In this issue of Gastroenterology and in an upcoming issue of Clinical Gastroenterology and Hepatology, an important behind-the-scenes change is occurring. Specifically, both journals will continue to publish important and timely reviews and commentaries, but the formulation and design of some of these articles will now be driven by a new committee. The newly formed American Gastroenterological Association (AGA) Institute Clinical Practice Updates Committee (CPUC) is charged with providing authoritative and balanced articles for the two journals that have the greatest impact on the clinical practice of gastroenterology and hepatology. Potential subjects for these articles will derive from several sources in coordination with the AGA Institute Clinical Guidelines Committee.

First, important topics that are proposed initially for an AGA guideline but do not meet rigid criteria for guideline grading will be sent to the CPUC for review and consideration. Second, ideas for topics will also be generated by the CPUC members and journal editors, as well as by other AGA committees and AGA members themselves. Third, summaries of important symposia such as the yearly Freston Conference will be included. Topics can be presented in the form of a comprehensive, narrative review or, for particularly timely issues in gastroenterology, hepatology, and health care in general, as a rapid commentary.

We believe that the vetting process of these articles is important. All prospective topics and selected authors will be approved by the CPUC with guidance from the AGA Institute Governing Board. At least 2 authors who are recognized authorities will be invited to write an article and will be chosen from different institutions. It is anticipated that the authors will often have differing opinions, to help ensure balance and achieve consensus. A member of the CPUC with expertise in the field will guide the writing to ensure the highest quality and greatest balance in the final product. Once an article is written, it will be submitted for evaluation by the Editors of Gastroenterology and Clinical Gastroenterology and Hepatology, who will decide whether to accept the paper or send it for further review before acceptance.

With seasoned and motivated authors and the guidance of the CPUC, we expect outstanding reviews that will be published in a timely manner and provide AGA members and readers of the journals the most up-to-date and scholarly information across the spectrum of gastroenterology, hepatology, and nutrition. We are excited about this new process as a means to enhance our already outstanding journals, which are dedicated to publishing the best research and practice information in our field. Because this is a new process, we welcome feedback and suggestions for improvement and look forward to providing content that helps your research and clinical practice.

Dr. Katzka is at Mayo Clinic, Rochester, Minn.; Dr. Friedman is at Newton-Wellesley Hospital, Newton, Mass.; Dr. Inadomi is at University of Washington School of Medicine, Seattle; Dr. Kalloo is at Johns Hopkins Hospital, Baltimore; Dr. Kim is at South Denver Gastroenterology, P.C., Littleton, Colo.; Dr. Koch is at Virginia Mason Medical Center, Seattle; Dr. Lieberman is at Oregon Health and Science University, Portland; Dr. Lichtenstein is at the Hospital of the University of Pennsylvania, Merion Station, Penn.: Dr. Lim is at Yale University School of Medicine, New Haven, Conn.; Dr. Pandolfino is at Northwestern University, Chicago; Dr. Shin is at Indiana University School of Medicine, Indianapolis; and Dr. Siedler is Committee Liaison, American Gastroenterological Association.

In this issue of Gastroenterology and in an upcoming issue of Clinical Gastroenterology and Hepatology, an important behind-the-scenes change is occurring. Specifically, both journals will continue to publish important and timely reviews and commentaries, but the formulation and design of some of these articles will now be driven by a new committee. The newly formed American Gastroenterological Association (AGA) Institute Clinical Practice Updates Committee (CPUC) is charged with providing authoritative and balanced articles for the two journals that have the greatest impact on the clinical practice of gastroenterology and hepatology. Potential subjects for these articles will derive from several sources in coordination with the AGA Institute Clinical Guidelines Committee.

First, important topics that are proposed initially for an AGA guideline but do not meet rigid criteria for guideline grading will be sent to the CPUC for review and consideration. Second, ideas for topics will also be generated by the CPUC members and journal editors, as well as by other AGA committees and AGA members themselves. Third, summaries of important symposia such as the yearly Freston Conference will be included. Topics can be presented in the form of a comprehensive, narrative review or, for particularly timely issues in gastroenterology, hepatology, and health care in general, as a rapid commentary.

We believe that the vetting process of these articles is important. All prospective topics and selected authors will be approved by the CPUC with guidance from the AGA Institute Governing Board. At least 2 authors who are recognized authorities will be invited to write an article and will be chosen from different institutions. It is anticipated that the authors will often have differing opinions, to help ensure balance and achieve consensus. A member of the CPUC with expertise in the field will guide the writing to ensure the highest quality and greatest balance in the final product. Once an article is written, it will be submitted for evaluation by the Editors of Gastroenterology and Clinical Gastroenterology and Hepatology, who will decide whether to accept the paper or send it for further review before acceptance.

With seasoned and motivated authors and the guidance of the CPUC, we expect outstanding reviews that will be published in a timely manner and provide AGA members and readers of the journals the most up-to-date and scholarly information across the spectrum of gastroenterology, hepatology, and nutrition. We are excited about this new process as a means to enhance our already outstanding journals, which are dedicated to publishing the best research and practice information in our field. Because this is a new process, we welcome feedback and suggestions for improvement and look forward to providing content that helps your research and clinical practice.

Dr. Katzka is at Mayo Clinic, Rochester, Minn.; Dr. Friedman is at Newton-Wellesley Hospital, Newton, Mass.; Dr. Inadomi is at University of Washington School of Medicine, Seattle; Dr. Kalloo is at Johns Hopkins Hospital, Baltimore; Dr. Kim is at South Denver Gastroenterology, P.C., Littleton, Colo.; Dr. Koch is at Virginia Mason Medical Center, Seattle; Dr. Lieberman is at Oregon Health and Science University, Portland; Dr. Lichtenstein is at the Hospital of the University of Pennsylvania, Merion Station, Penn.: Dr. Lim is at Yale University School of Medicine, New Haven, Conn.; Dr. Pandolfino is at Northwestern University, Chicago; Dr. Shin is at Indiana University School of Medicine, Indianapolis; and Dr. Siedler is Committee Liaison, American Gastroenterological Association.

In this issue of Gastroenterology and in an upcoming issue of Clinical Gastroenterology and Hepatology, an important behind-the-scenes change is occurring. Specifically, both journals will continue to publish important and timely reviews and commentaries, but the formulation and design of some of these articles will now be driven by a new committee. The newly formed American Gastroenterological Association (AGA) Institute Clinical Practice Updates Committee (CPUC) is charged with providing authoritative and balanced articles for the two journals that have the greatest impact on the clinical practice of gastroenterology and hepatology. Potential subjects for these articles will derive from several sources in coordination with the AGA Institute Clinical Guidelines Committee.

First, important topics that are proposed initially for an AGA guideline but do not meet rigid criteria for guideline grading will be sent to the CPUC for review and consideration. Second, ideas for topics will also be generated by the CPUC members and journal editors, as well as by other AGA committees and AGA members themselves. Third, summaries of important symposia such as the yearly Freston Conference will be included. Topics can be presented in the form of a comprehensive, narrative review or, for particularly timely issues in gastroenterology, hepatology, and health care in general, as a rapid commentary.

We believe that the vetting process of these articles is important. All prospective topics and selected authors will be approved by the CPUC with guidance from the AGA Institute Governing Board. At least 2 authors who are recognized authorities will be invited to write an article and will be chosen from different institutions. It is anticipated that the authors will often have differing opinions, to help ensure balance and achieve consensus. A member of the CPUC with expertise in the field will guide the writing to ensure the highest quality and greatest balance in the final product. Once an article is written, it will be submitted for evaluation by the Editors of Gastroenterology and Clinical Gastroenterology and Hepatology, who will decide whether to accept the paper or send it for further review before acceptance.

With seasoned and motivated authors and the guidance of the CPUC, we expect outstanding reviews that will be published in a timely manner and provide AGA members and readers of the journals the most up-to-date and scholarly information across the spectrum of gastroenterology, hepatology, and nutrition. We are excited about this new process as a means to enhance our already outstanding journals, which are dedicated to publishing the best research and practice information in our field. Because this is a new process, we welcome feedback and suggestions for improvement and look forward to providing content that helps your research and clinical practice.

Dr. Katzka is at Mayo Clinic, Rochester, Minn.; Dr. Friedman is at Newton-Wellesley Hospital, Newton, Mass.; Dr. Inadomi is at University of Washington School of Medicine, Seattle; Dr. Kalloo is at Johns Hopkins Hospital, Baltimore; Dr. Kim is at South Denver Gastroenterology, P.C., Littleton, Colo.; Dr. Koch is at Virginia Mason Medical Center, Seattle; Dr. Lieberman is at Oregon Health and Science University, Portland; Dr. Lichtenstein is at the Hospital of the University of Pennsylvania, Merion Station, Penn.: Dr. Lim is at Yale University School of Medicine, New Haven, Conn.; Dr. Pandolfino is at Northwestern University, Chicago; Dr. Shin is at Indiana University School of Medicine, Indianapolis; and Dr. Siedler is Committee Liaison, American Gastroenterological Association.

Medicine in the United States is undergoing fundamental changes that will continue despite 2016 presidential election results. Changes include consolidation of provider networks, movement from volume- to value-based reimbursement, demands for price and quality transparency, and a shift from focusing solely on individual physician-patient interactions to a broader triple aim focus that incorporates individual patients, population, health, and cost. In this month’s column, Sameer Saini and colleagues suggest that we broaden our view of colorectal cancer screening quality metrics from a colonoscopy-centric focus to a focus on the bottom line: Do we reduce cancer in the population of patients that we serve? When we extend our view to a population level, we use current colonoscopy registries only as internal process controls. A successful health system will develop a mechanism to assess and demonstrate how well the collective team of providers accomplishes the only outcome that matters to patients: preventing colon cancer.

John I. Allen, MD, MBA, AGAF, Special Section Editor

Colorectal cancer (CRC) screening is one of the most valuable services provided by gastroenterologists. The evidence that screening “works” on a population level is undeniable. But not every screening program is equally effective. Data indicate ongoing underuse of screening, particularly in high-risk, vulnerable, and minority communities.^1,2 Other data indicate that screening is overused, particularly in low-risk patients and in those with limited life expectancy.^3-5 It is also known that endoscopist skill plays an important role in the effectiveness of screening. In short, there is ample room for improvement in the quality of CRC screening, and payers and the public have taken notice. Unsurprisingly, gastroenterologists are often focused on procedural quality indicators, such as adenoma detection and cecal intubation rates.⁶ These endoscopic quality measures are important indicators of high-quality colonoscopy, but colonoscopy is the common touch point of a much broader system of care that includes other screening tests and other providers (e.g., primary care providers [PCPs], pathologists, and anesthesiologists). Coordinating care across this system is essential for improving the health of patients. As the stewards of digestive health, we owe it to our patients to take a more comprehensive view of CRC screening quality and move beyond colonoscopy alone.

AGA Institute

The complex web of care that comprises CRC screening is shown schematically in Figure 1. Appropriate screening begins with selection of suitable screening candidates. In the United States, where most screening is initiated during a clinician encounter, this important task falls primarily on the shoulders of PCPs. It is typically the role of the PCP to assess the two key patient factors that determine screening benefit: CRC risk (using personal and family history) and life expectancy (using age and overall health status). Once a patient has been deemed an appropriate candidate for screening, an acceptable screening test must be selected. Here, patient and practitioner are faced with a menu of options, including fecal occult blood testing (FOBT), colonoscopy, multitarget stool DNA, and computed tomography colonography. For average-risk screening, the ideal test depends primarily on patient preference and local availability.

If a screening test other than colonoscopy is selected, it becomes critical that a positive test is followed by timely and high-quality colonoscopy. High-quality colonoscopy begins with evidence-based preprocedure education and preparation, including appropriate selection of anesthesia services. Once a patient has been well prepared and adequately sedated, an endoscopist must carefully examine the colonic mucosa and completely resect any suspicious polyps. Unless discarded, resected polyps must be reviewed and categorized by a pathologist, including appropriate identification of serrated polyps. Finally, pathology results must be correctly interpreted by the clinician, with evidence-based follow-up recommendations made and effectively communicated to the patient and the referring provider. Additionally, in the short term, delayed gastrointestinal (GI) and non-GI complications of colonoscopy must be recognized and appropriately addressed. In the long term, the rate of interval cancers must be monitored.

Recognizing the importance of CRC screening, GI specialty societies have proposed a variety of quality measures to ensure that patients receive high-quality and high-value colonoscopy. Several of these measures have been adopted by CMS as part of the Physician Quality Reporting System. Non-GI groups, such as the National Center for Quality Assurance and the Ambulatory Surgery Center Association, have also proposed their own CRC screening–related measures.

Despite the proliferation of measures in the domain of CRC screening, current measures fall short in several ways. First, they are largely focused on colonoscopy technical performance, with less attention paid to the important steps that occur before and after colonoscopy. For example, the existing Healthcare Effectiveness Data and Information Set measure for underuse of CRC screening assesses the proportion of patients in a health plan between the ages 50 and 75 who are up to date for CRC screening. This measure is satisfied if a patient completes FOBT, regardless of the result. But FOBT alone is not sufficient to reduce mortality from CRC. Rather, it is imperative that a positive FOBT test be followed by colonoscopy. Numerous studies suggest a quality gap in this critical referral step.⁷

Yet, outside of selected clinical settings (e.g., the Veterans Affairs Healthcare System), no existing quality measure focuses on colonoscopy completion after positive FOBT. Other examples of important performance gaps beyond colonoscopy technical performance include appropriate use of monitored anesthesia care (data suggest overuse) and appropriate pathology interpretation (data suggest variation in the interpretation of serrated lesions, some of which are associated with increased risk of CRC).

Second, existing measures fail to consider individual patient factors that are known to be predictive of screening benefit, such as life expectancy and personal or familial cancer risk.⁸

Returning to the Healthcare Effectiveness Data and Information Set measure as an example, this measure relies on age alone to identify patients who are candidates for screening. Yet, it is widely recognized that life expectancy is a critically important factor when considering screening, particularly in older patients. However, existing measures fail to incorporate estimates of life expectancy. As a result, clinicians are encouraged to screen based on age alone. Data suggest that this leads to overuse in older, sicker patients younger than age 75 (the age cutoff suggested by guidelines and incorporated into the Healthcare Effectiveness Data and Information Set measure) and underuse in healthy and unscreened patients older than age 75.⁹

Furthermore, existing measures fail to systematically consider patient preferences and undervalue shared decision making. Data suggest, for instance, that patients who are offered a “menu” of options for screening rather than a single screening test are more likely to complete a screening test.¹⁰

But existing measures do not consider whether a physician assessed a patient’s preferences, or offered more than one screening option. Of course, measuring the quality of decision making is an evolving science that presents challenges and requires creative solutions.¹¹

Finally, existing measures do not capture the collaborative nature of modern health care. For example, most existing measures focus on the performance of gastroenterologists and GI practices. Although such a focus is appropriate for specialty-specific quality improvement efforts, it neglects to capture the important interactions and hand-offs between providers needed for successful completion of screening (and downstream reduction in cancer mortality). As a result, this specialty-focused approach fails to meet the needs of patients, who are increasingly interested in whether the care they receive is improving their health regardless of who provides it. It also fails to meet the needs of payers, who are interested in whether a network of providers is delivering high-value care for its members. Developing measures that capture the collaborative nature of modern health care becomes increasingly important as payers embrace alternative payment models and other value-based reimbursement systems.

Given these challenges with existing measures, we propose the following concepts for consideration as noncolonoscopy quality measures of CRC screening:

1. Appropriateness of referral for CRC screening (PCP): Measures in this domain should incorporate assessment of family history, prior screening history, and/or life expectancy, all of which are predictive of screening benefit and can be extracted from structured electronic health record data.

2. Shared decision making in choosing a CRC screening test (PCP): Currently, measures in this domain are (by necessity) relatively simple, such as assessment of documentation of whether stool testing was offered alongside colonoscopy during a clinic visit.

3. Percentage of individuals with a positive noncolonoscopy CRC screening test who complete a colonoscopy within 6 months (PCP and GI): A measure in this domain can be developed and implemented using existing infrastructure. The Veterans Affairs Healthcare System currently uses such a measure to monitor appropriate follow-up of positive fecal immunochemical tests.

4. Predicted reduction in CRC mortality: This measure, which provides an estimate of the effectiveness and value of a screening program, represents the “bottom line” that is ultimately of interest to both patients and payers. However, composite measures that use projected results require sophisticated statistical approaches and case-mix adjustment. They must also contend with “churn” in the covered population.

Although a more comprehensive view of screening is desirable, operationalizing measure concepts, such as those proposed previously, is challenging for several reasons. First, as we have outlined, CRC screening is truly a “team sport.” The stakeholders in CRC screening include public health, primary care, gastroenterology, colorectal surgery, oncology, anesthesiology, and pathology practitioners. As a result, screening has no natural and obvious steward. Rather, various components of care are adopted by different specialty groups, and this approach leads to unmonitored gaps in care. We believe that gastroenterologists can and should take the lead in developing comprehensive quality measures for CRC screening. Such comprehensive measures will be of value to patients and to payers. Second, assessing quality of care more comprehensively has traditionally been infeasible. For example, incorporating life expectancy into quality measures requires electronic assessment of health status.

Traditionally, such efforts have been hampered by the lack of systematic clinical data collection. However, as meaningful use of electronic health records increases, measures that incorporate such information are likely to become increasingly feasible. Finally, we also need to consider how to make these improvements while avoiding measure proliferation. Proliferation leads to provider fatigue and discourages thoughtful clinical decision making, potentially worsening quality of care. Creative approaches, such as rotating measure sets over time, use of clinical decision support tools, and balancing underuse measures with overuse measures, may be warranted. Additionally, composite measures may prove to be more meaningful and more practical for patients, providers, and payers. Ultimately, a distinction must be made between quality assurance and quality improvement; both are important, but the types of measures and the level of measure sophistication used in each program undoubtedly vary.

In summary, gastroenterologists are uniquely positioned to advocate for high-quality CRC screening that extends beyond simply providing a high-quality colonoscopy. This broader view of quality benefits patients by ensuring that our expertise informs the metrics by which delivery of CRC screening is measured. It also ensures that we hold ourselves and our colleagues to the highest standards across the continuum of care. Additionally, as alternative payment models and value-based contracting are implemented, nonendoscopic screening methods will likely become more commonplace. Advocating for high-quality nonendoscopic screening will help maintain gastroenterologists’ role as the stewards of CRC screening and digestive health. Although operationalizing measure concepts such as those proposed here may be difficult, it is critical if we are to provide the best possible care for our patients.

References

1. Sabatino, S.A., White, M.C., Thompson, T.D., et al. Cancer screening test use – United States, 2013. MMWR Morb Mortal Wkly Rep. 2015;64:464-8.

2. Anderson, A.E., Henry, K.A., Samadder, N.J., et al. Rural vs urban residence affects risk-appropriate colorectal cancer screening. Clin Gastroenterol Hepatol. 2013;11:526-33.

3. Walter, L.C., Lindquist, K., Nugent, S., et al. Impact of age and comorbidity on colorectal cancer screening among older veterans. Ann Intern Med. 2009;150:465-73.

4. Murphy, C.C., Sandler, R.S., Grubber, J.M., et al. Underuse and overuse of colonoscopy for repeat screening and surveillance in the Veterans Health Administration. Clin Gastroenterol Hepatol. 2016;14:436-44.

5. Mittal, S., Lin, Y.-L., Tan, A., et al. Limited life expectancy among a subgroup of Medicare beneficiaries receiving screening colonoscopies. Clin Gastroenterol Hepatol. 2014;12:443-50.e1

6. Allen, J.I. Quality measures for colonoscopy: where should we be in 2015?. Curr Gastroenterol Rep. 2015;17:10.

7. Fisher, D.A., Jeffreys, A., Coffman, C.J., et al. Barriers to full colon evaluation for a positive fecal occult blood test. Cancer Epidemiol Biomark Prev. 2006;15:1232-5.

8. Saini, S.D., van Hees, F., Vijan, S. Smarter screening for cancer: possibilities and challenges of personalization. JAMA. 2014;312:2211-2.

9. Saini, S.D., Vijan, S., Schoenfeld, P., et al. Role of quality measurement in inappropriate use of screening for colorectal cancer: retrospective cohort study. BMJ. 2014;348:g1247.

10. Inadomi, J.M., Vijan, S., Janz, N.K., et al. Adherence to colorectal cancer screening: a randomized clinical trial of competing strategies. Arch Intern Med. 2012;172:575-82.

11. Writing Committee Members, Drozda, J.P., Ferguson, T.B., et al. 2015 ACC/AHA focused update of secondary prevention lipid performance measures: a report of the American College of Cardiology/American Heart Association Task Force on Performance Measures. J Am Coll Cardiol. 2016;67:558-87.

Dr. Saini is a research scientist at the VA Center for Clinical Management Research and an assistant professor of internal medicine at the University of Michigan, Ann Arbor; Dr. Adams is a clinical lecturer in the division of gastroenterology, department of internal medicine, University of Michigan, and a research investigator, VA Center for Clinical Management Research; Dr. Brill is the chief medical officer of Predictive Health, Paradise Valley, Ariz., and a clinical assistant professor of medicine, University of Arizona School of Medicine, Phoenix; Dr. Gupta is codirector of Digestive Health Center, director of interventional endoscopy, and associate professor of medicine in the division of gastroenterology at Loyola University Medical Center; Dr. Naveed is a clinical assistant professor in the department of gastroenterology and hepatology, University of Iowa Hospitals and Clinics; Dr. Rosenberg is at Illinois Gastroenterology Group; and Dr. Gellad is associate professor of medicine at Duke University School of Medicine, Durham, N.C. Dr. Saini’s and Dr. Gellad’s research is funded by Veterans Affairs Health Services Research and Development Career Development Awards (CDA 09-213-2 and CDA 14-158). Dr. Gupta has received research support from Cook Medical, Cosmo Pharmaceuticals, and CDx Diagnostics.

Medicine in the United States is undergoing fundamental changes that will continue despite 2016 presidential election results. Changes include consolidation of provider networks, movement from volume- to value-based reimbursement, demands for price and quality transparency, and a shift from focusing solely on individual physician-patient interactions to a broader triple aim focus that incorporates individual patients, population, health, and cost. In this month’s column, Sameer Saini and colleagues suggest that we broaden our view of colorectal cancer screening quality metrics from a colonoscopy-centric focus to a focus on the bottom line: Do we reduce cancer in the population of patients that we serve? When we extend our view to a population level, we use current colonoscopy registries only as internal process controls. A successful health system will develop a mechanism to assess and demonstrate how well the collective team of providers accomplishes the only outcome that matters to patients: preventing colon cancer.

John I. Allen, MD, MBA, AGAF, Special Section Editor

Colorectal cancer (CRC) screening is one of the most valuable services provided by gastroenterologists. The evidence that screening “works” on a population level is undeniable. But not every screening program is equally effective. Data indicate ongoing underuse of screening, particularly in high-risk, vulnerable, and minority communities.^1,2 Other data indicate that screening is overused, particularly in low-risk patients and in those with limited life expectancy.^3-5 It is also known that endoscopist skill plays an important role in the effectiveness of screening. In short, there is ample room for improvement in the quality of CRC screening, and payers and the public have taken notice. Unsurprisingly, gastroenterologists are often focused on procedural quality indicators, such as adenoma detection and cecal intubation rates.⁶ These endoscopic quality measures are important indicators of high-quality colonoscopy, but colonoscopy is the common touch point of a much broader system of care that includes other screening tests and other providers (e.g., primary care providers [PCPs], pathologists, and anesthesiologists). Coordinating care across this system is essential for improving the health of patients. As the stewards of digestive health, we owe it to our patients to take a more comprehensive view of CRC screening quality and move beyond colonoscopy alone.

AGA Institute

The complex web of care that comprises CRC screening is shown schematically in Figure 1. Appropriate screening begins with selection of suitable screening candidates. In the United States, where most screening is initiated during a clinician encounter, this important task falls primarily on the shoulders of PCPs. It is typically the role of the PCP to assess the two key patient factors that determine screening benefit: CRC risk (using personal and family history) and life expectancy (using age and overall health status). Once a patient has been deemed an appropriate candidate for screening, an acceptable screening test must be selected. Here, patient and practitioner are faced with a menu of options, including fecal occult blood testing (FOBT), colonoscopy, multitarget stool DNA, and computed tomography colonography. For average-risk screening, the ideal test depends primarily on patient preference and local availability.

If a screening test other than colonoscopy is selected, it becomes critical that a positive test is followed by timely and high-quality colonoscopy. High-quality colonoscopy begins with evidence-based preprocedure education and preparation, including appropriate selection of anesthesia services. Once a patient has been well prepared and adequately sedated, an endoscopist must carefully examine the colonic mucosa and completely resect any suspicious polyps. Unless discarded, resected polyps must be reviewed and categorized by a pathologist, including appropriate identification of serrated polyps. Finally, pathology results must be correctly interpreted by the clinician, with evidence-based follow-up recommendations made and effectively communicated to the patient and the referring provider. Additionally, in the short term, delayed gastrointestinal (GI) and non-GI complications of colonoscopy must be recognized and appropriately addressed. In the long term, the rate of interval cancers must be monitored.

Recognizing the importance of CRC screening, GI specialty societies have proposed a variety of quality measures to ensure that patients receive high-quality and high-value colonoscopy. Several of these measures have been adopted by CMS as part of the Physician Quality Reporting System. Non-GI groups, such as the National Center for Quality Assurance and the Ambulatory Surgery Center Association, have also proposed their own CRC screening–related measures.

Despite the proliferation of measures in the domain of CRC screening, current measures fall short in several ways. First, they are largely focused on colonoscopy technical performance, with less attention paid to the important steps that occur before and after colonoscopy. For example, the existing Healthcare Effectiveness Data and Information Set measure for underuse of CRC screening assesses the proportion of patients in a health plan between the ages 50 and 75 who are up to date for CRC screening. This measure is satisfied if a patient completes FOBT, regardless of the result. But FOBT alone is not sufficient to reduce mortality from CRC. Rather, it is imperative that a positive FOBT test be followed by colonoscopy. Numerous studies suggest a quality gap in this critical referral step.⁷

Yet, outside of selected clinical settings (e.g., the Veterans Affairs Healthcare System), no existing quality measure focuses on colonoscopy completion after positive FOBT. Other examples of important performance gaps beyond colonoscopy technical performance include appropriate use of monitored anesthesia care (data suggest overuse) and appropriate pathology interpretation (data suggest variation in the interpretation of serrated lesions, some of which are associated with increased risk of CRC).

Second, existing measures fail to consider individual patient factors that are known to be predictive of screening benefit, such as life expectancy and personal or familial cancer risk.⁸

Returning to the Healthcare Effectiveness Data and Information Set measure as an example, this measure relies on age alone to identify patients who are candidates for screening. Yet, it is widely recognized that life expectancy is a critically important factor when considering screening, particularly in older patients. However, existing measures fail to incorporate estimates of life expectancy. As a result, clinicians are encouraged to screen based on age alone. Data suggest that this leads to overuse in older, sicker patients younger than age 75 (the age cutoff suggested by guidelines and incorporated into the Healthcare Effectiveness Data and Information Set measure) and underuse in healthy and unscreened patients older than age 75.⁹

Furthermore, existing measures fail to systematically consider patient preferences and undervalue shared decision making. Data suggest, for instance, that patients who are offered a “menu” of options for screening rather than a single screening test are more likely to complete a screening test.¹⁰

But existing measures do not consider whether a physician assessed a patient’s preferences, or offered more than one screening option. Of course, measuring the quality of decision making is an evolving science that presents challenges and requires creative solutions.¹¹

Finally, existing measures do not capture the collaborative nature of modern health care. For example, most existing measures focus on the performance of gastroenterologists and GI practices. Although such a focus is appropriate for specialty-specific quality improvement efforts, it neglects to capture the important interactions and hand-offs between providers needed for successful completion of screening (and downstream reduction in cancer mortality). As a result, this specialty-focused approach fails to meet the needs of patients, who are increasingly interested in whether the care they receive is improving their health regardless of who provides it. It also fails to meet the needs of payers, who are interested in whether a network of providers is delivering high-value care for its members. Developing measures that capture the collaborative nature of modern health care becomes increasingly important as payers embrace alternative payment models and other value-based reimbursement systems.

Given these challenges with existing measures, we propose the following concepts for consideration as noncolonoscopy quality measures of CRC screening:

1. Appropriateness of referral for CRC screening (PCP): Measures in this domain should incorporate assessment of family history, prior screening history, and/or life expectancy, all of which are predictive of screening benefit and can be extracted from structured electronic health record data.

2. Shared decision making in choosing a CRC screening test (PCP): Currently, measures in this domain are (by necessity) relatively simple, such as assessment of documentation of whether stool testing was offered alongside colonoscopy during a clinic visit.

3. Percentage of individuals with a positive noncolonoscopy CRC screening test who complete a colonoscopy within 6 months (PCP and GI): A measure in this domain can be developed and implemented using existing infrastructure. The Veterans Affairs Healthcare System currently uses such a measure to monitor appropriate follow-up of positive fecal immunochemical tests.

4. Predicted reduction in CRC mortality: This measure, which provides an estimate of the effectiveness and value of a screening program, represents the “bottom line” that is ultimately of interest to both patients and payers. However, composite measures that use projected results require sophisticated statistical approaches and case-mix adjustment. They must also contend with “churn” in the covered population.

Although a more comprehensive view of screening is desirable, operationalizing measure concepts, such as those proposed previously, is challenging for several reasons. First, as we have outlined, CRC screening is truly a “team sport.” The stakeholders in CRC screening include public health, primary care, gastroenterology, colorectal surgery, oncology, anesthesiology, and pathology practitioners. As a result, screening has no natural and obvious steward. Rather, various components of care are adopted by different specialty groups, and this approach leads to unmonitored gaps in care. We believe that gastroenterologists can and should take the lead in developing comprehensive quality measures for CRC screening. Such comprehensive measures will be of value to patients and to payers. Second, assessing quality of care more comprehensively has traditionally been infeasible. For example, incorporating life expectancy into quality measures requires electronic assessment of health status.

Traditionally, such efforts have been hampered by the lack of systematic clinical data collection. However, as meaningful use of electronic health records increases, measures that incorporate such information are likely to become increasingly feasible. Finally, we also need to consider how to make these improvements while avoiding measure proliferation. Proliferation leads to provider fatigue and discourages thoughtful clinical decision making, potentially worsening quality of care. Creative approaches, such as rotating measure sets over time, use of clinical decision support tools, and balancing underuse measures with overuse measures, may be warranted. Additionally, composite measures may prove to be more meaningful and more practical for patients, providers, and payers. Ultimately, a distinction must be made between quality assurance and quality improvement; both are important, but the types of measures and the level of measure sophistication used in each program undoubtedly vary.

In summary, gastroenterologists are uniquely positioned to advocate for high-quality CRC screening that extends beyond simply providing a high-quality colonoscopy. This broader view of quality benefits patients by ensuring that our expertise informs the metrics by which delivery of CRC screening is measured. It also ensures that we hold ourselves and our colleagues to the highest standards across the continuum of care. Additionally, as alternative payment models and value-based contracting are implemented, nonendoscopic screening methods will likely become more commonplace. Advocating for high-quality nonendoscopic screening will help maintain gastroenterologists’ role as the stewards of CRC screening and digestive health. Although operationalizing measure concepts such as those proposed here may be difficult, it is critical if we are to provide the best possible care for our patients.

References

1. Sabatino, S.A., White, M.C., Thompson, T.D., et al. Cancer screening test use – United States, 2013. MMWR Morb Mortal Wkly Rep. 2015;64:464-8.

2. Anderson, A.E., Henry, K.A., Samadder, N.J., et al. Rural vs urban residence affects risk-appropriate colorectal cancer screening. Clin Gastroenterol Hepatol. 2013;11:526-33.

3. Walter, L.C., Lindquist, K., Nugent, S., et al. Impact of age and comorbidity on colorectal cancer screening among older veterans. Ann Intern Med. 2009;150:465-73.

4. Murphy, C.C., Sandler, R.S., Grubber, J.M., et al. Underuse and overuse of colonoscopy for repeat screening and surveillance in the Veterans Health Administration. Clin Gastroenterol Hepatol. 2016;14:436-44.

5. Mittal, S., Lin, Y.-L., Tan, A., et al. Limited life expectancy among a subgroup of Medicare beneficiaries receiving screening colonoscopies. Clin Gastroenterol Hepatol. 2014;12:443-50.e1

6. Allen, J.I. Quality measures for colonoscopy: where should we be in 2015?. Curr Gastroenterol Rep. 2015;17:10.

7. Fisher, D.A., Jeffreys, A., Coffman, C.J., et al. Barriers to full colon evaluation for a positive fecal occult blood test. Cancer Epidemiol Biomark Prev. 2006;15:1232-5.

8. Saini, S.D., van Hees, F., Vijan, S. Smarter screening for cancer: possibilities and challenges of personalization. JAMA. 2014;312:2211-2.

9. Saini, S.D., Vijan, S., Schoenfeld, P., et al. Role of quality measurement in inappropriate use of screening for colorectal cancer: retrospective cohort study. BMJ. 2014;348:g1247.

10. Inadomi, J.M., Vijan, S., Janz, N.K., et al. Adherence to colorectal cancer screening: a randomized clinical trial of competing strategies. Arch Intern Med. 2012;172:575-82.

11. Writing Committee Members, Drozda, J.P., Ferguson, T.B., et al. 2015 ACC/AHA focused update of secondary prevention lipid performance measures: a report of the American College of Cardiology/American Heart Association Task Force on Performance Measures. J Am Coll Cardiol. 2016;67:558-87.

Dr. Saini is a research scientist at the VA Center for Clinical Management Research and an assistant professor of internal medicine at the University of Michigan, Ann Arbor; Dr. Adams is a clinical lecturer in the division of gastroenterology, department of internal medicine, University of Michigan, and a research investigator, VA Center for Clinical Management Research; Dr. Brill is the chief medical officer of Predictive Health, Paradise Valley, Ariz., and a clinical assistant professor of medicine, University of Arizona School of Medicine, Phoenix; Dr. Gupta is codirector of Digestive Health Center, director of interventional endoscopy, and associate professor of medicine in the division of gastroenterology at Loyola University Medical Center; Dr. Naveed is a clinical assistant professor in the department of gastroenterology and hepatology, University of Iowa Hospitals and Clinics; Dr. Rosenberg is at Illinois Gastroenterology Group; and Dr. Gellad is associate professor of medicine at Duke University School of Medicine, Durham, N.C. Dr. Saini’s and Dr. Gellad’s research is funded by Veterans Affairs Health Services Research and Development Career Development Awards (CDA 09-213-2 and CDA 14-158). Dr. Gupta has received research support from Cook Medical, Cosmo Pharmaceuticals, and CDx Diagnostics.

Medicine in the United States is undergoing fundamental changes that will continue despite 2016 presidential election results. Changes include consolidation of provider networks, movement from volume- to value-based reimbursement, demands for price and quality transparency, and a shift from focusing solely on individual physician-patient interactions to a broader triple aim focus that incorporates individual patients, population, health, and cost. In this month’s column, Sameer Saini and colleagues suggest that we broaden our view of colorectal cancer screening quality metrics from a colonoscopy-centric focus to a focus on the bottom line: Do we reduce cancer in the population of patients that we serve? When we extend our view to a population level, we use current colonoscopy registries only as internal process controls. A successful health system will develop a mechanism to assess and demonstrate how well the collective team of providers accomplishes the only outcome that matters to patients: preventing colon cancer.

John I. Allen, MD, MBA, AGAF, Special Section Editor

Colorectal cancer (CRC) screening is one of the most valuable services provided by gastroenterologists. The evidence that screening “works” on a population level is undeniable. But not every screening program is equally effective. Data indicate ongoing underuse of screening, particularly in high-risk, vulnerable, and minority communities.^1,2 Other data indicate that screening is overused, particularly in low-risk patients and in those with limited life expectancy.^3-5 It is also known that endoscopist skill plays an important role in the effectiveness of screening. In short, there is ample room for improvement in the quality of CRC screening, and payers and the public have taken notice. Unsurprisingly, gastroenterologists are often focused on procedural quality indicators, such as adenoma detection and cecal intubation rates.⁶ These endoscopic quality measures are important indicators of high-quality colonoscopy, but colonoscopy is the common touch point of a much broader system of care that includes other screening tests and other providers (e.g., primary care providers [PCPs], pathologists, and anesthesiologists). Coordinating care across this system is essential for improving the health of patients. As the stewards of digestive health, we owe it to our patients to take a more comprehensive view of CRC screening quality and move beyond colonoscopy alone.

AGA Institute

The complex web of care that comprises CRC screening is shown schematically in Figure 1. Appropriate screening begins with selection of suitable screening candidates. In the United States, where most screening is initiated during a clinician encounter, this important task falls primarily on the shoulders of PCPs. It is typically the role of the PCP to assess the two key patient factors that determine screening benefit: CRC risk (using personal and family history) and life expectancy (using age and overall health status). Once a patient has been deemed an appropriate candidate for screening, an acceptable screening test must be selected. Here, patient and practitioner are faced with a menu of options, including fecal occult blood testing (FOBT), colonoscopy, multitarget stool DNA, and computed tomography colonography. For average-risk screening, the ideal test depends primarily on patient preference and local availability.

If a screening test other than colonoscopy is selected, it becomes critical that a positive test is followed by timely and high-quality colonoscopy. High-quality colonoscopy begins with evidence-based preprocedure education and preparation, including appropriate selection of anesthesia services. Once a patient has been well prepared and adequately sedated, an endoscopist must carefully examine the colonic mucosa and completely resect any suspicious polyps. Unless discarded, resected polyps must be reviewed and categorized by a pathologist, including appropriate identification of serrated polyps. Finally, pathology results must be correctly interpreted by the clinician, with evidence-based follow-up recommendations made and effectively communicated to the patient and the referring provider. Additionally, in the short term, delayed gastrointestinal (GI) and non-GI complications of colonoscopy must be recognized and appropriately addressed. In the long term, the rate of interval cancers must be monitored.

Recognizing the importance of CRC screening, GI specialty societies have proposed a variety of quality measures to ensure that patients receive high-quality and high-value colonoscopy. Several of these measures have been adopted by CMS as part of the Physician Quality Reporting System. Non-GI groups, such as the National Center for Quality Assurance and the Ambulatory Surgery Center Association, have also proposed their own CRC screening–related measures.

Despite the proliferation of measures in the domain of CRC screening, current measures fall short in several ways. First, they are largely focused on colonoscopy technical performance, with less attention paid to the important steps that occur before and after colonoscopy. For example, the existing Healthcare Effectiveness Data and Information Set measure for underuse of CRC screening assesses the proportion of patients in a health plan between the ages 50 and 75 who are up to date for CRC screening. This measure is satisfied if a patient completes FOBT, regardless of the result. But FOBT alone is not sufficient to reduce mortality from CRC. Rather, it is imperative that a positive FOBT test be followed by colonoscopy. Numerous studies suggest a quality gap in this critical referral step.⁷

Yet, outside of selected clinical settings (e.g., the Veterans Affairs Healthcare System), no existing quality measure focuses on colonoscopy completion after positive FOBT. Other examples of important performance gaps beyond colonoscopy technical performance include appropriate use of monitored anesthesia care (data suggest overuse) and appropriate pathology interpretation (data suggest variation in the interpretation of serrated lesions, some of which are associated with increased risk of CRC).

Second, existing measures fail to consider individual patient factors that are known to be predictive of screening benefit, such as life expectancy and personal or familial cancer risk.⁸

Returning to the Healthcare Effectiveness Data and Information Set measure as an example, this measure relies on age alone to identify patients who are candidates for screening. Yet, it is widely recognized that life expectancy is a critically important factor when considering screening, particularly in older patients. However, existing measures fail to incorporate estimates of life expectancy. As a result, clinicians are encouraged to screen based on age alone. Data suggest that this leads to overuse in older, sicker patients younger than age 75 (the age cutoff suggested by guidelines and incorporated into the Healthcare Effectiveness Data and Information Set measure) and underuse in healthy and unscreened patients older than age 75.⁹

Furthermore, existing measures fail to systematically consider patient preferences and undervalue shared decision making. Data suggest, for instance, that patients who are offered a “menu” of options for screening rather than a single screening test are more likely to complete a screening test.¹⁰

But existing measures do not consider whether a physician assessed a patient’s preferences, or offered more than one screening option. Of course, measuring the quality of decision making is an evolving science that presents challenges and requires creative solutions.¹¹

Finally, existing measures do not capture the collaborative nature of modern health care. For example, most existing measures focus on the performance of gastroenterologists and GI practices. Although such a focus is appropriate for specialty-specific quality improvement efforts, it neglects to capture the important interactions and hand-offs between providers needed for successful completion of screening (and downstream reduction in cancer mortality). As a result, this specialty-focused approach fails to meet the needs of patients, who are increasingly interested in whether the care they receive is improving their health regardless of who provides it. It also fails to meet the needs of payers, who are interested in whether a network of providers is delivering high-value care for its members. Developing measures that capture the collaborative nature of modern health care becomes increasingly important as payers embrace alternative payment models and other value-based reimbursement systems.

Given these challenges with existing measures, we propose the following concepts for consideration as noncolonoscopy quality measures of CRC screening:

1. Appropriateness of referral for CRC screening (PCP): Measures in this domain should incorporate assessment of family history, prior screening history, and/or life expectancy, all of which are predictive of screening benefit and can be extracted from structured electronic health record data.

2. Shared decision making in choosing a CRC screening test (PCP): Currently, measures in this domain are (by necessity) relatively simple, such as assessment of documentation of whether stool testing was offered alongside colonoscopy during a clinic visit.

3. Percentage of individuals with a positive noncolonoscopy CRC screening test who complete a colonoscopy within 6 months (PCP and GI): A measure in this domain can be developed and implemented using existing infrastructure. The Veterans Affairs Healthcare System currently uses such a measure to monitor appropriate follow-up of positive fecal immunochemical tests.

4. Predicted reduction in CRC mortality: This measure, which provides an estimate of the effectiveness and value of a screening program, represents the “bottom line” that is ultimately of interest to both patients and payers. However, composite measures that use projected results require sophisticated statistical approaches and case-mix adjustment. They must also contend with “churn” in the covered population.

Although a more comprehensive view of screening is desirable, operationalizing measure concepts, such as those proposed previously, is challenging for several reasons. First, as we have outlined, CRC screening is truly a “team sport.” The stakeholders in CRC screening include public health, primary care, gastroenterology, colorectal surgery, oncology, anesthesiology, and pathology practitioners. As a result, screening has no natural and obvious steward. Rather, various components of care are adopted by different specialty groups, and this approach leads to unmonitored gaps in care. We believe that gastroenterologists can and should take the lead in developing comprehensive quality measures for CRC screening. Such comprehensive measures will be of value to patients and to payers. Second, assessing quality of care more comprehensively has traditionally been infeasible. For example, incorporating life expectancy into quality measures requires electronic assessment of health status.

Traditionally, such efforts have been hampered by the lack of systematic clinical data collection. However, as meaningful use of electronic health records increases, measures that incorporate such information are likely to become increasingly feasible. Finally, we also need to consider how to make these improvements while avoiding measure proliferation. Proliferation leads to provider fatigue and discourages thoughtful clinical decision making, potentially worsening quality of care. Creative approaches, such as rotating measure sets over time, use of clinical decision support tools, and balancing underuse measures with overuse measures, may be warranted. Additionally, composite measures may prove to be more meaningful and more practical for patients, providers, and payers. Ultimately, a distinction must be made between quality assurance and quality improvement; both are important, but the types of measures and the level of measure sophistication used in each program undoubtedly vary.

In summary, gastroenterologists are uniquely positioned to advocate for high-quality CRC screening that extends beyond simply providing a high-quality colonoscopy. This broader view of quality benefits patients by ensuring that our expertise informs the metrics by which delivery of CRC screening is measured. It also ensures that we hold ourselves and our colleagues to the highest standards across the continuum of care. Additionally, as alternative payment models and value-based contracting are implemented, nonendoscopic screening methods will likely become more commonplace. Advocating for high-quality nonendoscopic screening will help maintain gastroenterologists’ role as the stewards of CRC screening and digestive health. Although operationalizing measure concepts such as those proposed here may be difficult, it is critical if we are to provide the best possible care for our patients.

References

1. Sabatino, S.A., White, M.C., Thompson, T.D., et al. Cancer screening test use – United States, 2013. MMWR Morb Mortal Wkly Rep. 2015;64:464-8.

2. Anderson, A.E., Henry, K.A., Samadder, N.J., et al. Rural vs urban residence affects risk-appropriate colorectal cancer screening. Clin Gastroenterol Hepatol. 2013;11:526-33.

3. Walter, L.C., Lindquist, K., Nugent, S., et al. Impact of age and comorbidity on colorectal cancer screening among older veterans. Ann Intern Med. 2009;150:465-73.

4. Murphy, C.C., Sandler, R.S., Grubber, J.M., et al. Underuse and overuse of colonoscopy for repeat screening and surveillance in the Veterans Health Administration. Clin Gastroenterol Hepatol. 2016;14:436-44.

5. Mittal, S., Lin, Y.-L., Tan, A., et al. Limited life expectancy among a subgroup of Medicare beneficiaries receiving screening colonoscopies. Clin Gastroenterol Hepatol. 2014;12:443-50.e1

6. Allen, J.I. Quality measures for colonoscopy: where should we be in 2015?. Curr Gastroenterol Rep. 2015;17:10.

7. Fisher, D.A., Jeffreys, A., Coffman, C.J., et al. Barriers to full colon evaluation for a positive fecal occult blood test. Cancer Epidemiol Biomark Prev. 2006;15:1232-5.

8. Saini, S.D., van Hees, F., Vijan, S. Smarter screening for cancer: possibilities and challenges of personalization. JAMA. 2014;312:2211-2.

9. Saini, S.D., Vijan, S., Schoenfeld, P., et al. Role of quality measurement in inappropriate use of screening for colorectal cancer: retrospective cohort study. BMJ. 2014;348:g1247.

10. Inadomi, J.M., Vijan, S., Janz, N.K., et al. Adherence to colorectal cancer screening: a randomized clinical trial of competing strategies. Arch Intern Med. 2012;172:575-82.

11. Writing Committee Members, Drozda, J.P., Ferguson, T.B., et al. 2015 ACC/AHA focused update of secondary prevention lipid performance measures: a report of the American College of Cardiology/American Heart Association Task Force on Performance Measures. J Am Coll Cardiol. 2016;67:558-87.

Dr. Saini is a research scientist at the VA Center for Clinical Management Research and an assistant professor of internal medicine at the University of Michigan, Ann Arbor; Dr. Adams is a clinical lecturer in the division of gastroenterology, department of internal medicine, University of Michigan, and a research investigator, VA Center for Clinical Management Research; Dr. Brill is the chief medical officer of Predictive Health, Paradise Valley, Ariz., and a clinical assistant professor of medicine, University of Arizona School of Medicine, Phoenix; Dr. Gupta is codirector of Digestive Health Center, director of interventional endoscopy, and associate professor of medicine in the division of gastroenterology at Loyola University Medical Center; Dr. Naveed is a clinical assistant professor in the department of gastroenterology and hepatology, University of Iowa Hospitals and Clinics; Dr. Rosenberg is at Illinois Gastroenterology Group; and Dr. Gellad is associate professor of medicine at Duke University School of Medicine, Durham, N.C. Dr. Saini’s and Dr. Gellad’s research is funded by Veterans Affairs Health Services Research and Development Career Development Awards (CDA 09-213-2 and CDA 14-158). Dr. Gupta has received research support from Cook Medical, Cosmo Pharmaceuticals, and CDx Diagnostics.

For most physicians, the resolution of patients’ complaints ranks second only to firing an employee on the Least Favorite Tasks List. With so many potential problems, and so many ways patients can react to them, it seems impossible to construct any sort of template for consistent, mutually satisfactory resolutions.

But it can be done, and it’s not as complex as it appears, once you realize that the vast majority of complaints have the same basic root: The patient’s expectations have not been met. Sometimes it’s your fault, sometimes the patient’s, and often a bit of both. Either way, the result is the same: You have an unhappy patient, and you must deal with it.

In most cases, this is not a job you should delegate. Unless the complaint is trivial or purely administrative, you should address it yourself. It’s what you would want if you were the complainant, and it’s often too important to trust to a subordinate.

I have distilled this unpleasant duty down to a simple three-part strategy:

• Discover which expectations went unmet, and why.

• Agree on a solution.

• Learn from the experience, to prevent similar future complaints.

At this point, you may be asking, “Why should I care? Is the personal expenditure of my time and effort necessary to resolve complaints really worth it?” Absolutely, because the old cliché is true: A satisfied patient will refer 5 new patients, but a dissatisfied one will chase away 20 or more. Besides, if the complaint is significant, and you won’t resolve it, the patient is likely to find someone who will; and chances are you won’t like the choice, or the venue – or the eventual resolution.

Of course, the easiest way to deal with complaints is to prevent as many as possible in the first place. Try to nip unrealistic expectations in the bud. Take the time to explain all treatments and procedures, and their most likely outcomes, in a clear and honest manner. And since even the most astute patients will not absorb everything you tell them, make liberal use of written handouts and other visual aids.

And, of course, document everything you have explained. Documentation is like garlic: There is no such thing as too much of it.

But despite your best efforts, there will always be complaints, and handling them is a skill set worth honing. The most important skill in that set is the one most people – especially physicians – do poorly: listening to the complaint. Before you can resolve a problem you have to know what it is, and this is precisely the wrong time to make assumptions or jump to conclusions.

So listen to the entire complaint without interrupting, defending, or justifying. Angry patients don’t care why the problem occurred, and they are not interested in your side of the story. This is not about you, so listen and understand.

As you listen, the unmet expectations will become clear. When the patient is finished, I like to summarize the complaint in that context: “So if I understand you correctly, you expected “X” to happen, but “Y” happened instead.” If I’m wrong, I modify my summary until the patient agrees that I understand the problem.

Once you know the problem, you can talk about a solution. The patient usually has one in mind – additional treatment, a referral elsewhere, a fee adjustment, or sometimes simply an apology. Consider it.

If the patient’s solution is reasonable, by all means, agree to it; if it is unreasonable, try to offer a reasonable alternative. The temptation here is to think more about protecting yourself than making the patient happy, but that often leads to bigger problems. Don’t be defensive. Again, this is not about you.

I am often asked if refunding a fee is a reasonable option. Some patients (and lawyers) will interpret a refund as a tacit admission of guilt, so I generally try to avoid them. However, canceling a small fee for an angry patient can be an expedient solution, and in my opinion looks exactly like what it is: an honest effort to rectify the situation. But in general, additional materials or services, at reduced or waived fees, are a better alternative than refunding money.

Once you have arrived at a mutually satisfactory solution, again, document everything; but consider reserving a “private” chart area for such documentation (unless it is a bona fide clinical issue), so that it won’t go out to referrers and other third parties with copies of your clinical notes. Also, consider having the patient sign off on the documentation, acknowledging that the complaint has been resolved.

Finally, always try to learn something from the experience. Ask yourself how you might prevent a repetition of the complaint, what you did that you can avoid doing next time, and how you might prevent unrealistic expectations in a similar future situation.

Above all, never take complaints personally – even when they are personal. It’s always worth reminding yourself that no matter how hard you try, you can never please everyone.

Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters, and is a long-time monthly columnist for Dermatology News. Write to him at [email protected].

For most physicians, the resolution of patients’ complaints ranks second only to firing an employee on the Least Favorite Tasks List. With so many potential problems, and so many ways patients can react to them, it seems impossible to construct any sort of template for consistent, mutually satisfactory resolutions.

But it can be done, and it’s not as complex as it appears, once you realize that the vast majority of complaints have the same basic root: The patient’s expectations have not been met. Sometimes it’s your fault, sometimes the patient’s, and often a bit of both. Either way, the result is the same: You have an unhappy patient, and you must deal with it.

In most cases, this is not a job you should delegate. Unless the complaint is trivial or purely administrative, you should address it yourself. It’s what you would want if you were the complainant, and it’s often too important to trust to a subordinate.

I have distilled this unpleasant duty down to a simple three-part strategy:

• Discover which expectations went unmet, and why.

• Agree on a solution.

• Learn from the experience, to prevent similar future complaints.

At this point, you may be asking, “Why should I care? Is the personal expenditure of my time and effort necessary to resolve complaints really worth it?” Absolutely, because the old cliché is true: A satisfied patient will refer 5 new patients, but a dissatisfied one will chase away 20 or more. Besides, if the complaint is significant, and you won’t resolve it, the patient is likely to find someone who will; and chances are you won’t like the choice, or the venue – or the eventual resolution.

Of course, the easiest way to deal with complaints is to prevent as many as possible in the first place. Try to nip unrealistic expectations in the bud. Take the time to explain all treatments and procedures, and their most likely outcomes, in a clear and honest manner. And since even the most astute patients will not absorb everything you tell them, make liberal use of written handouts and other visual aids.

And, of course, document everything you have explained. Documentation is like garlic: There is no such thing as too much of it.

But despite your best efforts, there will always be complaints, and handling them is a skill set worth honing. The most important skill in that set is the one most people – especially physicians – do poorly: listening to the complaint. Before you can resolve a problem you have to know what it is, and this is precisely the wrong time to make assumptions or jump to conclusions.

So listen to the entire complaint without interrupting, defending, or justifying. Angry patients don’t care why the problem occurred, and they are not interested in your side of the story. This is not about you, so listen and understand.

As you listen, the unmet expectations will become clear. When the patient is finished, I like to summarize the complaint in that context: “So if I understand you correctly, you expected “X” to happen, but “Y” happened instead.” If I’m wrong, I modify my summary until the patient agrees that I understand the problem.

Once you know the problem, you can talk about a solution. The patient usually has one in mind – additional treatment, a referral elsewhere, a fee adjustment, or sometimes simply an apology. Consider it.

If the patient’s solution is reasonable, by all means, agree to it; if it is unreasonable, try to offer a reasonable alternative. The temptation here is to think more about protecting yourself than making the patient happy, but that often leads to bigger problems. Don’t be defensive. Again, this is not about you.

I am often asked if refunding a fee is a reasonable option. Some patients (and lawyers) will interpret a refund as a tacit admission of guilt, so I generally try to avoid them. However, canceling a small fee for an angry patient can be an expedient solution, and in my opinion looks exactly like what it is: an honest effort to rectify the situation. But in general, additional materials or services, at reduced or waived fees, are a better alternative than refunding money.

Once you have arrived at a mutually satisfactory solution, again, document everything; but consider reserving a “private” chart area for such documentation (unless it is a bona fide clinical issue), so that it won’t go out to referrers and other third parties with copies of your clinical notes. Also, consider having the patient sign off on the documentation, acknowledging that the complaint has been resolved.

Finally, always try to learn something from the experience. Ask yourself how you might prevent a repetition of the complaint, what you did that you can avoid doing next time, and how you might prevent unrealistic expectations in a similar future situation.

Above all, never take complaints personally – even when they are personal. It’s always worth reminding yourself that no matter how hard you try, you can never please everyone.

Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters, and is a long-time monthly columnist for Dermatology News. Write to him at [email protected].

For most physicians, the resolution of patients’ complaints ranks second only to firing an employee on the Least Favorite Tasks List. With so many potential problems, and so many ways patients can react to them, it seems impossible to construct any sort of template for consistent, mutually satisfactory resolutions.

But it can be done, and it’s not as complex as it appears, once you realize that the vast majority of complaints have the same basic root: The patient’s expectations have not been met. Sometimes it’s your fault, sometimes the patient’s, and often a bit of both. Either way, the result is the same: You have an unhappy patient, and you must deal with it.

In most cases, this is not a job you should delegate. Unless the complaint is trivial or purely administrative, you should address it yourself. It’s what you would want if you were the complainant, and it’s often too important to trust to a subordinate.

I have distilled this unpleasant duty down to a simple three-part strategy:

• Discover which expectations went unmet, and why.

• Agree on a solution.

• Learn from the experience, to prevent similar future complaints.

At this point, you may be asking, “Why should I care? Is the personal expenditure of my time and effort necessary to resolve complaints really worth it?” Absolutely, because the old cliché is true: A satisfied patient will refer 5 new patients, but a dissatisfied one will chase away 20 or more. Besides, if the complaint is significant, and you won’t resolve it, the patient is likely to find someone who will; and chances are you won’t like the choice, or the venue – or the eventual resolution.

Of course, the easiest way to deal with complaints is to prevent as many as possible in the first place. Try to nip unrealistic expectations in the bud. Take the time to explain all treatments and procedures, and their most likely outcomes, in a clear and honest manner. And since even the most astute patients will not absorb everything you tell them, make liberal use of written handouts and other visual aids.

And, of course, document everything you have explained. Documentation is like garlic: There is no such thing as too much of it.

But despite your best efforts, there will always be complaints, and handling them is a skill set worth honing. The most important skill in that set is the one most people – especially physicians – do poorly: listening to the complaint. Before you can resolve a problem you have to know what it is, and this is precisely the wrong time to make assumptions or jump to conclusions.

So listen to the entire complaint without interrupting, defending, or justifying. Angry patients don’t care why the problem occurred, and they are not interested in your side of the story. This is not about you, so listen and understand.

As you listen, the unmet expectations will become clear. When the patient is finished, I like to summarize the complaint in that context: “So if I understand you correctly, you expected “X” to happen, but “Y” happened instead.” If I’m wrong, I modify my summary until the patient agrees that I understand the problem.

Once you know the problem, you can talk about a solution. The patient usually has one in mind – additional treatment, a referral elsewhere, a fee adjustment, or sometimes simply an apology. Consider it.

If the patient’s solution is reasonable, by all means, agree to it; if it is unreasonable, try to offer a reasonable alternative. The temptation here is to think more about protecting yourself than making the patient happy, but that often leads to bigger problems. Don’t be defensive. Again, this is not about you.

I am often asked if refunding a fee is a reasonable option. Some patients (and lawyers) will interpret a refund as a tacit admission of guilt, so I generally try to avoid them. However, canceling a small fee for an angry patient can be an expedient solution, and in my opinion looks exactly like what it is: an honest effort to rectify the situation. But in general, additional materials or services, at reduced or waived fees, are a better alternative than refunding money.

Once you have arrived at a mutually satisfactory solution, again, document everything; but consider reserving a “private” chart area for such documentation (unless it is a bona fide clinical issue), so that it won’t go out to referrers and other third parties with copies of your clinical notes. Also, consider having the patient sign off on the documentation, acknowledging that the complaint has been resolved.

Finally, always try to learn something from the experience. Ask yourself how you might prevent a repetition of the complaint, what you did that you can avoid doing next time, and how you might prevent unrealistic expectations in a similar future situation.

Above all, never take complaints personally – even when they are personal. It’s always worth reminding yourself that no matter how hard you try, you can never please everyone.

Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters, and is a long-time monthly columnist for Dermatology News. Write to him at [email protected].

On behalf of the SVS Publications Committee I am delighted to announce the appointment of Malachi Sheahan, III, M.D., as Associate Medical Editor of Vascular Specialist. I am sure readers will realize this official newspaper of the Society for Vascular Surgery has grown substantially over the last few years. With the help of generous advertisers we now “publish” Vascular Specialist not only in print but in multiple formats. These include electronic versions on the Web, Facebook, and Twitter, as well as mobile versions for smartphones and tablets. The print version is now published monthly and most often as 20 pages.

Further, www.vascularspecialistonline.com includes many articles not found in the print edition. Articles can be searched based on subject and author and the print version can be seen in PDF version. The web version also allows readers to answer polls posed in the print edition. These are archived for review.

A recent survey of 250 members of the SVS confirmed that Vascular Specialist is now the most widely read vascular news publication. More importantly, it was considered by far the most authoritative.

This expansion requires a significant expenditure of time by the Associate Editors and the Medical Editor in particular. Accordingly, it is essential that the medical editorial staff be supplemented by an Associate Medical Editor. This will also allow the smooth transition when the Medical Editor’s appointment terminates.

Mal has already proven to be an excellent writer, and his commitment to the SVS, resident/fellow training, and his sense of humor make him an outstanding choice to assume this position. Mal completed his vascular surgery training at the Beth Israel Deaconess program in 2003. Shortly thereafter he joined the faculty at the Louisiana State University Health Sciences Center in New Orleans. He currently serves as the program director for both their integrated and independent vascular training programs. In 2014, he was named the Claude C. Craighead Jr. Professor and Chair of the Division of Vascular and Endovascular Surgery.

I have previously requested that all members consider themselves not only readers but also contributors. Once again I encourage you to send Mal and me opinion pieces or letters to the editor. We also welcome Tips and Tricks. These can be quite short and do not require any references. They are meant to highlight a technique that you have found to be helpful in performing an open or endovascular procedure. One or two photos often help the piece but they must be in .jpg format and at least 124kb. If you are so inclined we will also print your photo and affiliation alongside. However, we regret you cannot submit your high school photo or substitute one of Tom Cruise or Beyoncé! Don’t worry that you may not be a Pulitzer Prize journalist since we have professional writers who will tidy up your writing as necessary. We also welcome suggestions about news items that we may have missed or overlooked. These may be news items from the lay press or a manuscript you read in a journal other than the JVS. Again, our professional reporters will turn the item into a news article. You can also send us a comment and, if appropriate, we will print it as a sidebar to the article.

Further, we encourage news about your comings and goings which we can publish in the “From the community” section. Executive members of the various regional Societies can also utilize this section to bring us news about their Societies activities.

In order to keep the commentaries fresh, we do need to rotate the members of the editorial board. So, if you would like to be considered for such a position, please send us a short biography and your area of interest. This could be related to a disease process, treatment, or socioeconomic issues. Associate Editors will be required to read short news items about 12 times a year and to provide commentary when requested. Even if you are not selected we may occasionally turn to you to write a comment on a news item related to your stated interest.

The SVS wants Vascular Specialist to be YOUR newspaper. Please help us achieve that goal as we continue to make Vascular Specialist the most read and respected supplier of news and opinions about vascular surgery and vascular surgeons.

You can contact me at [email protected] and Dr. Sheahan at [email protected].

On behalf of the SVS Publications Committee I am delighted to announce the appointment of Malachi Sheahan, III, M.D., as Associate Medical Editor of Vascular Specialist. I am sure readers will realize this official newspaper of the Society for Vascular Surgery has grown substantially over the last few years. With the help of generous advertisers we now “publish” Vascular Specialist not only in print but in multiple formats. These include electronic versions on the Web, Facebook, and Twitter, as well as mobile versions for smartphones and tablets. The print version is now published monthly and most often as 20 pages.

Further, www.vascularspecialistonline.com includes many articles not found in the print edition. Articles can be searched based on subject and author and the print version can be seen in PDF version. The web version also allows readers to answer polls posed in the print edition. These are archived for review.

A recent survey of 250 members of the SVS confirmed that Vascular Specialist is now the most widely read vascular news publication. More importantly, it was considered by far the most authoritative.

This expansion requires a significant expenditure of time by the Associate Editors and the Medical Editor in particular. Accordingly, it is essential that the medical editorial staff be supplemented by an Associate Medical Editor. This will also allow the smooth transition when the Medical Editor’s appointment terminates.

Mal has already proven to be an excellent writer, and his commitment to the SVS, resident/fellow training, and his sense of humor make him an outstanding choice to assume this position. Mal completed his vascular surgery training at the Beth Israel Deaconess program in 2003. Shortly thereafter he joined the faculty at the Louisiana State University Health Sciences Center in New Orleans. He currently serves as the program director for both their integrated and independent vascular training programs. In 2014, he was named the Claude C. Craighead Jr. Professor and Chair of the Division of Vascular and Endovascular Surgery.

I have previously requested that all members consider themselves not only readers but also contributors. Once again I encourage you to send Mal and me opinion pieces or letters to the editor. We also welcome Tips and Tricks. These can be quite short and do not require any references. They are meant to highlight a technique that you have found to be helpful in performing an open or endovascular procedure. One or two photos often help the piece but they must be in .jpg format and at least 124kb. If you are so inclined we will also print your photo and affiliation alongside. However, we regret you cannot submit your high school photo or substitute one of Tom Cruise or Beyoncé! Don’t worry that you may not be a Pulitzer Prize journalist since we have professional writers who will tidy up your writing as necessary. We also welcome suggestions about news items that we may have missed or overlooked. These may be news items from the lay press or a manuscript you read in a journal other than the JVS. Again, our professional reporters will turn the item into a news article. You can also send us a comment and, if appropriate, we will print it as a sidebar to the article.

Further, we encourage news about your comings and goings which we can publish in the “From the community” section. Executive members of the various regional Societies can also utilize this section to bring us news about their Societies activities.

In order to keep the commentaries fresh, we do need to rotate the members of the editorial board. So, if you would like to be considered for such a position, please send us a short biography and your area of interest. This could be related to a disease process, treatment, or socioeconomic issues. Associate Editors will be required to read short news items about 12 times a year and to provide commentary when requested. Even if you are not selected we may occasionally turn to you to write a comment on a news item related to your stated interest.

The SVS wants Vascular Specialist to be YOUR newspaper. Please help us achieve that goal as we continue to make Vascular Specialist the most read and respected supplier of news and opinions about vascular surgery and vascular surgeons.

You can contact me at [email protected] and Dr. Sheahan at [email protected].

On behalf of the SVS Publications Committee I am delighted to announce the appointment of Malachi Sheahan, III, M.D., as Associate Medical Editor of Vascular Specialist. I am sure readers will realize this official newspaper of the Society for Vascular Surgery has grown substantially over the last few years. With the help of generous advertisers we now “publish” Vascular Specialist not only in print but in multiple formats. These include electronic versions on the Web, Facebook, and Twitter, as well as mobile versions for smartphones and tablets. The print version is now published monthly and most often as 20 pages.

Further, www.vascularspecialistonline.com includes many articles not found in the print edition. Articles can be searched based on subject and author and the print version can be seen in PDF version. The web version also allows readers to answer polls posed in the print edition. These are archived for review.

A recent survey of 250 members of the SVS confirmed that Vascular Specialist is now the most widely read vascular news publication. More importantly, it was considered by far the most authoritative.

This expansion requires a significant expenditure of time by the Associate Editors and the Medical Editor in particular. Accordingly, it is essential that the medical editorial staff be supplemented by an Associate Medical Editor. This will also allow the smooth transition when the Medical Editor’s appointment terminates.

Mal has already proven to be an excellent writer, and his commitment to the SVS, resident/fellow training, and his sense of humor make him an outstanding choice to assume this position. Mal completed his vascular surgery training at the Beth Israel Deaconess program in 2003. Shortly thereafter he joined the faculty at the Louisiana State University Health Sciences Center in New Orleans. He currently serves as the program director for both their integrated and independent vascular training programs. In 2014, he was named the Claude C. Craighead Jr. Professor and Chair of the Division of Vascular and Endovascular Surgery.

I have previously requested that all members consider themselves not only readers but also contributors. Once again I encourage you to send Mal and me opinion pieces or letters to the editor. We also welcome Tips and Tricks. These can be quite short and do not require any references. They are meant to highlight a technique that you have found to be helpful in performing an open or endovascular procedure. One or two photos often help the piece but they must be in .jpg format and at least 124kb. If you are so inclined we will also print your photo and affiliation alongside. However, we regret you cannot submit your high school photo or substitute one of Tom Cruise or Beyoncé! Don’t worry that you may not be a Pulitzer Prize journalist since we have professional writers who will tidy up your writing as necessary. We also welcome suggestions about news items that we may have missed or overlooked. These may be news items from the lay press or a manuscript you read in a journal other than the JVS. Again, our professional reporters will turn the item into a news article. You can also send us a comment and, if appropriate, we will print it as a sidebar to the article.

Further, we encourage news about your comings and goings which we can publish in the “From the community” section. Executive members of the various regional Societies can also utilize this section to bring us news about their Societies activities.

In order to keep the commentaries fresh, we do need to rotate the members of the editorial board. So, if you would like to be considered for such a position, please send us a short biography and your area of interest. This could be related to a disease process, treatment, or socioeconomic issues. Associate Editors will be required to read short news items about 12 times a year and to provide commentary when requested. Even if you are not selected we may occasionally turn to you to write a comment on a news item related to your stated interest.

The SVS wants Vascular Specialist to be YOUR newspaper. Please help us achieve that goal as we continue to make Vascular Specialist the most read and respected supplier of news and opinions about vascular surgery and vascular surgeons.

You can contact me at [email protected] and Dr. Sheahan at [email protected].

To encourage adoption of the recent diabetic foot guideline, SVS has created a new educatonal slide set for members to use in their presentations.

The slideset is based on “The Management of the Diabetic Foot: A Clinical Practice Guideline by the Society for Vascular Surgery in Collaboration with the American Podiatric Medical Association and the Society for Vascular Medicine” published in the Journal of Vascular Surgery, February 2016 Supplement Volume 63, Issue 2, Pages 3S–21S

To get the slideset in PDF form, click here.

To encourage adoption of the recent diabetic foot guideline, SVS has created a new educatonal slide set for members to use in their presentations.

The slideset is based on “The Management of the Diabetic Foot: A Clinical Practice Guideline by the Society for Vascular Surgery in Collaboration with the American Podiatric Medical Association and the Society for Vascular Medicine” published in the Journal of Vascular Surgery, February 2016 Supplement Volume 63, Issue 2, Pages 3S–21S

To get the slideset in PDF form, click here.

To encourage adoption of the recent diabetic foot guideline, SVS has created a new educatonal slide set for members to use in their presentations.

The slideset is based on “The Management of the Diabetic Foot: A Clinical Practice Guideline by the Society for Vascular Surgery in Collaboration with the American Podiatric Medical Association and the Society for Vascular Medicine” published in the Journal of Vascular Surgery, February 2016 Supplement Volume 63, Issue 2, Pages 3S–21S

To get the slideset in PDF form, click here.

Registration is open for the “First Annual UCLA/SVS Symposium: A Comprehensive Review and Update of What’s New in Vascular and Endovascular Surgery.”

The course will be Aug. 27 to 29 at the Beverly Hilton in Beverly Hills, Calif., and will offer an in-depth review of our specialty for those preparing to take the vascular board examinations as well as providing the basic didactic education for the vascular residents and fellows in training.

Registration is open for the “First Annual UCLA/SVS Symposium: A Comprehensive Review and Update of What’s New in Vascular and Endovascular Surgery.”

The course will be Aug. 27 to 29 at the Beverly Hilton in Beverly Hills, Calif., and will offer an in-depth review of our specialty for those preparing to take the vascular board examinations as well as providing the basic didactic education for the vascular residents and fellows in training.

Registration is open for the “First Annual UCLA/SVS Symposium: A Comprehensive Review and Update of What’s New in Vascular and Endovascular Surgery.”

The course will be Aug. 27 to 29 at the Beverly Hilton in Beverly Hills, Calif., and will offer an in-depth review of our specialty for those preparing to take the vascular board examinations as well as providing the basic didactic education for the vascular residents and fellows in training.

The SVS Foundation has announced a new award opportunity, the Research Career Development Travel Awards, designed to support early-career vascular surgeons with an interest in basic science, translational or clinical research.

Applications for these awards are due Aug. 8.

In addition to $1,500 in financial support to attend an established research career development course, awardees also will be assigned an SVS research mentor to provide guidance and discuss academic career advancement, including other available resources and opportunities.

Learn more at the link above.

The SVS Foundation has announced a new award opportunity, the Research Career Development Travel Awards, designed to support early-career vascular surgeons with an interest in basic science, translational or clinical research.

Applications for these awards are due Aug. 8.

In addition to $1,500 in financial support to attend an established research career development course, awardees also will be assigned an SVS research mentor to provide guidance and discuss academic career advancement, including other available resources and opportunities.

Learn more at the link above.

The SVS Foundation has announced a new award opportunity, the Research Career Development Travel Awards, designed to support early-career vascular surgeons with an interest in basic science, translational or clinical research.

Applications for these awards are due Aug. 8.

In addition to $1,500 in financial support to attend an established research career development course, awardees also will be assigned an SVS research mentor to provide guidance and discuss academic career advancement, including other available resources and opportunities.

Learn more at the link above.

NEW YORK - About a third of heart failure patients have anemia and most also have iron deficiency, according to UK researchers.

This observational analysis, Dr. John G.F. Cleland told Reuters Health by email, "shows that iron deficiency is very common in patients with heart failure and often leads to anemia and that the prevalence of both iron deficiency and anemia are both highly sensitive to the criteria used to define them."

In a June 29 online paper in JAMA Cardiology, Dr. Cleland, of the University of Hull, and colleagues report that they came to this conclusion after studying data on more than 4,400 patients seen at a local clinic over a 10-year period. All were referred because of suspected heart failure, and their median age was 73 years.

Data collected included hemoglobin, serum iron, transferrin saturation, and serum ferritin concentrations.

Overall, 1,237 patients (27.8%) had anemia, with a higher prevalence (33.3%) in patients who met the criteria for heart failure with or without left ventricular systolic dysfunction (LVSD).

Depending on the definition used, iron deficiency was present in 270 (43.2%) to 425 (68.0%) patients with anemia. This was the case in 260 (14.7%) to 624 (35.3%) of those without anemia.

Lower concentrations of hemoglobin (hazard ratio 0.92) and serum iron (HR 0.98) were independently associated with higher all-cause and cardiovascular mortality in multivariable analyses.

Moreover, said Dr. Cleland, "Serum iron and transferrin saturation were highly correlated (raising the question of the need to measure both) and both were strongly related to anemia. In contrast, serum ferritin, the most widely (supposed) measure of iron deficiency, was more strongly related to measures of inflammation than anemia."

"Lower concentrations of hemoglobin and serum iron and lower transferrin saturation," he stressed, "were associated with a higher mortality. In contrast, lower serum ferritin was associated with a better prognosis, probably because it is more a measure of inflammation than of iron deficiency."

Dr. Cleland concluded, "Serum ferritin is a poor measure of iron deficiency in patients with heart failure. Many patients with normal serum ferritin (defined by many as greater than 100 ng/mL) have iron deficiency. Clinical trials of intravenous iron for patients with heart failure should be aware of this issue to ensure they enroll appropriate patients."

The National Heart Service, Vifor Pharma, and Amgen supported this research. Dr. Cleland reported research support from Vifor and Amgen.

SOURCE: http://bit.ly/29ukoX4

JAMA Cardiol 2016.

NEW YORK - About a third of heart failure patients have anemia and most also have iron deficiency, according to UK researchers.

This observational analysis, Dr. John G.F. Cleland told Reuters Health by email, "shows that iron deficiency is very common in patients with heart failure and often leads to anemia and that the prevalence of both iron deficiency and anemia are both highly sensitive to the criteria used to define them."

In a June 29 online paper in JAMA Cardiology, Dr. Cleland, of the University of Hull, and colleagues report that they came to this conclusion after studying data on more than 4,400 patients seen at a local clinic over a 10-year period. All were referred because of suspected heart failure, and their median age was 73 years.

Data collected included hemoglobin, serum iron, transferrin saturation, and serum ferritin concentrations.

Overall, 1,237 patients (27.8%) had anemia, with a higher prevalence (33.3%) in patients who met the criteria for heart failure with or without left ventricular systolic dysfunction (LVSD).

Depending on the definition used, iron deficiency was present in 270 (43.2%) to 425 (68.0%) patients with anemia. This was the case in 260 (14.7%) to 624 (35.3%) of those without anemia.

Lower concentrations of hemoglobin (hazard ratio 0.92) and serum iron (HR 0.98) were independently associated with higher all-cause and cardiovascular mortality in multivariable analyses.

Moreover, said Dr. Cleland, "Serum iron and transferrin saturation were highly correlated (raising the question of the need to measure both) and both were strongly related to anemia. In contrast, serum ferritin, the most widely (supposed) measure of iron deficiency, was more strongly related to measures of inflammation than anemia."

"Lower concentrations of hemoglobin and serum iron and lower transferrin saturation," he stressed, "were associated with a higher mortality. In contrast, lower serum ferritin was associated with a better prognosis, probably because it is more a measure of inflammation than of iron deficiency."

Dr. Cleland concluded, "Serum ferritin is a poor measure of iron deficiency in patients with heart failure. Many patients with normal serum ferritin (defined by many as greater than 100 ng/mL) have iron deficiency. Clinical trials of intravenous iron for patients with heart failure should be aware of this issue to ensure they enroll appropriate patients."

The National Heart Service, Vifor Pharma, and Amgen supported this research. Dr. Cleland reported research support from Vifor and Amgen.

SOURCE: http://bit.ly/29ukoX4

JAMA Cardiol 2016.

NEW YORK - About a third of heart failure patients have anemia and most also have iron deficiency, according to UK researchers.

This observational analysis, Dr. John G.F. Cleland told Reuters Health by email, "shows that iron deficiency is very common in patients with heart failure and often leads to anemia and that the prevalence of both iron deficiency and anemia are both highly sensitive to the criteria used to define them."

In a June 29 online paper in JAMA Cardiology, Dr. Cleland, of the University of Hull, and colleagues report that they came to this conclusion after studying data on more than 4,400 patients seen at a local clinic over a 10-year period. All were referred because of suspected heart failure, and their median age was 73 years.

Data collected included hemoglobin, serum iron, transferrin saturation, and serum ferritin concentrations.

Overall, 1,237 patients (27.8%) had anemia, with a higher prevalence (33.3%) in patients who met the criteria for heart failure with or without left ventricular systolic dysfunction (LVSD).

Depending on the definition used, iron deficiency was present in 270 (43.2%) to 425 (68.0%) patients with anemia. This was the case in 260 (14.7%) to 624 (35.3%) of those without anemia.

Lower concentrations of hemoglobin (hazard ratio 0.92) and serum iron (HR 0.98) were independently associated with higher all-cause and cardiovascular mortality in multivariable analyses.

Moreover, said Dr. Cleland, "Serum iron and transferrin saturation were highly correlated (raising the question of the need to measure both) and both were strongly related to anemia. In contrast, serum ferritin, the most widely (supposed) measure of iron deficiency, was more strongly related to measures of inflammation than anemia."

"Lower concentrations of hemoglobin and serum iron and lower transferrin saturation," he stressed, "were associated with a higher mortality. In contrast, lower serum ferritin was associated with a better prognosis, probably because it is more a measure of inflammation than of iron deficiency."

Dr. Cleland concluded, "Serum ferritin is a poor measure of iron deficiency in patients with heart failure. Many patients with normal serum ferritin (defined by many as greater than 100 ng/mL) have iron deficiency. Clinical trials of intravenous iron for patients with heart failure should be aware of this issue to ensure they enroll appropriate patients."

The National Heart Service, Vifor Pharma, and Amgen supported this research. Dr. Cleland reported research support from Vifor and Amgen.

SOURCE: http://bit.ly/29ukoX4

JAMA Cardiol 2016.

SCOTTSDALE, ARIZ. – Children with severe atopic dermatitis were significantly more likely to log at least 5 hours of screen time a day, and were significantly less likely to exercise than were nonatopic controls, said the lead investigator of a large national study.

“Atopic dermatitis overall was not associated with sedentary behavior. It was severe disease only,” said Mark Strom of the department of dermatology, Northwestern University, Chicago, during an oral presentation at the annual meeting of the Society for Investigative Dermatology. Patients tended to be even more sedentary if they suffered from disturbed sleep in addition to severe eczema, he added.

Heat and sweat worsen the intense itch of atopic dermatitis. Hypothesizing that this would deter affected children from physical activity, Mr. Strom and his associates analyzed data for 131,783 respondents aged 18 and under from the National Survey of Children’s Health. The survey assesses physical activity by asking how many days a week the respondent sweated and breathed hard for at least 20 minutes. Screen time is measured by asking about daily hours spent watching television and playing video games, and sleep quality is assessed by asking how many nights a week the child slept the normal amount for his or her age.

Simply having atopic dermatitis was linked with only a slight increase in the chance of having a sedentary lifestyle after controlling for demographic factors, insurance status, geographic location, and educational level, according to Mr. Strom. Specifically, eczema was significantly associated with a 12% lower odds of having exercised on at least 3 days of the previous week (odds ratio, 0.88). However, severe atopic dermatitis significantly reduced the odds that a child exercised at least one day a week by 61% (OR, 0.39). Furthermore, severe atopic dermatitis was associated with more than double the odds of having at least 5 hours of daily screen time (OR, 2.62). And having either moderate or severe eczema was tied to a significant decrease in the odds of having participated in sports in the past year, Mr. Strom said.

“Atopic dermatitis and sleep disturbance each contribute to sedentary behavior,” he reported. Nonatopic children who did not sleep enough on most nights had nearly double the odds of heavy television and video game use, compared with children who slept more, a significant difference. When poor sleepers also had atopic dermatitis, their odds of heavy screen use more than tripled. Poor sleepers were also significantly less likely to join sports teams, even when they did not have eczema, Mr. Strom said.

“Children with more severe atopic dermatitis may have more profound exacerbations of activity-related symptoms, which would lead to these findings,” he concluded. Future studies should explore whether better symptom control can help improve sedentary behaviors, he added.

The study was sponsored by the Maternal and Child Health Bureau of the U.S. Department of Health and Human Services. Mr. Strom had no disclosures.

SCOTTSDALE, ARIZ. – Children with severe atopic dermatitis were significantly more likely to log at least 5 hours of screen time a day, and were significantly less likely to exercise than were nonatopic controls, said the lead investigator of a large national study.

“Atopic dermatitis overall was not associated with sedentary behavior. It was severe disease only,” said Mark Strom of the department of dermatology, Northwestern University, Chicago, during an oral presentation at the annual meeting of the Society for Investigative Dermatology. Patients tended to be even more sedentary if they suffered from disturbed sleep in addition to severe eczema, he added.

Heat and sweat worsen the intense itch of atopic dermatitis. Hypothesizing that this would deter affected children from physical activity, Mr. Strom and his associates analyzed data for 131,783 respondents aged 18 and under from the National Survey of Children’s Health. The survey assesses physical activity by asking how many days a week the respondent sweated and breathed hard for at least 20 minutes. Screen time is measured by asking about daily hours spent watching television and playing video games, and sleep quality is assessed by asking how many nights a week the child slept the normal amount for his or her age.

Simply having atopic dermatitis was linked with only a slight increase in the chance of having a sedentary lifestyle after controlling for demographic factors, insurance status, geographic location, and educational level, according to Mr. Strom. Specifically, eczema was significantly associated with a 12% lower odds of having exercised on at least 3 days of the previous week (odds ratio, 0.88). However, severe atopic dermatitis significantly reduced the odds that a child exercised at least one day a week by 61% (OR, 0.39). Furthermore, severe atopic dermatitis was associated with more than double the odds of having at least 5 hours of daily screen time (OR, 2.62). And having either moderate or severe eczema was tied to a significant decrease in the odds of having participated in sports in the past year, Mr. Strom said.

“Atopic dermatitis and sleep disturbance each contribute to sedentary behavior,” he reported. Nonatopic children who did not sleep enough on most nights had nearly double the odds of heavy television and video game use, compared with children who slept more, a significant difference. When poor sleepers also had atopic dermatitis, their odds of heavy screen use more than tripled. Poor sleepers were also significantly less likely to join sports teams, even when they did not have eczema, Mr. Strom said.

“Children with more severe atopic dermatitis may have more profound exacerbations of activity-related symptoms, which would lead to these findings,” he concluded. Future studies should explore whether better symptom control can help improve sedentary behaviors, he added.

The study was sponsored by the Maternal and Child Health Bureau of the U.S. Department of Health and Human Services. Mr. Strom had no disclosures.

SCOTTSDALE, ARIZ. – Children with severe atopic dermatitis were significantly more likely to log at least 5 hours of screen time a day, and were significantly less likely to exercise than were nonatopic controls, said the lead investigator of a large national study.

“Atopic dermatitis overall was not associated with sedentary behavior. It was severe disease only,” said Mark Strom of the department of dermatology, Northwestern University, Chicago, during an oral presentation at the annual meeting of the Society for Investigative Dermatology. Patients tended to be even more sedentary if they suffered from disturbed sleep in addition to severe eczema, he added.

Heat and sweat worsen the intense itch of atopic dermatitis. Hypothesizing that this would deter affected children from physical activity, Mr. Strom and his associates analyzed data for 131,783 respondents aged 18 and under from the National Survey of Children’s Health. The survey assesses physical activity by asking how many days a week the respondent sweated and breathed hard for at least 20 minutes. Screen time is measured by asking about daily hours spent watching television and playing video games, and sleep quality is assessed by asking how many nights a week the child slept the normal amount for his or her age.

Simply having atopic dermatitis was linked with only a slight increase in the chance of having a sedentary lifestyle after controlling for demographic factors, insurance status, geographic location, and educational level, according to Mr. Strom. Specifically, eczema was significantly associated with a 12% lower odds of having exercised on at least 3 days of the previous week (odds ratio, 0.88). However, severe atopic dermatitis significantly reduced the odds that a child exercised at least one day a week by 61% (OR, 0.39). Furthermore, severe atopic dermatitis was associated with more than double the odds of having at least 5 hours of daily screen time (OR, 2.62). And having either moderate or severe eczema was tied to a significant decrease in the odds of having participated in sports in the past year, Mr. Strom said.

“Atopic dermatitis and sleep disturbance each contribute to sedentary behavior,” he reported. Nonatopic children who did not sleep enough on most nights had nearly double the odds of heavy television and video game use, compared with children who slept more, a significant difference. When poor sleepers also had atopic dermatitis, their odds of heavy screen use more than tripled. Poor sleepers were also significantly less likely to join sports teams, even when they did not have eczema, Mr. Strom said.

“Children with more severe atopic dermatitis may have more profound exacerbations of activity-related symptoms, which would lead to these findings,” he concluded. Future studies should explore whether better symptom control can help improve sedentary behaviors, he added.

The study was sponsored by the Maternal and Child Health Bureau of the U.S. Department of Health and Human Services. Mr. Strom had no disclosures.

SCOTTSDALE, ARIZ. – Children with severe atopic dermatitis were significantly more likely to log at least 5 hours of screen time a day, and were significantly less likely to exercise than were nonatopic controls, said the lead investigator of a large national study.

“Atopic dermatitis overall was not associated with sedentary behavior. It was severe disease only,” said Mark Strom of the department of dermatology, Northwestern University, Chicago, during an oral presentation at the annual meeting of the Society for Investigative Dermatology. Patients tended to be even more sedentary if they suffered from disturbed sleep in addition to severe eczema, he added.

Heat and sweat worsen the intense itch of atopic dermatitis. Hypothesizing that this would deter affected children from physical activity, Mr. Strom and his associates analyzed data for 131,783 respondents aged 18 and under from the National Survey of Children’s Health. The survey assesses physical activity by asking how many days a week the respondent sweated and breathed hard for at least 20 minutes. Screen time is measured by asking about daily hours spent watching television and playing video games, and sleep quality is assessed by asking how many nights a week the child slept the normal amount for his or her age.

Simply having atopic dermatitis was linked with only a slight increase in the chance of having a sedentary lifestyle after controlling for demographic factors, insurance status, geographic location, and educational level, according to Mr. Strom. Specifically, eczema was significantly associated with a 12% lower odds of having exercised on at least 3 days of the previous week (odds ratio, 0.88). However, severe atopic dermatitis significantly reduced the odds that a child exercised at least one day a week by 61% (OR, 0.39). Furthermore, severe atopic dermatitis was associated with more than double the odds of having at least 5 hours of daily screen time (OR, 2.62). And having either moderate or severe eczema was tied to a significant decrease in the odds of having participated in sports in the past year, Mr. Strom said.

“Atopic dermatitis and sleep disturbance each contribute to sedentary behavior,” he reported. Nonatopic children who did not sleep enough on most nights had nearly double the odds of heavy television and video game use, compared with children who slept more, a significant difference. When poor sleepers also had atopic dermatitis, their odds of heavy screen use more than tripled. Poor sleepers were also significantly less likely to join sports teams, even when they did not have eczema, Mr. Strom said.

“Children with more severe atopic dermatitis may have more profound exacerbations of activity-related symptoms, which would lead to these findings,” he concluded. Future studies should explore whether better symptom control can help improve sedentary behaviors, he added.

The study was sponsored by the Maternal and Child Health Bureau of the U.S. Department of Health and Human Services. Mr. Strom had no disclosures.

SCOTTSDALE, ARIZ. – Children with severe atopic dermatitis were significantly more likely to log at least 5 hours of screen time a day, and were significantly less likely to exercise than were nonatopic controls, said the lead investigator of a large national study.

“Atopic dermatitis overall was not associated with sedentary behavior. It was severe disease only,” said Mark Strom of the department of dermatology, Northwestern University, Chicago, during an oral presentation at the annual meeting of the Society for Investigative Dermatology. Patients tended to be even more sedentary if they suffered from disturbed sleep in addition to severe eczema, he added.

Heat and sweat worsen the intense itch of atopic dermatitis. Hypothesizing that this would deter affected children from physical activity, Mr. Strom and his associates analyzed data for 131,783 respondents aged 18 and under from the National Survey of Children’s Health. The survey assesses physical activity by asking how many days a week the respondent sweated and breathed hard for at least 20 minutes. Screen time is measured by asking about daily hours spent watching television and playing video games, and sleep quality is assessed by asking how many nights a week the child slept the normal amount for his or her age.

Simply having atopic dermatitis was linked with only a slight increase in the chance of having a sedentary lifestyle after controlling for demographic factors, insurance status, geographic location, and educational level, according to Mr. Strom. Specifically, eczema was significantly associated with a 12% lower odds of having exercised on at least 3 days of the previous week (odds ratio, 0.88). However, severe atopic dermatitis significantly reduced the odds that a child exercised at least one day a week by 61% (OR, 0.39). Furthermore, severe atopic dermatitis was associated with more than double the odds of having at least 5 hours of daily screen time (OR, 2.62). And having either moderate or severe eczema was tied to a significant decrease in the odds of having participated in sports in the past year, Mr. Strom said.

“Atopic dermatitis and sleep disturbance each contribute to sedentary behavior,” he reported. Nonatopic children who did not sleep enough on most nights had nearly double the odds of heavy television and video game use, compared with children who slept more, a significant difference. When poor sleepers also had atopic dermatitis, their odds of heavy screen use more than tripled. Poor sleepers were also significantly less likely to join sports teams, even when they did not have eczema, Mr. Strom said.

“Children with more severe atopic dermatitis may have more profound exacerbations of activity-related symptoms, which would lead to these findings,” he concluded. Future studies should explore whether better symptom control can help improve sedentary behaviors, he added.

The study was sponsored by the Maternal and Child Health Bureau of the U.S. Department of Health and Human Services. Mr. Strom had no disclosures.

SCOTTSDALE, ARIZ. – Children with severe atopic dermatitis were significantly more likely to log at least 5 hours of screen time a day, and were significantly less likely to exercise than were nonatopic controls, said the lead investigator of a large national study.

“Atopic dermatitis overall was not associated with sedentary behavior. It was severe disease only,” said Mark Strom of the department of dermatology, Northwestern University, Chicago, during an oral presentation at the annual meeting of the Society for Investigative Dermatology. Patients tended to be even more sedentary if they suffered from disturbed sleep in addition to severe eczema, he added.

Heat and sweat worsen the intense itch of atopic dermatitis. Hypothesizing that this would deter affected children from physical activity, Mr. Strom and his associates analyzed data for 131,783 respondents aged 18 and under from the National Survey of Children’s Health. The survey assesses physical activity by asking how many days a week the respondent sweated and breathed hard for at least 20 minutes. Screen time is measured by asking about daily hours spent watching television and playing video games, and sleep quality is assessed by asking how many nights a week the child slept the normal amount for his or her age.

Simply having atopic dermatitis was linked with only a slight increase in the chance of having a sedentary lifestyle after controlling for demographic factors, insurance status, geographic location, and educational level, according to Mr. Strom. Specifically, eczema was significantly associated with a 12% lower odds of having exercised on at least 3 days of the previous week (odds ratio, 0.88). However, severe atopic dermatitis significantly reduced the odds that a child exercised at least one day a week by 61% (OR, 0.39). Furthermore, severe atopic dermatitis was associated with more than double the odds of having at least 5 hours of daily screen time (OR, 2.62). And having either moderate or severe eczema was tied to a significant decrease in the odds of having participated in sports in the past year, Mr. Strom said.

“Atopic dermatitis and sleep disturbance each contribute to sedentary behavior,” he reported. Nonatopic children who did not sleep enough on most nights had nearly double the odds of heavy television and video game use, compared with children who slept more, a significant difference. When poor sleepers also had atopic dermatitis, their odds of heavy screen use more than tripled. Poor sleepers were also significantly less likely to join sports teams, even when they did not have eczema, Mr. Strom said.

“Children with more severe atopic dermatitis may have more profound exacerbations of activity-related symptoms, which would lead to these findings,” he concluded. Future studies should explore whether better symptom control can help improve sedentary behaviors, he added.

The study was sponsored by the Maternal and Child Health Bureau of the U.S. Department of Health and Human Services. Mr. Strom had no disclosures.