Section 10332 of the Affordable Care Act (ACA) allows the Centers for Medicare & Medicaid Services (CMS) to provide Medicare claims data to “qualified” private organizations for the purpose of reporting provider performance information. On June 8, CMS issued a proposed rule that includes tight parameters on who qualifies to receive the data, beneficiary privacy protections, and the rights of providers to correct errors before reports are made public. CMS also included estimates of the fees to receive the claims data: $275,000.

The fees are not a price as much as an effort to recoup the expense associated with providing the data. CMS has interpreted expenses to include the cost of providing technical assistance, processing qualified entities’ applications, and monitoring of qualified entities to ensure appropriate use of the data and appropriate adherence to data privacy and security standards.

For hospitalists, the opportunity to access this data presents both positives and negatives. On the positive side, research and QI data sources will be greatly expanded. Currently, it is not unheard of to receive multiple, sometimes contradictory, reports from different sources because they are based on different data from piecemeal claims or measures. This initiative grants the ability to combine private sector data with the enormous amount of data at CMS, which should result in the more useful quality reports. This broad pool of data also will allow for a new level of accuracy when it comes to analyzing quality, efficiency, and resource use.

On the negative side, the expense of obtaining this data could be cost-prohibitive for smaller organizations, and access could end up being limited to those with deeper pockets. Additionally, it will be critical to identify errors and inaccuracies in reports. As a result, hospitalists could be forced to spend time and resources reviewing privately produced performance reports before they are made public.

There is potential in this initiative to change the quality measurement landscape. If done well, the opportunity to combine claims data from both Medicare and the private sector will produce a wealth of information related to how providers and suppliers are performing.

SHM will be voicing support for the concept because it serves to increase performance transparency, not just for hospitalists but for all stakeholders.

Ready to Lead Hospital Medicine?

Join an SHM Committee

Dr. Li

When Kim Dickinson, MD, joined SHM’s Administrators Committee, it expanded her network of HM professionals. It also gave her an opportunity to take some of the best practices in the specialty to others within her company.

For other hospitalists interested in flexing leadership muscles and growing their network of hospitalists, now is the time to apply for positions on more than 30 of SHM’s committees and task forces. Potential applicants are encouraged to apply before January 2012.

Committee information and applications are available at www.hospitalmedicine.org/committees.

“SHM’s committees and task forces are the engines that drive SHM toward a vision of transforming healthcare and revolutionizing patient care in the hospital,” says SHM president Joseph Li, MD, SFHM. “And the broad span of issues covered by our committees gives every aspiring hospitalist an opportunity to channel their energy into something meaningful.”

Dr. Dickinson sees committee participation as a way to learn and grow.

“I always tell people about being on committees,” she says. “It’s a good learning experience for people, and it exposes you to a wide variety of people and different perspectives. What applies to a four-member group is very different than what applies to 40-member group.

“A lot of learning that can come from that.”

SHM’s Atchley Leadership Fund Supports the Next Generation of Hospitalist Leaders

Dr. Atchley

Hospitalist Bill Atchley, MD, SFHM, was there at the beginning of SHM’s Leadership Academy. Now, he’s helping it to endure.

After participating in the first Leadership Academy, he was hooked on the concept and later became a course facilitator.

As much as Bill has been a fixture at Leadership Academy, so has his wife, Anne. There, she saw firsthand her husband’s passion not only for the specialty, but also his passion for helping groom the next generation of hospitalist leaders. The academies also were the place where many got to see Bill and Anne together after hours, a scene that reminds hospitalists that leadership is not a solitary journey, but one to embark on with both colleagues and those closest to us.

When Anne passed in December 2009, following a valiant fight against cancer, Bill worked with SHM to create the Atchley Leadership Fund. The fund honors Anne’s memory by providing partial scholarships for Leadership Academy participants.

Hospitalists can join Bill in paying tribute to Anne and paving the way for new hospitalist leaders in healthcare by making a tax-free donation to the Atchley Leadership Fund. For more information, visit www.hospitalmedicine.org/atchley.

Section 10332 of the Affordable Care Act (ACA) allows the Centers for Medicare & Medicaid Services (CMS) to provide Medicare claims data to “qualified” private organizations for the purpose of reporting provider performance information. On June 8, CMS issued a proposed rule that includes tight parameters on who qualifies to receive the data, beneficiary privacy protections, and the rights of providers to correct errors before reports are made public. CMS also included estimates of the fees to receive the claims data: $275,000.

The fees are not a price as much as an effort to recoup the expense associated with providing the data. CMS has interpreted expenses to include the cost of providing technical assistance, processing qualified entities’ applications, and monitoring of qualified entities to ensure appropriate use of the data and appropriate adherence to data privacy and security standards.

For hospitalists, the opportunity to access this data presents both positives and negatives. On the positive side, research and QI data sources will be greatly expanded. Currently, it is not unheard of to receive multiple, sometimes contradictory, reports from different sources because they are based on different data from piecemeal claims or measures. This initiative grants the ability to combine private sector data with the enormous amount of data at CMS, which should result in the more useful quality reports. This broad pool of data also will allow for a new level of accuracy when it comes to analyzing quality, efficiency, and resource use.

On the negative side, the expense of obtaining this data could be cost-prohibitive for smaller organizations, and access could end up being limited to those with deeper pockets. Additionally, it will be critical to identify errors and inaccuracies in reports. As a result, hospitalists could be forced to spend time and resources reviewing privately produced performance reports before they are made public.

There is potential in this initiative to change the quality measurement landscape. If done well, the opportunity to combine claims data from both Medicare and the private sector will produce a wealth of information related to how providers and suppliers are performing.

SHM will be voicing support for the concept because it serves to increase performance transparency, not just for hospitalists but for all stakeholders.

Ready to Lead Hospital Medicine?

Join an SHM Committee

Dr. Li

When Kim Dickinson, MD, joined SHM’s Administrators Committee, it expanded her network of HM professionals. It also gave her an opportunity to take some of the best practices in the specialty to others within her company.

For other hospitalists interested in flexing leadership muscles and growing their network of hospitalists, now is the time to apply for positions on more than 30 of SHM’s committees and task forces. Potential applicants are encouraged to apply before January 2012.

Committee information and applications are available at www.hospitalmedicine.org/committees.

“SHM’s committees and task forces are the engines that drive SHM toward a vision of transforming healthcare and revolutionizing patient care in the hospital,” says SHM president Joseph Li, MD, SFHM. “And the broad span of issues covered by our committees gives every aspiring hospitalist an opportunity to channel their energy into something meaningful.”

Dr. Dickinson sees committee participation as a way to learn and grow.

“I always tell people about being on committees,” she says. “It’s a good learning experience for people, and it exposes you to a wide variety of people and different perspectives. What applies to a four-member group is very different than what applies to 40-member group.

“A lot of learning that can come from that.”

SHM’s Atchley Leadership Fund Supports the Next Generation of Hospitalist Leaders

Dr. Atchley

Hospitalist Bill Atchley, MD, SFHM, was there at the beginning of SHM’s Leadership Academy. Now, he’s helping it to endure.

After participating in the first Leadership Academy, he was hooked on the concept and later became a course facilitator.

As much as Bill has been a fixture at Leadership Academy, so has his wife, Anne. There, she saw firsthand her husband’s passion not only for the specialty, but also his passion for helping groom the next generation of hospitalist leaders. The academies also were the place where many got to see Bill and Anne together after hours, a scene that reminds hospitalists that leadership is not a solitary journey, but one to embark on with both colleagues and those closest to us.

When Anne passed in December 2009, following a valiant fight against cancer, Bill worked with SHM to create the Atchley Leadership Fund. The fund honors Anne’s memory by providing partial scholarships for Leadership Academy participants.

Hospitalists can join Bill in paying tribute to Anne and paving the way for new hospitalist leaders in healthcare by making a tax-free donation to the Atchley Leadership Fund. For more information, visit www.hospitalmedicine.org/atchley.

Section 10332 of the Affordable Care Act (ACA) allows the Centers for Medicare & Medicaid Services (CMS) to provide Medicare claims data to “qualified” private organizations for the purpose of reporting provider performance information. On June 8, CMS issued a proposed rule that includes tight parameters on who qualifies to receive the data, beneficiary privacy protections, and the rights of providers to correct errors before reports are made public. CMS also included estimates of the fees to receive the claims data: $275,000.

The fees are not a price as much as an effort to recoup the expense associated with providing the data. CMS has interpreted expenses to include the cost of providing technical assistance, processing qualified entities’ applications, and monitoring of qualified entities to ensure appropriate use of the data and appropriate adherence to data privacy and security standards.

For hospitalists, the opportunity to access this data presents both positives and negatives. On the positive side, research and QI data sources will be greatly expanded. Currently, it is not unheard of to receive multiple, sometimes contradictory, reports from different sources because they are based on different data from piecemeal claims or measures. This initiative grants the ability to combine private sector data with the enormous amount of data at CMS, which should result in the more useful quality reports. This broad pool of data also will allow for a new level of accuracy when it comes to analyzing quality, efficiency, and resource use.

On the negative side, the expense of obtaining this data could be cost-prohibitive for smaller organizations, and access could end up being limited to those with deeper pockets. Additionally, it will be critical to identify errors and inaccuracies in reports. As a result, hospitalists could be forced to spend time and resources reviewing privately produced performance reports before they are made public.

There is potential in this initiative to change the quality measurement landscape. If done well, the opportunity to combine claims data from both Medicare and the private sector will produce a wealth of information related to how providers and suppliers are performing.

SHM will be voicing support for the concept because it serves to increase performance transparency, not just for hospitalists but for all stakeholders.

Ready to Lead Hospital Medicine?

Join an SHM Committee

Dr. Li

When Kim Dickinson, MD, joined SHM’s Administrators Committee, it expanded her network of HM professionals. It also gave her an opportunity to take some of the best practices in the specialty to others within her company.

For other hospitalists interested in flexing leadership muscles and growing their network of hospitalists, now is the time to apply for positions on more than 30 of SHM’s committees and task forces. Potential applicants are encouraged to apply before January 2012.

Committee information and applications are available at www.hospitalmedicine.org/committees.

“SHM’s committees and task forces are the engines that drive SHM toward a vision of transforming healthcare and revolutionizing patient care in the hospital,” says SHM president Joseph Li, MD, SFHM. “And the broad span of issues covered by our committees gives every aspiring hospitalist an opportunity to channel their energy into something meaningful.”

Dr. Dickinson sees committee participation as a way to learn and grow.

“I always tell people about being on committees,” she says. “It’s a good learning experience for people, and it exposes you to a wide variety of people and different perspectives. What applies to a four-member group is very different than what applies to 40-member group.

“A lot of learning that can come from that.”

SHM’s Atchley Leadership Fund Supports the Next Generation of Hospitalist Leaders

Dr. Atchley

Hospitalist Bill Atchley, MD, SFHM, was there at the beginning of SHM’s Leadership Academy. Now, he’s helping it to endure.

After participating in the first Leadership Academy, he was hooked on the concept and later became a course facilitator.

As much as Bill has been a fixture at Leadership Academy, so has his wife, Anne. There, she saw firsthand her husband’s passion not only for the specialty, but also his passion for helping groom the next generation of hospitalist leaders. The academies also were the place where many got to see Bill and Anne together after hours, a scene that reminds hospitalists that leadership is not a solitary journey, but one to embark on with both colleagues and those closest to us.

When Anne passed in December 2009, following a valiant fight against cancer, Bill worked with SHM to create the Atchley Leadership Fund. The fund honors Anne’s memory by providing partial scholarships for Leadership Academy participants.

Hospitalists can join Bill in paying tribute to Anne and paving the way for new hospitalist leaders in healthcare by making a tax-free donation to the Atchley Leadership Fund. For more information, visit www.hospitalmedicine.org/atchley.

A new risk prediction model for venous thromboembolism (VTE) that was validated in a recent study in England may portend a quicker way to test patients in the U.S.

A research team from the University of Nottingham in England developed an algorithm to measure a patient’s risk for VTE using data points often already collected by hospitalists, including information about chronic renal disease, heart failure, and body mass index. In the study, the risk prediction equation explained 33% of the variation in women and 34% in men in the validation cohort evaluated at five years (BMJ. 2011;343:d4656). The report added that the D statistic was 1.43 for women and 1.45 for men, while the receiver operating curve statistic was 0.75 for both sexes.

The researchers then created a website where physicians can input a set of data points on patients and generate a risk profile.

"The algorithm should be validated in the U.S., though we have no reason to think it won’t work in the U.S.," senior author Julia Hippisley-Cox, MD, FRCGP, MRCP, professor of clinical epidemiology and general practice at the University of Nottingham wrote in an email. "And assuming it performs well, then it could be used by hospital doctors to systematically risk assess patients for VTE risk on admission. Patients at high risk could be given prophylaxis."

Dr. Hippisley-Cox says it's too early to tell if the site will become a popular reference tool.

"The algorithm is published as open-source software, so anyone can use it for research," she writes. It "would be ... interesting to have a team of academics in the U.S. use it in a research project."

A new risk prediction model for venous thromboembolism (VTE) that was validated in a recent study in England may portend a quicker way to test patients in the U.S.

A research team from the University of Nottingham in England developed an algorithm to measure a patient’s risk for VTE using data points often already collected by hospitalists, including information about chronic renal disease, heart failure, and body mass index. In the study, the risk prediction equation explained 33% of the variation in women and 34% in men in the validation cohort evaluated at five years (BMJ. 2011;343:d4656). The report added that the D statistic was 1.43 for women and 1.45 for men, while the receiver operating curve statistic was 0.75 for both sexes.

The researchers then created a website where physicians can input a set of data points on patients and generate a risk profile.

"The algorithm should be validated in the U.S., though we have no reason to think it won’t work in the U.S.," senior author Julia Hippisley-Cox, MD, FRCGP, MRCP, professor of clinical epidemiology and general practice at the University of Nottingham wrote in an email. "And assuming it performs well, then it could be used by hospital doctors to systematically risk assess patients for VTE risk on admission. Patients at high risk could be given prophylaxis."

Dr. Hippisley-Cox says it's too early to tell if the site will become a popular reference tool.

"The algorithm is published as open-source software, so anyone can use it for research," she writes. It "would be ... interesting to have a team of academics in the U.S. use it in a research project."

A new risk prediction model for venous thromboembolism (VTE) that was validated in a recent study in England may portend a quicker way to test patients in the U.S.

A research team from the University of Nottingham in England developed an algorithm to measure a patient’s risk for VTE using data points often already collected by hospitalists, including information about chronic renal disease, heart failure, and body mass index. In the study, the risk prediction equation explained 33% of the variation in women and 34% in men in the validation cohort evaluated at five years (BMJ. 2011;343:d4656). The report added that the D statistic was 1.43 for women and 1.45 for men, while the receiver operating curve statistic was 0.75 for both sexes.

The researchers then created a website where physicians can input a set of data points on patients and generate a risk profile.

"The algorithm should be validated in the U.S., though we have no reason to think it won’t work in the U.S.," senior author Julia Hippisley-Cox, MD, FRCGP, MRCP, professor of clinical epidemiology and general practice at the University of Nottingham wrote in an email. "And assuming it performs well, then it could be used by hospital doctors to systematically risk assess patients for VTE risk on admission. Patients at high risk could be given prophylaxis."

Dr. Hippisley-Cox says it's too early to tell if the site will become a popular reference tool.

"The algorithm is published as open-source software, so anyone can use it for research," she writes. It "would be ... interesting to have a team of academics in the U.S. use it in a research project."

Clinical question: Is dalteparin better than unfractionated heparin at preventing venous thromboembolism (VTE) in ICU patients?

Background: VTE is an important health problem for critically ill patients, but prevention is possible, with both unfractionated heparin (UFH) and low-molecular-weight heparin (LMWH) superior to placebo in previous studies. Studies comparing UFH and LMWH in ICU patients have been inconclusive thus far.

Study design: Randomized controlled trial.

Setting: Sixty-seven ICUs in six countries from 2006 to 2010.

Synopsis: Researchers randomized 3,746 patients who met the enrollment criteria to either the LMWH dalteparin 5,000 units daily or UFH 5,000 IU twice daily. The drug was held if major bleeding occurred or the patient developed thrombocytopenia concerning heparin-induced thrombocytopenia (HIT). Patients were followed until discharge or death. VTE was evaluated by ultrasound two days after ICU admission and then twice weekly.

There was no difference in incidence of VTE in patients receiving dalteparin versus UFH [5.1% vs. 5.8%, HR 0.92 (CI 0.68-1.23), P=0.57]. Fewer pulmonary emboli occurred in the dalteparin group (1.3% vs. 2.3%, HR 0.51, P=0.01). There was no difference in major bleeding or HIT between groups.

Bottom line: Dalteparin and UFH were equally effective at preventing proximal VTE in ICU patients, but dalteparin prevented more pulmonary emboli.

Citation: The PROTECT investigators for the Canadian Critical Care Trials Group and the Australian and New Zealand Intensive Care Society Clinical Trials Group. Dalteparin versus unfractionated heparin in critically ill patients. N Engl J Med. 2010;364(14):1305-1314.

For more physician reviews of HM-related research, visit our website.

Clinical question: Is dalteparin better than unfractionated heparin at preventing venous thromboembolism (VTE) in ICU patients?

Background: VTE is an important health problem for critically ill patients, but prevention is possible, with both unfractionated heparin (UFH) and low-molecular-weight heparin (LMWH) superior to placebo in previous studies. Studies comparing UFH and LMWH in ICU patients have been inconclusive thus far.

Study design: Randomized controlled trial.

Setting: Sixty-seven ICUs in six countries from 2006 to 2010.

Synopsis: Researchers randomized 3,746 patients who met the enrollment criteria to either the LMWH dalteparin 5,000 units daily or UFH 5,000 IU twice daily. The drug was held if major bleeding occurred or the patient developed thrombocytopenia concerning heparin-induced thrombocytopenia (HIT). Patients were followed until discharge or death. VTE was evaluated by ultrasound two days after ICU admission and then twice weekly.

There was no difference in incidence of VTE in patients receiving dalteparin versus UFH [5.1% vs. 5.8%, HR 0.92 (CI 0.68-1.23), P=0.57]. Fewer pulmonary emboli occurred in the dalteparin group (1.3% vs. 2.3%, HR 0.51, P=0.01). There was no difference in major bleeding or HIT between groups.

Bottom line: Dalteparin and UFH were equally effective at preventing proximal VTE in ICU patients, but dalteparin prevented more pulmonary emboli.

Citation: The PROTECT investigators for the Canadian Critical Care Trials Group and the Australian and New Zealand Intensive Care Society Clinical Trials Group. Dalteparin versus unfractionated heparin in critically ill patients. N Engl J Med. 2010;364(14):1305-1314.

For more physician reviews of HM-related research, visit our website.

Clinical question: Is dalteparin better than unfractionated heparin at preventing venous thromboembolism (VTE) in ICU patients?

Background: VTE is an important health problem for critically ill patients, but prevention is possible, with both unfractionated heparin (UFH) and low-molecular-weight heparin (LMWH) superior to placebo in previous studies. Studies comparing UFH and LMWH in ICU patients have been inconclusive thus far.

Study design: Randomized controlled trial.

Setting: Sixty-seven ICUs in six countries from 2006 to 2010.

Synopsis: Researchers randomized 3,746 patients who met the enrollment criteria to either the LMWH dalteparin 5,000 units daily or UFH 5,000 IU twice daily. The drug was held if major bleeding occurred or the patient developed thrombocytopenia concerning heparin-induced thrombocytopenia (HIT). Patients were followed until discharge or death. VTE was evaluated by ultrasound two days after ICU admission and then twice weekly.

There was no difference in incidence of VTE in patients receiving dalteparin versus UFH [5.1% vs. 5.8%, HR 0.92 (CI 0.68-1.23), P=0.57]. Fewer pulmonary emboli occurred in the dalteparin group (1.3% vs. 2.3%, HR 0.51, P=0.01). There was no difference in major bleeding or HIT between groups.

Bottom line: Dalteparin and UFH were equally effective at preventing proximal VTE in ICU patients, but dalteparin prevented more pulmonary emboli.

Citation: The PROTECT investigators for the Canadian Critical Care Trials Group and the Australian and New Zealand Intensive Care Society Clinical Trials Group. Dalteparin versus unfractionated heparin in critically ill patients. N Engl J Med. 2010;364(14):1305-1314.

For more physician reviews of HM-related research, visit our website.

Micrograph showing HL

The US Food and Drug Administration (FDA) has granted accelerated approval for brentuximab vedotin (Adcetris) to treat patients with Hodgkin lymphoma (HL) and systemic anaplastic large-cell lymphoma (sALCL).

The drug can now be used to treat HL patients after the failure of autologous stem cell transplant (ASCT) or, in patients who are not ASCT candidates, after they fail at least 2 prior multiagent chemotherapy regimens.

Brentuximab vedotin can also be used to treat patients with sALCL after the failure of at least 1 prior multiagent chemotherapy regimen.

About accelerated approval

The FDA instituted its accelerated approval program to allow for earlier approval of drugs that treat serious conditions and fill an unmet medical need. The approval is based on a surrogate endpoint that is not a measure of clinical benefit.

Drug companies are still required to conduct studies to confirm the anticipated clinical benefit. If these confirmatory trials suggest the drug actually provides a clinical benefit, the FDA grants traditional approval for the drug. If the confirmatory trial does not show a clinical benefit, FDA has regulatory procedures in place that could lead to removing the drug from the market.

Brentuximab vedotin in HL

Accelerated approval for the HL indication was based on a single-arm, multicenter trial to evaluate the objective response rate of brentuximab vedotin as a single agent. The 102 patients enrolled in the trial had CD30-positive HL that relapsed following ASCT.

Brentuximab vedotin prompted an overall response rate in these patients of 73%, with a median response duration of 6.7 months.

Thirty-two percent of patients achieved a complete remission, with a median duration of 20.5 months. Forty percent of patients achieved a partial remission, with a median duration of 3.5 months.

Brentuximab vedotin in sALCL

Accelerated approval for the treatment of sALCL was based on a single-arm, multicenter trial as well. The study included 58 patients with CD30-positive sALCL who had previously received frontline, multiagent chemotherapy treatment.

The primary efficacy endpoint of overall response rate was achieved in 86% of sALCL patients, with a median duration of 12.6 months.

Fifty-seven percent of patients achieved a complete remission, with a median duration of 13.2 months. Twenty-nine percent of patients achieved a partial response, with a median duration of 2.1 months.

The recommended dose and schedule for both indications is 1.8 mg/kg given intravenously over 30 minutes every 3 weeks. Treatment may last a total of 16 cycles, or until disease progresses or toxicity becomes unacceptable.

The agent, manufactured by Seattle Genetics under the trade name Adcetris, is the first new treatment for HL to be approved by the FDA since 1977 and the first to be indicated for sALCL.

Micrograph showing HL

The US Food and Drug Administration (FDA) has granted accelerated approval for brentuximab vedotin (Adcetris) to treat patients with Hodgkin lymphoma (HL) and systemic anaplastic large-cell lymphoma (sALCL).

The drug can now be used to treat HL patients after the failure of autologous stem cell transplant (ASCT) or, in patients who are not ASCT candidates, after they fail at least 2 prior multiagent chemotherapy regimens.

Brentuximab vedotin can also be used to treat patients with sALCL after the failure of at least 1 prior multiagent chemotherapy regimen.

About accelerated approval

The FDA instituted its accelerated approval program to allow for earlier approval of drugs that treat serious conditions and fill an unmet medical need. The approval is based on a surrogate endpoint that is not a measure of clinical benefit.

Drug companies are still required to conduct studies to confirm the anticipated clinical benefit. If these confirmatory trials suggest the drug actually provides a clinical benefit, the FDA grants traditional approval for the drug. If the confirmatory trial does not show a clinical benefit, FDA has regulatory procedures in place that could lead to removing the drug from the market.

Brentuximab vedotin in HL

Accelerated approval for the HL indication was based on a single-arm, multicenter trial to evaluate the objective response rate of brentuximab vedotin as a single agent. The 102 patients enrolled in the trial had CD30-positive HL that relapsed following ASCT.

Brentuximab vedotin prompted an overall response rate in these patients of 73%, with a median response duration of 6.7 months.

Thirty-two percent of patients achieved a complete remission, with a median duration of 20.5 months. Forty percent of patients achieved a partial remission, with a median duration of 3.5 months.

Brentuximab vedotin in sALCL

Accelerated approval for the treatment of sALCL was based on a single-arm, multicenter trial as well. The study included 58 patients with CD30-positive sALCL who had previously received frontline, multiagent chemotherapy treatment.

The primary efficacy endpoint of overall response rate was achieved in 86% of sALCL patients, with a median duration of 12.6 months.

Fifty-seven percent of patients achieved a complete remission, with a median duration of 13.2 months. Twenty-nine percent of patients achieved a partial response, with a median duration of 2.1 months.

The recommended dose and schedule for both indications is 1.8 mg/kg given intravenously over 30 minutes every 3 weeks. Treatment may last a total of 16 cycles, or until disease progresses or toxicity becomes unacceptable.

The agent, manufactured by Seattle Genetics under the trade name Adcetris, is the first new treatment for HL to be approved by the FDA since 1977 and the first to be indicated for sALCL.

Micrograph showing HL

The US Food and Drug Administration (FDA) has granted accelerated approval for brentuximab vedotin (Adcetris) to treat patients with Hodgkin lymphoma (HL) and systemic anaplastic large-cell lymphoma (sALCL).

The drug can now be used to treat HL patients after the failure of autologous stem cell transplant (ASCT) or, in patients who are not ASCT candidates, after they fail at least 2 prior multiagent chemotherapy regimens.

Brentuximab vedotin can also be used to treat patients with sALCL after the failure of at least 1 prior multiagent chemotherapy regimen.

About accelerated approval

The FDA instituted its accelerated approval program to allow for earlier approval of drugs that treat serious conditions and fill an unmet medical need. The approval is based on a surrogate endpoint that is not a measure of clinical benefit.

Drug companies are still required to conduct studies to confirm the anticipated clinical benefit. If these confirmatory trials suggest the drug actually provides a clinical benefit, the FDA grants traditional approval for the drug. If the confirmatory trial does not show a clinical benefit, FDA has regulatory procedures in place that could lead to removing the drug from the market.

Brentuximab vedotin in HL

Accelerated approval for the HL indication was based on a single-arm, multicenter trial to evaluate the objective response rate of brentuximab vedotin as a single agent. The 102 patients enrolled in the trial had CD30-positive HL that relapsed following ASCT.

Brentuximab vedotin prompted an overall response rate in these patients of 73%, with a median response duration of 6.7 months.

Thirty-two percent of patients achieved a complete remission, with a median duration of 20.5 months. Forty percent of patients achieved a partial remission, with a median duration of 3.5 months.

Brentuximab vedotin in sALCL

Accelerated approval for the treatment of sALCL was based on a single-arm, multicenter trial as well. The study included 58 patients with CD30-positive sALCL who had previously received frontline, multiagent chemotherapy treatment.

The primary efficacy endpoint of overall response rate was achieved in 86% of sALCL patients, with a median duration of 12.6 months.

Fifty-seven percent of patients achieved a complete remission, with a median duration of 13.2 months. Twenty-nine percent of patients achieved a partial response, with a median duration of 2.1 months.

The recommended dose and schedule for both indications is 1.8 mg/kg given intravenously over 30 minutes every 3 weeks. Treatment may last a total of 16 cycles, or until disease progresses or toxicity becomes unacceptable.

The agent, manufactured by Seattle Genetics under the trade name Adcetris, is the first new treatment for HL to be approved by the FDA since 1977 and the first to be indicated for sALCL.

The Food and Drug Administration on Aug. 19 approved brentuximab, a CD30-directed antibody drug-conjugate, for the treatment of Hodgkin’s lymphoma and systemic anaplastic large-cell lymphoma, after other treatments have failed.

Specifically, brentuximab was approved for the treatment of patients with Hodgkin’s lymphoma (HL) after failure of autologous stem cell transplant (ASCT) or after failure of at least two prior multiagent chemotherapy regimens in patients who are not ASCT candidates. It is the first new treatment approved for HL by the FDA since 1977, according to the FDA statement. The indications are based on response rates, and there are no available data that show "improvement in patient reported outcomes or survival" with treatment, according to the prescribing information.

The FDA also approved brentuximab for patients with systemic anaplastic large-cell lymphoma (ALCL), a rare form of lymphoma, after failure of at least one prior multiagent chemotherapy regimen. It is the first treatment approved for this rare lymphoma; approximately 2,000 new cases are diagnosed yearly in the United States.

Both types of lymphomas express the CD30 antigen. Brentuximab is a combination of an anti-CD30 antibody and a drug, monomethyl auristatin E (MMAE), a microtubule disrupting agent. The antibody directs the drug to C30-expressing tumor cells, where it is released.

Brentuximab is administered intravenously every 3 weeks; it will be marketed in the United States as Adcetris by Seattle Genetics. It will be available the week of Aug. 22, according to a company spokesperson.

The product was approved under the FDA’s accelerated approval program, which allows the agency to approve a drug for a serious disease based on data showing the drug is effective on a surrogate end point that is "reasonably likely" to predict clinical benefit. Accelerated approvals provide patients with access to promising treatments, but companies are required to provide confirmatory clinical data in order for the drug to be converted to a full approval and remain on the market.

"Early clinical data suggest that patients who received Adcetris for Hodgkin’s lymphoma and systemic anaplastic lymphoma experienced a significant response to the therapy," Dr. Richard Pazdur, director of the Office of Oncology Drug Products in the FDA’s Center for Drug Evaluation and Research, said in the statement.

In a study of 102 patients with HL treated with brentuximab, 73% of the patients had either a complete or partial response to treatment. In a similarly designed study of 58 patients with ALCL, 86% achieved a partial or complete response to treatment. Neutropenia, peripheral sensory neuropathy, fatigue, nausea, anemia, upper-respiratory infection, diarrhea, fever, cough, vomiting, and thrombocytopenia were among the most common adverse effects associated with treatment, according to the FDA.

At a meeting in July, an FDA advisory panel recommended the accelerated approval of both indications.

Brentuximab is under review for the same indications in Europe; a decision on approval is expected in the first half of 2012, according to a spokesperson for Millennium: the Takeda Oncology Co., which has rights to commercialize brentuximab outside the United States and Canada.

The Food and Drug Administration on Aug. 19 approved brentuximab, a CD30-directed antibody drug-conjugate, for the treatment of Hodgkin’s lymphoma and systemic anaplastic large-cell lymphoma, after other treatments have failed.

Specifically, brentuximab was approved for the treatment of patients with Hodgkin’s lymphoma (HL) after failure of autologous stem cell transplant (ASCT) or after failure of at least two prior multiagent chemotherapy regimens in patients who are not ASCT candidates. It is the first new treatment approved for HL by the FDA since 1977, according to the FDA statement. The indications are based on response rates, and there are no available data that show "improvement in patient reported outcomes or survival" with treatment, according to the prescribing information.

The FDA also approved brentuximab for patients with systemic anaplastic large-cell lymphoma (ALCL), a rare form of lymphoma, after failure of at least one prior multiagent chemotherapy regimen. It is the first treatment approved for this rare lymphoma; approximately 2,000 new cases are diagnosed yearly in the United States.

Both types of lymphomas express the CD30 antigen. Brentuximab is a combination of an anti-CD30 antibody and a drug, monomethyl auristatin E (MMAE), a microtubule disrupting agent. The antibody directs the drug to C30-expressing tumor cells, where it is released.

Brentuximab is administered intravenously every 3 weeks; it will be marketed in the United States as Adcetris by Seattle Genetics. It will be available the week of Aug. 22, according to a company spokesperson.

The product was approved under the FDA’s accelerated approval program, which allows the agency to approve a drug for a serious disease based on data showing the drug is effective on a surrogate end point that is "reasonably likely" to predict clinical benefit. Accelerated approvals provide patients with access to promising treatments, but companies are required to provide confirmatory clinical data in order for the drug to be converted to a full approval and remain on the market.

"Early clinical data suggest that patients who received Adcetris for Hodgkin’s lymphoma and systemic anaplastic lymphoma experienced a significant response to the therapy," Dr. Richard Pazdur, director of the Office of Oncology Drug Products in the FDA’s Center for Drug Evaluation and Research, said in the statement.

In a study of 102 patients with HL treated with brentuximab, 73% of the patients had either a complete or partial response to treatment. In a similarly designed study of 58 patients with ALCL, 86% achieved a partial or complete response to treatment. Neutropenia, peripheral sensory neuropathy, fatigue, nausea, anemia, upper-respiratory infection, diarrhea, fever, cough, vomiting, and thrombocytopenia were among the most common adverse effects associated with treatment, according to the FDA.

At a meeting in July, an FDA advisory panel recommended the accelerated approval of both indications.

Brentuximab is under review for the same indications in Europe; a decision on approval is expected in the first half of 2012, according to a spokesperson for Millennium: the Takeda Oncology Co., which has rights to commercialize brentuximab outside the United States and Canada.

The Food and Drug Administration on Aug. 19 approved brentuximab, a CD30-directed antibody drug-conjugate, for the treatment of Hodgkin’s lymphoma and systemic anaplastic large-cell lymphoma, after other treatments have failed.

Specifically, brentuximab was approved for the treatment of patients with Hodgkin’s lymphoma (HL) after failure of autologous stem cell transplant (ASCT) or after failure of at least two prior multiagent chemotherapy regimens in patients who are not ASCT candidates. It is the first new treatment approved for HL by the FDA since 1977, according to the FDA statement. The indications are based on response rates, and there are no available data that show "improvement in patient reported outcomes or survival" with treatment, according to the prescribing information.

The FDA also approved brentuximab for patients with systemic anaplastic large-cell lymphoma (ALCL), a rare form of lymphoma, after failure of at least one prior multiagent chemotherapy regimen. It is the first treatment approved for this rare lymphoma; approximately 2,000 new cases are diagnosed yearly in the United States.

Both types of lymphomas express the CD30 antigen. Brentuximab is a combination of an anti-CD30 antibody and a drug, monomethyl auristatin E (MMAE), a microtubule disrupting agent. The antibody directs the drug to C30-expressing tumor cells, where it is released.

Brentuximab is administered intravenously every 3 weeks; it will be marketed in the United States as Adcetris by Seattle Genetics. It will be available the week of Aug. 22, according to a company spokesperson.

The product was approved under the FDA’s accelerated approval program, which allows the agency to approve a drug for a serious disease based on data showing the drug is effective on a surrogate end point that is "reasonably likely" to predict clinical benefit. Accelerated approvals provide patients with access to promising treatments, but companies are required to provide confirmatory clinical data in order for the drug to be converted to a full approval and remain on the market.

"Early clinical data suggest that patients who received Adcetris for Hodgkin’s lymphoma and systemic anaplastic lymphoma experienced a significant response to the therapy," Dr. Richard Pazdur, director of the Office of Oncology Drug Products in the FDA’s Center for Drug Evaluation and Research, said in the statement.

In a study of 102 patients with HL treated with brentuximab, 73% of the patients had either a complete or partial response to treatment. In a similarly designed study of 58 patients with ALCL, 86% achieved a partial or complete response to treatment. Neutropenia, peripheral sensory neuropathy, fatigue, nausea, anemia, upper-respiratory infection, diarrhea, fever, cough, vomiting, and thrombocytopenia were among the most common adverse effects associated with treatment, according to the FDA.

At a meeting in July, an FDA advisory panel recommended the accelerated approval of both indications.

Brentuximab is under review for the same indications in Europe; a decision on approval is expected in the first half of 2012, according to a spokesperson for Millennium: the Takeda Oncology Co., which has rights to commercialize brentuximab outside the United States and Canada.

There are no hard and fast rules for crafting an investment strategy, especially early in your career. As with so many domains, the devil’s in the details, according to two top financial advisors.

Disability Coverage Checkup

Protecting your income is job one when creating a sound investment strategy. “Your biggest asset is your earning power,” says Bob Wacker, CFP, president of R.E. Wacker Associates Inc. in San Luis Obispo, Calif. That’s why you need to examine your disability coverage as soon as you start working.

Joel Greenwald, MD, CFP, partner at Sterling Retirement Resources in St. Louis Park, Minn., who often presents financial workshops to groups of residents at the University of Minnesota Medical School, agrees. Many physicians assume that group disability coverage offered through the hospital or physicians group is adequate. But it might not be.

Group insurance policies differ from individual policies in key ways. For example, group carriers might supply disability benefits for two to five years, based on one definition of your occupation, and then, according to their definition of “reasonable” occupation, stop paying if you do not take work in a related capacity.

What you want, says Dr. Greenwald, is a policy—often an individual one—that ties the definition of disability to the performance of activities specific to your specialty. A financial advisor or an insurance agent who specializes in disability insurance can review your coverage and help tailor it to your needs.

For more on this issue, visit http://issuu.com/metrodoctors/docs/julyaugust2010.

Analyze and Prioritize Debt

One of the first questions high-income earners have to ask themselves is: Should I pay off my debt right away or start saving? “There is no right answer,” Dr. Greenwald says.

High-interest credit card debt is bad, so physicians should eliminate it as soon as possible.

School loans? The experts suggest paying off the higher-interest loans first. But if you can, you should resist the urge to pay down low-interest loans. The interest on your debt, Wacker explains, might be tax-deductible. Look for a financial planner who has a “robust” tax background to help you weigh the tax consequences of debt payoff versus savings.

Investment Literacy

When you choose a financial planner (see “Finding an Advisor”), expect to examine your disability and debt portfolios, as well as create an estate plan. Make sure you fully fund your retirement plan at work. A 401(k) allows you to contribute $16,500 per year, and most plans match your contributions at 25%, 50%, or 100%, which automatically boosts your balance sheet. It’s also a good idea to establish 529 plans for your children’s education.

Remember that a financial plan is not static; it will require revisiting on a regular basis. And that will entail learning about a whole new body of knowledge. Choose your guides wisely.

Gretchen Henkel is a freelance writer based in California.

There are no hard and fast rules for crafting an investment strategy, especially early in your career. As with so many domains, the devil’s in the details, according to two top financial advisors.

Disability Coverage Checkup

Protecting your income is job one when creating a sound investment strategy. “Your biggest asset is your earning power,” says Bob Wacker, CFP, president of R.E. Wacker Associates Inc. in San Luis Obispo, Calif. That’s why you need to examine your disability coverage as soon as you start working.

Joel Greenwald, MD, CFP, partner at Sterling Retirement Resources in St. Louis Park, Minn., who often presents financial workshops to groups of residents at the University of Minnesota Medical School, agrees. Many physicians assume that group disability coverage offered through the hospital or physicians group is adequate. But it might not be.

Group insurance policies differ from individual policies in key ways. For example, group carriers might supply disability benefits for two to five years, based on one definition of your occupation, and then, according to their definition of “reasonable” occupation, stop paying if you do not take work in a related capacity.

What you want, says Dr. Greenwald, is a policy—often an individual one—that ties the definition of disability to the performance of activities specific to your specialty. A financial advisor or an insurance agent who specializes in disability insurance can review your coverage and help tailor it to your needs.

For more on this issue, visit http://issuu.com/metrodoctors/docs/julyaugust2010.

Analyze and Prioritize Debt

One of the first questions high-income earners have to ask themselves is: Should I pay off my debt right away or start saving? “There is no right answer,” Dr. Greenwald says.

High-interest credit card debt is bad, so physicians should eliminate it as soon as possible.

School loans? The experts suggest paying off the higher-interest loans first. But if you can, you should resist the urge to pay down low-interest loans. The interest on your debt, Wacker explains, might be tax-deductible. Look for a financial planner who has a “robust” tax background to help you weigh the tax consequences of debt payoff versus savings.

Investment Literacy

When you choose a financial planner (see “Finding an Advisor”), expect to examine your disability and debt portfolios, as well as create an estate plan. Make sure you fully fund your retirement plan at work. A 401(k) allows you to contribute $16,500 per year, and most plans match your contributions at 25%, 50%, or 100%, which automatically boosts your balance sheet. It’s also a good idea to establish 529 plans for your children’s education.

Remember that a financial plan is not static; it will require revisiting on a regular basis. And that will entail learning about a whole new body of knowledge. Choose your guides wisely.

Gretchen Henkel is a freelance writer based in California.

There are no hard and fast rules for crafting an investment strategy, especially early in your career. As with so many domains, the devil’s in the details, according to two top financial advisors.

Disability Coverage Checkup

Protecting your income is job one when creating a sound investment strategy. “Your biggest asset is your earning power,” says Bob Wacker, CFP, president of R.E. Wacker Associates Inc. in San Luis Obispo, Calif. That’s why you need to examine your disability coverage as soon as you start working.

Joel Greenwald, MD, CFP, partner at Sterling Retirement Resources in St. Louis Park, Minn., who often presents financial workshops to groups of residents at the University of Minnesota Medical School, agrees. Many physicians assume that group disability coverage offered through the hospital or physicians group is adequate. But it might not be.

Group insurance policies differ from individual policies in key ways. For example, group carriers might supply disability benefits for two to five years, based on one definition of your occupation, and then, according to their definition of “reasonable” occupation, stop paying if you do not take work in a related capacity.

What you want, says Dr. Greenwald, is a policy—often an individual one—that ties the definition of disability to the performance of activities specific to your specialty. A financial advisor or an insurance agent who specializes in disability insurance can review your coverage and help tailor it to your needs.

For more on this issue, visit http://issuu.com/metrodoctors/docs/julyaugust2010.

Analyze and Prioritize Debt

One of the first questions high-income earners have to ask themselves is: Should I pay off my debt right away or start saving? “There is no right answer,” Dr. Greenwald says.

High-interest credit card debt is bad, so physicians should eliminate it as soon as possible.

School loans? The experts suggest paying off the higher-interest loans first. But if you can, you should resist the urge to pay down low-interest loans. The interest on your debt, Wacker explains, might be tax-deductible. Look for a financial planner who has a “robust” tax background to help you weigh the tax consequences of debt payoff versus savings.

Investment Literacy

When you choose a financial planner (see “Finding an Advisor”), expect to examine your disability and debt portfolios, as well as create an estate plan. Make sure you fully fund your retirement plan at work. A 401(k) allows you to contribute $16,500 per year, and most plans match your contributions at 25%, 50%, or 100%, which automatically boosts your balance sheet. It’s also a good idea to establish 529 plans for your children’s education.

Remember that a financial plan is not static; it will require revisiting on a regular basis. And that will entail learning about a whole new body of knowledge. Choose your guides wisely.

Gretchen Henkel is a freelance writer based in California.

“Enter The Neurohospitalist” might sound like a medical spoof of a Bruce Lee movie, but it’s really a subspecialty’s announcement that it’s here to stay.

The clever moniker was the name of a plenary session at the 8th New York Symposium on Neurological Emergencies & Neurological Care, sponsored by Columbia University’s Center for Continuing Medical Education. The two-hour presentation on neurology’s take on HM was a new feature for the annual meeting, and to presenter

David Likosky, MD, SFHM, hospitalist and stroke program director at Evergreen Hospital Medical Center in Kirkland, Wash., it was the latest sign that the field of HM is cementing its future.

“The neurohospitalist world right now is where the hospital medicine world was, say, ten, fifteen years ago,” says Dr. Likosky, who is board-certified in both neurology and internal medicine.

Multiple fields have adopted the HM model, to the point that SHM is holding its first national specialty hospitalist meeting, Focused Practice in Hospital Medicine, on Nov. 4 in Las Vegas. The meeting is designed to help promote networking of people interested in the hospitalist model in various specialties, as well as to help identify issues related to those specialties. Click here for more information and registration.

But even within the growth of speciality hospitalist models, neurology might be the cohort embracing it the fastest. Dr. Likosky estimates there are 500 neurohospitalists practicing nationwide. The Neurohospitalist Society held its first meeting earlier this year, and the field’s first textbook, which he is contributing to, is set for release in November. The Academy of Neurology has a dedicated neurohospitalist section. And the subspecialty even has its own quarterly journal, The Neurohospitalist.

“There is now a critical mass of neurohospitalists,” Dr. Likosky says. “There’s also an increasing recognition by the neurointensivists that someone has to help them take care of these patients, either before they get to the unit or when they come out of the unit. … Most hospitals don’t have neurointensivists, but they have very ill neurology patients. That’s another niche for neurohospitalists. All specialties of intensivists are looking for help with these patients.”

Another panelist at the four-day Manhattan conference, William D. Freeman, MD, assistant professor of neurology at the Mayo Clinic in Jacksonville, Fla., says the continued success of the field will be judged on data. He says three areas of potential “low-hanging fruit” to focus on are:

• Increased use of intravenous tissue plasminogen activators (tPA). The FDA-approved “clot-busting therapy” has been shown to reverse the effects of ischemic stroke if given within a time-sensitive window of therapeutic opportunity.
• Reduced length of stay for stroke patients. Adherence to best practices, Dr. Freeman says, will most effectively reduce patient stays and will be the ones that also demonstrate quality and patient-safety attributes.
• Focus on stroke patient metrics. Administrators often focus on quality measures that are easily identifiable; Dr. Likosky says new programs have to be able to show they can meet those thresholds.

“Hospital administrators are new to the concept of a neurohospitalist,” Dr. Likosky adds. “It’s easier in that they get the hospitalist model because that’s been around for so long, but figuring out the expense of a neurohospitalist program, how that functionally works, are there enough volumes, are all questions that are being asked.”

Still, Drs. Freeman and Likosky agree that the advantages of the subspecialty—everything from physicians’ quality of life to newly satisfied specialists in other departments (who will have a quicker neuro consult available)—mean the nascent specialty can continue to grow in numbers and influence.

“The future is bright for neurohospitalists,” Dr. Freeman says.

Richard Quinn is a freelance writer based in New Jersey.

“Enter The Neurohospitalist” might sound like a medical spoof of a Bruce Lee movie, but it’s really a subspecialty’s announcement that it’s here to stay.

The clever moniker was the name of a plenary session at the 8th New York Symposium on Neurological Emergencies & Neurological Care, sponsored by Columbia University’s Center for Continuing Medical Education. The two-hour presentation on neurology’s take on HM was a new feature for the annual meeting, and to presenter

David Likosky, MD, SFHM, hospitalist and stroke program director at Evergreen Hospital Medical Center in Kirkland, Wash., it was the latest sign that the field of HM is cementing its future.

“The neurohospitalist world right now is where the hospital medicine world was, say, ten, fifteen years ago,” says Dr. Likosky, who is board-certified in both neurology and internal medicine.

Multiple fields have adopted the HM model, to the point that SHM is holding its first national specialty hospitalist meeting, Focused Practice in Hospital Medicine, on Nov. 4 in Las Vegas. The meeting is designed to help promote networking of people interested in the hospitalist model in various specialties, as well as to help identify issues related to those specialties. Click here for more information and registration.

But even within the growth of speciality hospitalist models, neurology might be the cohort embracing it the fastest. Dr. Likosky estimates there are 500 neurohospitalists practicing nationwide. The Neurohospitalist Society held its first meeting earlier this year, and the field’s first textbook, which he is contributing to, is set for release in November. The Academy of Neurology has a dedicated neurohospitalist section. And the subspecialty even has its own quarterly journal, The Neurohospitalist.

“There is now a critical mass of neurohospitalists,” Dr. Likosky says. “There’s also an increasing recognition by the neurointensivists that someone has to help them take care of these patients, either before they get to the unit or when they come out of the unit. … Most hospitals don’t have neurointensivists, but they have very ill neurology patients. That’s another niche for neurohospitalists. All specialties of intensivists are looking for help with these patients.”

Another panelist at the four-day Manhattan conference, William D. Freeman, MD, assistant professor of neurology at the Mayo Clinic in Jacksonville, Fla., says the continued success of the field will be judged on data. He says three areas of potential “low-hanging fruit” to focus on are:

• Increased use of intravenous tissue plasminogen activators (tPA). The FDA-approved “clot-busting therapy” has been shown to reverse the effects of ischemic stroke if given within a time-sensitive window of therapeutic opportunity.
• Reduced length of stay for stroke patients. Adherence to best practices, Dr. Freeman says, will most effectively reduce patient stays and will be the ones that also demonstrate quality and patient-safety attributes.
• Focus on stroke patient metrics. Administrators often focus on quality measures that are easily identifiable; Dr. Likosky says new programs have to be able to show they can meet those thresholds.

“Hospital administrators are new to the concept of a neurohospitalist,” Dr. Likosky adds. “It’s easier in that they get the hospitalist model because that’s been around for so long, but figuring out the expense of a neurohospitalist program, how that functionally works, are there enough volumes, are all questions that are being asked.”

Still, Drs. Freeman and Likosky agree that the advantages of the subspecialty—everything from physicians’ quality of life to newly satisfied specialists in other departments (who will have a quicker neuro consult available)—mean the nascent specialty can continue to grow in numbers and influence.

“The future is bright for neurohospitalists,” Dr. Freeman says.

Richard Quinn is a freelance writer based in New Jersey.

“Enter The Neurohospitalist” might sound like a medical spoof of a Bruce Lee movie, but it’s really a subspecialty’s announcement that it’s here to stay.

The clever moniker was the name of a plenary session at the 8th New York Symposium on Neurological Emergencies & Neurological Care, sponsored by Columbia University’s Center for Continuing Medical Education. The two-hour presentation on neurology’s take on HM was a new feature for the annual meeting, and to presenter

David Likosky, MD, SFHM, hospitalist and stroke program director at Evergreen Hospital Medical Center in Kirkland, Wash., it was the latest sign that the field of HM is cementing its future.

“The neurohospitalist world right now is where the hospital medicine world was, say, ten, fifteen years ago,” says Dr. Likosky, who is board-certified in both neurology and internal medicine.

Multiple fields have adopted the HM model, to the point that SHM is holding its first national specialty hospitalist meeting, Focused Practice in Hospital Medicine, on Nov. 4 in Las Vegas. The meeting is designed to help promote networking of people interested in the hospitalist model in various specialties, as well as to help identify issues related to those specialties. Click here for more information and registration.

But even within the growth of speciality hospitalist models, neurology might be the cohort embracing it the fastest. Dr. Likosky estimates there are 500 neurohospitalists practicing nationwide. The Neurohospitalist Society held its first meeting earlier this year, and the field’s first textbook, which he is contributing to, is set for release in November. The Academy of Neurology has a dedicated neurohospitalist section. And the subspecialty even has its own quarterly journal, The Neurohospitalist.

“There is now a critical mass of neurohospitalists,” Dr. Likosky says. “There’s also an increasing recognition by the neurointensivists that someone has to help them take care of these patients, either before they get to the unit or when they come out of the unit. … Most hospitals don’t have neurointensivists, but they have very ill neurology patients. That’s another niche for neurohospitalists. All specialties of intensivists are looking for help with these patients.”

Another panelist at the four-day Manhattan conference, William D. Freeman, MD, assistant professor of neurology at the Mayo Clinic in Jacksonville, Fla., says the continued success of the field will be judged on data. He says three areas of potential “low-hanging fruit” to focus on are:

• Increased use of intravenous tissue plasminogen activators (tPA). The FDA-approved “clot-busting therapy” has been shown to reverse the effects of ischemic stroke if given within a time-sensitive window of therapeutic opportunity.
• Reduced length of stay for stroke patients. Adherence to best practices, Dr. Freeman says, will most effectively reduce patient stays and will be the ones that also demonstrate quality and patient-safety attributes.
• Focus on stroke patient metrics. Administrators often focus on quality measures that are easily identifiable; Dr. Likosky says new programs have to be able to show they can meet those thresholds.

“Hospital administrators are new to the concept of a neurohospitalist,” Dr. Likosky adds. “It’s easier in that they get the hospitalist model because that’s been around for so long, but figuring out the expense of a neurohospitalist program, how that functionally works, are there enough volumes, are all questions that are being asked.”

Still, Drs. Freeman and Likosky agree that the advantages of the subspecialty—everything from physicians’ quality of life to newly satisfied specialists in other departments (who will have a quicker neuro consult available)—mean the nascent specialty can continue to grow in numbers and influence.

“The future is bright for neurohospitalists,” Dr. Freeman says.

Richard Quinn is a freelance writer based in New Jersey.

As a pediatrician, you are on the front line of acne treatment for neonates, children, and adolescents. Acne is a very common condition that will affect 80% of your patients at some point in their lives. It can be easy to diagnose, but acne is often difficult to evaluate and manage. Presentations vary from mild to severe, and you’re likely to see a wide range of acne severity as you treat babies, children, and adolescents through office consultations and regular wellness checks.

Minimal intervention is reasonable for children with mild, comedonal acne. Most are unaware and unconcerned about their acne. It is important to stress they should avoid aggressive facial scrubbing and "popping zits." A discussion of acne physiology that dispels common myths – for example, that junk foods and poor hygiene cause acne in children and adolescents – also is useful.

Early intervention is essential to successful management. Prompt initiation of acne therapy can prevent sequelae that, if left untreated, can include significant scarring and emotional distress for your patients.

Refer your patient to a dermatologic surgeon early if the child’s acne is recalcitrant to treatment or shows early signs of scarring. Dermatologic surgeons understand the science behind healthy skin and can help your patients with the special needs of skin through every stage of life.

The differential diagnosis for acneiform eruptions varies by age. Neonatal acne (or neonatal cephalic pustulosis, as it is sometimes called) can affect about one in five babies. It is usually self-limited and requires no treatment, although topical ketoconazole can be prescribed if the parents are concerned or the presentation is extensive.

Infantile acne is less common. This occurs between the ages of 6 months and 1 year. Typical lesions include comedones or more inflammatory lesions. Benzoyl peroxide products and/or topical retinoids can be used to treat infantile acne if it is comedonal.

Acne that appears at age 1-7 years is very rare. Toddlers and children with this early childhood acne also should be evaluated further and/or referred to a specialist. A careful history and physical examination are warranted. Measure height and weight, and plot them on the growth chart. Also look for signs of virilization or precocious sexual development.

An abnormal blood pressure can point to congenital adrenal hyperplasia in the neonatal period. Rule out hyperandrogenism, particularly with severe or persistent infantile acne or sudden onset childhood acne. Refer patients to an endocrinologist if you are uncertain, or if any of the following screening tests are abnormal: bone age, serum DHEA (dehydroepiandrosterone), and free testosterone levels. (Total testosterone can be checked if the free testosterone test is unavailable.) Also consider serologic measures of follicle stimulating hormone, luteinizing hormone, prolactin, and 17 alpha-hydroxyprogesterone.

Performance of an exhaustive search for hyperandrogenism in your office is unnecessary in the majority of neonates, infants, children, and adolescents. It is important to know when these screening tests should be ordered and when to refer to a specialist for further evaluation and/or management.

Prepubertal or adolescent acne can occur earlier than parents might expect (at around 8 years of age), and can be the first sign of pubertal maturation. Distinguish comedonal from inflammatory acne to determine appropriate therapy.

Treatment with topical retinoids is the best for comedonal acne. Take the time to educate parents and the child on proper application of a topical retinoid. Instruct them to apply a pea-sized amount to dry skin every other night (or even every third night) for the first 2-4 weeks. This initial small dose can be titrated up gradually over time to minimize adverse effects. Improper use can lead to significant irritation and dryness, and contribute to the lack of treatment compliance.

As with any disease process, patient education is extremely important and can have a great impact on outcomes. Extensively counsel patients and parents on therapy options, and stress the importance of compliance with your recommended treatment regimen.

If the child has inflammatory acne lesions, a combination of benzoyl peroxide and topical antibiotic therapy (erythromycin or clindamycin) is more effective than either agent alone. With more severe acne, oral antibiotics may be warranted. Keep in mind that the tetracycline family of antibiotics can interfere with bone and teeth development, and is contraindicated in children younger than 8 years. Treatment with erythromycin or with Mutual Pharmaceutical’s Bactrim (a combination of sulfamethoxazole and trimethoprim) is appropriate for this age group. For older children with fully developed teeth, oral tetracycline, minocycline, and doxycycline are often the antibiotics of choice.

Infants, children, or adolescents with severe, recalcitrant, or scarring acne should be referred to a specialist for more aggressive intervention. For adolescents with nodulocystic acne (severe acne characterized by inflammation, nodular breakouts, and cysts), early intervention with systemic therapies, including isotretinoin, is important to prevent scarring. Also refer patients to dermatologic surgeons for further evaluation and management if their acne causes them psychological distress, whether or not their clinical presentation is severe.

Dr. Sikora is a private practice dermatologist in Chestnut Hill, Mass., and a member of many professional organizations, including the American Society for Dermatologic Surgery (www.ASDS.net) and the American Academy of Dermatology. Dr. Sikora said she had no relevant financial disclosures.

As a pediatrician, you are on the front line of acne treatment for neonates, children, and adolescents. Acne is a very common condition that will affect 80% of your patients at some point in their lives. It can be easy to diagnose, but acne is often difficult to evaluate and manage. Presentations vary from mild to severe, and you’re likely to see a wide range of acne severity as you treat babies, children, and adolescents through office consultations and regular wellness checks.

Minimal intervention is reasonable for children with mild, comedonal acne. Most are unaware and unconcerned about their acne. It is important to stress they should avoid aggressive facial scrubbing and "popping zits." A discussion of acne physiology that dispels common myths – for example, that junk foods and poor hygiene cause acne in children and adolescents – also is useful.

Early intervention is essential to successful management. Prompt initiation of acne therapy can prevent sequelae that, if left untreated, can include significant scarring and emotional distress for your patients.

Refer your patient to a dermatologic surgeon early if the child’s acne is recalcitrant to treatment or shows early signs of scarring. Dermatologic surgeons understand the science behind healthy skin and can help your patients with the special needs of skin through every stage of life.

The differential diagnosis for acneiform eruptions varies by age. Neonatal acne (or neonatal cephalic pustulosis, as it is sometimes called) can affect about one in five babies. It is usually self-limited and requires no treatment, although topical ketoconazole can be prescribed if the parents are concerned or the presentation is extensive.

Infantile acne is less common. This occurs between the ages of 6 months and 1 year. Typical lesions include comedones or more inflammatory lesions. Benzoyl peroxide products and/or topical retinoids can be used to treat infantile acne if it is comedonal.

Acne that appears at age 1-7 years is very rare. Toddlers and children with this early childhood acne also should be evaluated further and/or referred to a specialist. A careful history and physical examination are warranted. Measure height and weight, and plot them on the growth chart. Also look for signs of virilization or precocious sexual development.

An abnormal blood pressure can point to congenital adrenal hyperplasia in the neonatal period. Rule out hyperandrogenism, particularly with severe or persistent infantile acne or sudden onset childhood acne. Refer patients to an endocrinologist if you are uncertain, or if any of the following screening tests are abnormal: bone age, serum DHEA (dehydroepiandrosterone), and free testosterone levels. (Total testosterone can be checked if the free testosterone test is unavailable.) Also consider serologic measures of follicle stimulating hormone, luteinizing hormone, prolactin, and 17 alpha-hydroxyprogesterone.

Performance of an exhaustive search for hyperandrogenism in your office is unnecessary in the majority of neonates, infants, children, and adolescents. It is important to know when these screening tests should be ordered and when to refer to a specialist for further evaluation and/or management.

Prepubertal or adolescent acne can occur earlier than parents might expect (at around 8 years of age), and can be the first sign of pubertal maturation. Distinguish comedonal from inflammatory acne to determine appropriate therapy.

Treatment with topical retinoids is the best for comedonal acne. Take the time to educate parents and the child on proper application of a topical retinoid. Instruct them to apply a pea-sized amount to dry skin every other night (or even every third night) for the first 2-4 weeks. This initial small dose can be titrated up gradually over time to minimize adverse effects. Improper use can lead to significant irritation and dryness, and contribute to the lack of treatment compliance.

As with any disease process, patient education is extremely important and can have a great impact on outcomes. Extensively counsel patients and parents on therapy options, and stress the importance of compliance with your recommended treatment regimen.

If the child has inflammatory acne lesions, a combination of benzoyl peroxide and topical antibiotic therapy (erythromycin or clindamycin) is more effective than either agent alone. With more severe acne, oral antibiotics may be warranted. Keep in mind that the tetracycline family of antibiotics can interfere with bone and teeth development, and is contraindicated in children younger than 8 years. Treatment with erythromycin or with Mutual Pharmaceutical’s Bactrim (a combination of sulfamethoxazole and trimethoprim) is appropriate for this age group. For older children with fully developed teeth, oral tetracycline, minocycline, and doxycycline are often the antibiotics of choice.

Infants, children, or adolescents with severe, recalcitrant, or scarring acne should be referred to a specialist for more aggressive intervention. For adolescents with nodulocystic acne (severe acne characterized by inflammation, nodular breakouts, and cysts), early intervention with systemic therapies, including isotretinoin, is important to prevent scarring. Also refer patients to dermatologic surgeons for further evaluation and management if their acne causes them psychological distress, whether or not their clinical presentation is severe.

Dr. Sikora is a private practice dermatologist in Chestnut Hill, Mass., and a member of many professional organizations, including the American Society for Dermatologic Surgery (www.ASDS.net) and the American Academy of Dermatology. Dr. Sikora said she had no relevant financial disclosures.

As a pediatrician, you are on the front line of acne treatment for neonates, children, and adolescents. Acne is a very common condition that will affect 80% of your patients at some point in their lives. It can be easy to diagnose, but acne is often difficult to evaluate and manage. Presentations vary from mild to severe, and you’re likely to see a wide range of acne severity as you treat babies, children, and adolescents through office consultations and regular wellness checks.

Minimal intervention is reasonable for children with mild, comedonal acne. Most are unaware and unconcerned about their acne. It is important to stress they should avoid aggressive facial scrubbing and "popping zits." A discussion of acne physiology that dispels common myths – for example, that junk foods and poor hygiene cause acne in children and adolescents – also is useful.

Early intervention is essential to successful management. Prompt initiation of acne therapy can prevent sequelae that, if left untreated, can include significant scarring and emotional distress for your patients.

Refer your patient to a dermatologic surgeon early if the child’s acne is recalcitrant to treatment or shows early signs of scarring. Dermatologic surgeons understand the science behind healthy skin and can help your patients with the special needs of skin through every stage of life.

The differential diagnosis for acneiform eruptions varies by age. Neonatal acne (or neonatal cephalic pustulosis, as it is sometimes called) can affect about one in five babies. It is usually self-limited and requires no treatment, although topical ketoconazole can be prescribed if the parents are concerned or the presentation is extensive.

Infantile acne is less common. This occurs between the ages of 6 months and 1 year. Typical lesions include comedones or more inflammatory lesions. Benzoyl peroxide products and/or topical retinoids can be used to treat infantile acne if it is comedonal.

Acne that appears at age 1-7 years is very rare. Toddlers and children with this early childhood acne also should be evaluated further and/or referred to a specialist. A careful history and physical examination are warranted. Measure height and weight, and plot them on the growth chart. Also look for signs of virilization or precocious sexual development.

An abnormal blood pressure can point to congenital adrenal hyperplasia in the neonatal period. Rule out hyperandrogenism, particularly with severe or persistent infantile acne or sudden onset childhood acne. Refer patients to an endocrinologist if you are uncertain, or if any of the following screening tests are abnormal: bone age, serum DHEA (dehydroepiandrosterone), and free testosterone levels. (Total testosterone can be checked if the free testosterone test is unavailable.) Also consider serologic measures of follicle stimulating hormone, luteinizing hormone, prolactin, and 17 alpha-hydroxyprogesterone.

Performance of an exhaustive search for hyperandrogenism in your office is unnecessary in the majority of neonates, infants, children, and adolescents. It is important to know when these screening tests should be ordered and when to refer to a specialist for further evaluation and/or management.

Prepubertal or adolescent acne can occur earlier than parents might expect (at around 8 years of age), and can be the first sign of pubertal maturation. Distinguish comedonal from inflammatory acne to determine appropriate therapy.

Treatment with topical retinoids is the best for comedonal acne. Take the time to educate parents and the child on proper application of a topical retinoid. Instruct them to apply a pea-sized amount to dry skin every other night (or even every third night) for the first 2-4 weeks. This initial small dose can be titrated up gradually over time to minimize adverse effects. Improper use can lead to significant irritation and dryness, and contribute to the lack of treatment compliance.

As with any disease process, patient education is extremely important and can have a great impact on outcomes. Extensively counsel patients and parents on therapy options, and stress the importance of compliance with your recommended treatment regimen.

If the child has inflammatory acne lesions, a combination of benzoyl peroxide and topical antibiotic therapy (erythromycin or clindamycin) is more effective than either agent alone. With more severe acne, oral antibiotics may be warranted. Keep in mind that the tetracycline family of antibiotics can interfere with bone and teeth development, and is contraindicated in children younger than 8 years. Treatment with erythromycin or with Mutual Pharmaceutical’s Bactrim (a combination of sulfamethoxazole and trimethoprim) is appropriate for this age group. For older children with fully developed teeth, oral tetracycline, minocycline, and doxycycline are often the antibiotics of choice.

Infants, children, or adolescents with severe, recalcitrant, or scarring acne should be referred to a specialist for more aggressive intervention. For adolescents with nodulocystic acne (severe acne characterized by inflammation, nodular breakouts, and cysts), early intervention with systemic therapies, including isotretinoin, is important to prevent scarring. Also refer patients to dermatologic surgeons for further evaluation and management if their acne causes them psychological distress, whether or not their clinical presentation is severe.

Dr. Sikora is a private practice dermatologist in Chestnut Hill, Mass., and a member of many professional organizations, including the American Society for Dermatologic Surgery (www.ASDS.net) and the American Academy of Dermatology. Dr. Sikora said she had no relevant financial disclosures.

Hospitalists unfamiliar with palliative care might think that older patients are the ones generating higher costs per day and longer length of stay (LOS). But new research from a fellow hospitalist suggests that's not the case.

A report in this month's Journal of Hospital Medicine found that patients 65 years and older had a significantly lower cost per day ($811; P=0.02) and LOS (-1.8 days; P=0.003) for each decade increase in age (J Hosp Med. 2011;6(6):338-343). The data also show patients on surgical specialty services generate higher costs and higher LOS, a likely nod to the complexity of cases that land on those services, says University of Colorado Denver hospitalist Jean Youngwerth, MD.

"We were anticipating more from the start that patients who were older were going to have higher costs per day and LOS," says Dr. Youngwerth, who also serves as associate program director for the Colorado Palliative Medicine Fellowship and Director of the University of Colorado Hospital Palliative Care Consult Service. "A lot of times, it is younger patients who are the sickest of the sick.

"People will go full force on them and they won't necessarily have a lot of the conversations they'd be having with older patients. The assumption is 'They're young, they shouldn't be dying' … even though they're a very sick person."

Dr. Youngwerth says hospitalists working without the aid of institutional support can still make palliative-care discussions a priority.

"You don't need a specialist for that," she adds, "[for] sitting down and setting goals of care, learning about the person, and then making sure that we're matching what their goals and values are to their plan of care."

Hospitalists unfamiliar with palliative care might think that older patients are the ones generating higher costs per day and longer length of stay (LOS). But new research from a fellow hospitalist suggests that's not the case.

A report in this month's Journal of Hospital Medicine found that patients 65 years and older had a significantly lower cost per day ($811; P=0.02) and LOS (-1.8 days; P=0.003) for each decade increase in age (J Hosp Med. 2011;6(6):338-343). The data also show patients on surgical specialty services generate higher costs and higher LOS, a likely nod to the complexity of cases that land on those services, says University of Colorado Denver hospitalist Jean Youngwerth, MD.

"We were anticipating more from the start that patients who were older were going to have higher costs per day and LOS," says Dr. Youngwerth, who also serves as associate program director for the Colorado Palliative Medicine Fellowship and Director of the University of Colorado Hospital Palliative Care Consult Service. "A lot of times, it is younger patients who are the sickest of the sick.

"People will go full force on them and they won't necessarily have a lot of the conversations they'd be having with older patients. The assumption is 'They're young, they shouldn't be dying' … even though they're a very sick person."

Dr. Youngwerth says hospitalists working without the aid of institutional support can still make palliative-care discussions a priority.

"You don't need a specialist for that," she adds, "[for] sitting down and setting goals of care, learning about the person, and then making sure that we're matching what their goals and values are to their plan of care."

Hospitalists unfamiliar with palliative care might think that older patients are the ones generating higher costs per day and longer length of stay (LOS). But new research from a fellow hospitalist suggests that's not the case.

A report in this month's Journal of Hospital Medicine found that patients 65 years and older had a significantly lower cost per day ($811; P=0.02) and LOS (-1.8 days; P=0.003) for each decade increase in age (J Hosp Med. 2011;6(6):338-343). The data also show patients on surgical specialty services generate higher costs and higher LOS, a likely nod to the complexity of cases that land on those services, says University of Colorado Denver hospitalist Jean Youngwerth, MD.

"We were anticipating more from the start that patients who were older were going to have higher costs per day and LOS," says Dr. Youngwerth, who also serves as associate program director for the Colorado Palliative Medicine Fellowship and Director of the University of Colorado Hospital Palliative Care Consult Service. "A lot of times, it is younger patients who are the sickest of the sick.

"People will go full force on them and they won't necessarily have a lot of the conversations they'd be having with older patients. The assumption is 'They're young, they shouldn't be dying' … even though they're a very sick person."

Dr. Youngwerth says hospitalists working without the aid of institutional support can still make palliative-care discussions a priority.

"You don't need a specialist for that," she adds, "[for] sitting down and setting goals of care, learning about the person, and then making sure that we're matching what their goals and values are to their plan of care."