interview.

Courtesy Dr. Lance Liotta Laboratory

LAS VEGAS – In fluid derived from pancreatic cysts, methylated DNA markers predict the presence of high-grade dysplasia (HGD) or cancer, and could help physicians decide whether to surgically remove cysts – a procedure that often has serious complications.

If validated in larger studies, the biomarkers have the potential to supplant the Fukuoka criteria that is currently used. “The markers could cause a paradigm shift in how we approach these lesions in our clinical practice,” Shounak Majumder, MD, a fellow at the Mayo Clinic in Rochester, Minn., said in an interview.

Courtesy Dr. Lance Liotta Laboratory

LAS VEGAS – In fluid derived from pancreatic cysts, methylated DNA markers predict the presence of high-grade dysplasia (HGD) or cancer, and could help physicians decide whether to surgically remove cysts – a procedure that often has serious complications.

If validated in larger studies, the biomarkers have the potential to supplant the Fukuoka criteria that is currently used. “The markers could cause a paradigm shift in how we approach these lesions in our clinical practice,” Shounak Majumder, MD, a fellow at the Mayo Clinic in Rochester, Minn., said in an interview.

Courtesy Dr. Lance Liotta Laboratory

Ultrasound examination of patients with at least one swollen joint or a subcutaneous nodule detected gout with a sensitivity of 76.9% and specificity of 84.3% in an international, multicenter study.

“Ultrasound is a good test for gout,” said study lead author Alexis R. Ogdie-Beatty, MD, of the University of Pennsylvania, Philadelphia. “It has high specificity, even among patients with early disease. The sensitivity was lower so it doesn’t pick up all cases of gout, although it was higher in people with a longer duration of disease.”

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Ultrasound examination of patients with at least one swollen joint or a subcutaneous nodule detected gout with a sensitivity of 76.9% and specificity of 84.3% in an international, multicenter study.

“Ultrasound is a good test for gout,” said study lead author Alexis R. Ogdie-Beatty, MD, of the University of Pennsylvania, Philadelphia. “It has high specificity, even among patients with early disease. The sensitivity was lower so it doesn’t pick up all cases of gout, although it was higher in people with a longer duration of disease.”

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Ultrasound examination of patients with at least one swollen joint or a subcutaneous nodule detected gout with a sensitivity of 76.9% and specificity of 84.3% in an international, multicenter study.

“Ultrasound is a good test for gout,” said study lead author Alexis R. Ogdie-Beatty, MD, of the University of Pennsylvania, Philadelphia. “It has high specificity, even among patients with early disease. The sensitivity was lower so it doesn’t pick up all cases of gout, although it was higher in people with a longer duration of disease.”

[email protected]