MDedge Pediatrics

I suspect that many of you have seen or read about a recent study regarding the “long COVID” enigma. The investigators surveyed the records of more than 4000 pediatric patients who had been infected and nearly 1400 who had not. The researchers then developed models in which 14 symptoms were more common in previous SARS-CoV2–infected individuals in all age groups, compared with the uninfected. There were four additional symptoms in children only and three additional symptoms in the adolescents.

Using these data, the investigators created research indices that “correlated with poor overall health and quality of life” and emphasized “neurocognitive, pain, and gastrointestinal symptoms in school-age children” and a “change or loss in smell or taste, pain, and fatigue/malaise-related symptoms in adolescents.”

So now thanks to these investigators we have research indices for characterizing PASC (post-acute sequelae of SARS-CoV-2, aka. long COVID). What should we to do with them? I’m not sure these results move us any further if our goal is finding something to help patients who believe, or have been told, that they have long COVID.

Even to a non-statistician like myself there appear to be some problems with this study. In an editorial accompanying this study, Suchitra Rao, MBBS, MSCS in the Department of Pediatrics, University of Colorado School of Medicine, Aurora, noted the study has the potential for ascertainment bias. For example, the researchers’ subject recruitment procedure resulted in a higher “proportion of neurocognitive/behavioral manifestations” may have skewed the results.

Also, some of the patient evaluations were not done at a consistent interval after the initial infection, which could result in recall bias. And, more importantly, because there were no baseline measurements to determine preinfection status, the investigators had no way of determining to what degree the patients’ underlying conditions may have reflected the quality of life scores.

Although I wouldn’t consider it a bias, I wonder if the investigators have a preconceived vision of what long COVID is going to look like once it is better understood. The fact that they undertook this project suggests that they believe the truth about the phenomenon will be discoverable using data based on collections of vague symptoms.

Or, do the researchers share my vision of long COVID that if it exists it will be something akin to the burst of Parkinson’s disease seen decades later in survivors of the 1918-1920 flu pandemic. Or, maybe it is something like post-polio syndrome, in which survivors in childhood develop atrophy and muscle weakness as they age. Do the researchers believe that COVID survivors are harboring some remnant of SARS-CoV-2 or its genome inside their bodies ticking like a time bomb ready to surface in the future? Think shingles.

I suspect that there are some folks who may or not share my ticking time bomb vision, but who, like me, wonder if there is really such a thing as long COVID – at least one in the form characterized by the work of these investigators. Unfortunately, the $1 billion the National Institutes of Health has invested in the Researching COVID to Enhance Recovery (RECOVER) initiative is not going to discover delayed sequelae until time is ready to tell us. What researchers are looking at now is a collection of patients, some who were not well to begin with but now describe a collection of vague symptoms, some of which are unique to COVID, but most are not. The loss of taste and smell being the one notable and important exception.

It is easy to understand why patients and their physicians would like to have a diagnosis like “long COVID” to at least validate their symptoms that up until now have eluded explanation or remedy. Not surprisingly, they may feel that, if researchers can’t find a cure, let’s at least have something we can lay the blame on.

A major flaw in this current attempt to characterize long COVID is the lack of a true control group. Yes, the subjects the researchers labeled as “uninfected” lived contemporaneously with the patients unfortunate enough to have acquired the virus. However, this illness was mysterious from its first appearance, continued to be more frightening as we struggled to learn more about it, and was clumsily managed in a way that turned our way of life upside down. This was particularly true for school-age children. It unmasked previously unsuspected underlying conditions and quickly acquired a poorly documented reputation for having a “long” variety.

Of course the “uninfected” also lived through these same tumultuous times. But knowing that you harbored, and may still harbor, this mysterious invader moves the infected and their families into a whole new level of concern and anxiety the rest of us who were more fortunate don’t share.

We must not ignore the fact that patients and their caregivers may receive some comfort when they have something to blame for their symptoms. However, we must shift our focus away from blame hunting, which up to this point has been fruitless. Instead, we must invest our energies into helping those struggling with long COVID find a manageable pathway toward improvement. Each patient should be treated as an individual and not part of a group with similar symptoms cobbled together with data acquired under a cloud of bias.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at [email protected].

I suspect that many of you have seen or read about a recent study regarding the “long COVID” enigma. The investigators surveyed the records of more than 4000 pediatric patients who had been infected and nearly 1400 who had not. The researchers then developed models in which 14 symptoms were more common in previous SARS-CoV2–infected individuals in all age groups, compared with the uninfected. There were four additional symptoms in children only and three additional symptoms in the adolescents.

Using these data, the investigators created research indices that “correlated with poor overall health and quality of life” and emphasized “neurocognitive, pain, and gastrointestinal symptoms in school-age children” and a “change or loss in smell or taste, pain, and fatigue/malaise-related symptoms in adolescents.”

So now thanks to these investigators we have research indices for characterizing PASC (post-acute sequelae of SARS-CoV-2, aka. long COVID). What should we to do with them? I’m not sure these results move us any further if our goal is finding something to help patients who believe, or have been told, that they have long COVID.

Even to a non-statistician like myself there appear to be some problems with this study. In an editorial accompanying this study, Suchitra Rao, MBBS, MSCS in the Department of Pediatrics, University of Colorado School of Medicine, Aurora, noted the study has the potential for ascertainment bias. For example, the researchers’ subject recruitment procedure resulted in a higher “proportion of neurocognitive/behavioral manifestations” may have skewed the results.

Also, some of the patient evaluations were not done at a consistent interval after the initial infection, which could result in recall bias. And, more importantly, because there were no baseline measurements to determine preinfection status, the investigators had no way of determining to what degree the patients’ underlying conditions may have reflected the quality of life scores.

Although I wouldn’t consider it a bias, I wonder if the investigators have a preconceived vision of what long COVID is going to look like once it is better understood. The fact that they undertook this project suggests that they believe the truth about the phenomenon will be discoverable using data based on collections of vague symptoms.

Or, do the researchers share my vision of long COVID that if it exists it will be something akin to the burst of Parkinson’s disease seen decades later in survivors of the 1918-1920 flu pandemic. Or, maybe it is something like post-polio syndrome, in which survivors in childhood develop atrophy and muscle weakness as they age. Do the researchers believe that COVID survivors are harboring some remnant of SARS-CoV-2 or its genome inside their bodies ticking like a time bomb ready to surface in the future? Think shingles.

I suspect that there are some folks who may or not share my ticking time bomb vision, but who, like me, wonder if there is really such a thing as long COVID – at least one in the form characterized by the work of these investigators. Unfortunately, the $1 billion the National Institutes of Health has invested in the Researching COVID to Enhance Recovery (RECOVER) initiative is not going to discover delayed sequelae until time is ready to tell us. What researchers are looking at now is a collection of patients, some who were not well to begin with but now describe a collection of vague symptoms, some of which are unique to COVID, but most are not. The loss of taste and smell being the one notable and important exception.

It is easy to understand why patients and their physicians would like to have a diagnosis like “long COVID” to at least validate their symptoms that up until now have eluded explanation or remedy. Not surprisingly, they may feel that, if researchers can’t find a cure, let’s at least have something we can lay the blame on.

A major flaw in this current attempt to characterize long COVID is the lack of a true control group. Yes, the subjects the researchers labeled as “uninfected” lived contemporaneously with the patients unfortunate enough to have acquired the virus. However, this illness was mysterious from its first appearance, continued to be more frightening as we struggled to learn more about it, and was clumsily managed in a way that turned our way of life upside down. This was particularly true for school-age children. It unmasked previously unsuspected underlying conditions and quickly acquired a poorly documented reputation for having a “long” variety.

Of course the “uninfected” also lived through these same tumultuous times. But knowing that you harbored, and may still harbor, this mysterious invader moves the infected and their families into a whole new level of concern and anxiety the rest of us who were more fortunate don’t share.

We must not ignore the fact that patients and their caregivers may receive some comfort when they have something to blame for their symptoms. However, we must shift our focus away from blame hunting, which up to this point has been fruitless. Instead, we must invest our energies into helping those struggling with long COVID find a manageable pathway toward improvement. Each patient should be treated as an individual and not part of a group with similar symptoms cobbled together with data acquired under a cloud of bias.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at [email protected].

I suspect that many of you have seen or read about a recent study regarding the “long COVID” enigma. The investigators surveyed the records of more than 4000 pediatric patients who had been infected and nearly 1400 who had not. The researchers then developed models in which 14 symptoms were more common in previous SARS-CoV2–infected individuals in all age groups, compared with the uninfected. There were four additional symptoms in children only and three additional symptoms in the adolescents.

Using these data, the investigators created research indices that “correlated with poor overall health and quality of life” and emphasized “neurocognitive, pain, and gastrointestinal symptoms in school-age children” and a “change or loss in smell or taste, pain, and fatigue/malaise-related symptoms in adolescents.”

So now thanks to these investigators we have research indices for characterizing PASC (post-acute sequelae of SARS-CoV-2, aka. long COVID). What should we to do with them? I’m not sure these results move us any further if our goal is finding something to help patients who believe, or have been told, that they have long COVID.

Even to a non-statistician like myself there appear to be some problems with this study. In an editorial accompanying this study, Suchitra Rao, MBBS, MSCS in the Department of Pediatrics, University of Colorado School of Medicine, Aurora, noted the study has the potential for ascertainment bias. For example, the researchers’ subject recruitment procedure resulted in a higher “proportion of neurocognitive/behavioral manifestations” may have skewed the results.

Also, some of the patient evaluations were not done at a consistent interval after the initial infection, which could result in recall bias. And, more importantly, because there were no baseline measurements to determine preinfection status, the investigators had no way of determining to what degree the patients’ underlying conditions may have reflected the quality of life scores.

Although I wouldn’t consider it a bias, I wonder if the investigators have a preconceived vision of what long COVID is going to look like once it is better understood. The fact that they undertook this project suggests that they believe the truth about the phenomenon will be discoverable using data based on collections of vague symptoms.

Or, do the researchers share my vision of long COVID that if it exists it will be something akin to the burst of Parkinson’s disease seen decades later in survivors of the 1918-1920 flu pandemic. Or, maybe it is something like post-polio syndrome, in which survivors in childhood develop atrophy and muscle weakness as they age. Do the researchers believe that COVID survivors are harboring some remnant of SARS-CoV-2 or its genome inside their bodies ticking like a time bomb ready to surface in the future? Think shingles.

I suspect that there are some folks who may or not share my ticking time bomb vision, but who, like me, wonder if there is really such a thing as long COVID – at least one in the form characterized by the work of these investigators. Unfortunately, the $1 billion the National Institutes of Health has invested in the Researching COVID to Enhance Recovery (RECOVER) initiative is not going to discover delayed sequelae until time is ready to tell us. What researchers are looking at now is a collection of patients, some who were not well to begin with but now describe a collection of vague symptoms, some of which are unique to COVID, but most are not. The loss of taste and smell being the one notable and important exception.

It is easy to understand why patients and their physicians would like to have a diagnosis like “long COVID” to at least validate their symptoms that up until now have eluded explanation or remedy. Not surprisingly, they may feel that, if researchers can’t find a cure, let’s at least have something we can lay the blame on.

A major flaw in this current attempt to characterize long COVID is the lack of a true control group. Yes, the subjects the researchers labeled as “uninfected” lived contemporaneously with the patients unfortunate enough to have acquired the virus. However, this illness was mysterious from its first appearance, continued to be more frightening as we struggled to learn more about it, and was clumsily managed in a way that turned our way of life upside down. This was particularly true for school-age children. It unmasked previously unsuspected underlying conditions and quickly acquired a poorly documented reputation for having a “long” variety.

Of course the “uninfected” also lived through these same tumultuous times. But knowing that you harbored, and may still harbor, this mysterious invader moves the infected and their families into a whole new level of concern and anxiety the rest of us who were more fortunate don’t share.

We must not ignore the fact that patients and their caregivers may receive some comfort when they have something to blame for their symptoms. However, we must shift our focus away from blame hunting, which up to this point has been fruitless. Instead, we must invest our energies into helping those struggling with long COVID find a manageable pathway toward improvement. Each patient should be treated as an individual and not part of a group with similar symptoms cobbled together with data acquired under a cloud of bias.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at [email protected].

Our son works for a Maine-based company that produces and sells clothing and outdoor recreation equipment. One of its tag lines is “Be an Outsider.” In his role as chief marketing officer, he was recently given an app for his phone that can calculate how many minutes he spends outside each day. He assured me: “Dad, you don’t need one of these on your phone. Your weather-beaten skin says you are already logging in way more than enough minutes outdoors.”

But, it got me thinking about several avenues of research where an app like that would be useful. As luck would have it, the following week I stumbled across a paper describing just such a study.

Researchers in Shanghai, China, placed smartwatches with technology similar to my son’s phone on nearly 3000 children and found “that outdoor exposure patterns characterized by a continuous period of at least 15 minutes, accompanied by a sunlight intensity of more than 2000 lux, were associated with less myopic shift.” In other words, children getting more time outside were less likely to become nearsighted.” Whether this was an effect of being outside instead of staring at a screen indoors is an interesting question.

I have alway suspected that being outdoors was important for wellness and this paper meshed nicely with an article I had recently read in The Washington Post titled, “How time in nature builds happier, healthier and more social children” (Jamie Friedlander Serrano, 2024 Aug 4). The reporter quotes numerous experts in child health and includes links to several articles that tout the benefits of outdoor experiences, particularly ones in a natural environment. There are the vitamin D effects on growth and bone health. There are studies suggesting that being out in nature can reduce stress, anxiety, and aggression, and improve working memory and attention.

In this country there is a small but growing group of schools modeling themselves after the “Forest kindergartens” that have become popular in Europe in which a large portion of the students’ days are spent outside surrounded by nature. It will be interesting to see how robustly this trend grows here in the United States. However, in a nation like ours in which the Environmental Protection Agency estimates that the average American spends 90% of his day indoors, it’s going to require a seismic shift in our societal norms.

I think my mother always knew that being outdoors was healthy for children. I also suspect that she and most my friends’ mothers were primarily motivated by a desire to have the house to themselves. This was primarily to allow them to get the housework done unimpeded by pestering children. But, there may have been times when a busy housewife simply needed to sit down with a book in the peace and quiet of a childless environment. We kids were told to get out of the house and return for lunch and dinner, hopefully not in the tow of a police officer. There were few rules and for the most part we were left to invent our own amusement.

Yes, you’ve heard this old-fogey legend before. But it was true. Those were the halcyon days of the 1950s in a small suburban town of 5000 of a little more than 1 square mile with its own swimming pool. My particular idyll was aptly named Pleasantville but I know we were not alone as the only community where children were allowed – or let’s say “encouraged” – to be outdoors if they weren’t in school. It was a different time.

I am not so naive to believe that we will ever return to those good old days when children roamed free, but it is worth considering what has changed to drive children inside and away from all the health benefits of being outdoors. Is there anything we can do to reverse this unfortunate trend?

First, we must first face up to the reality that our society has become so focused on the potential downsides of everything that we seem to be driven primarily by risk avoidance. We hear how things can go terribly wrong in the world outside, a world we can’t control. Although the data from the pandemic don’t support it, more of us believe children are safer indoors. Parents in particular seem to worry more now than they did 75 years ago. I don’t think we can point to a single event such as the tragedies of September 11 to explain the shift.

While bad news has always traveled fast, today (with communication being almost instantaneous) a story about a child abduction at 6 in the morning in Nevada can be on my local TV channel by lunchtime here in Maine. Parents worry that if bad stuff can happen to a child in Mount Elsewhere, it could happen to my child playing in the backyard across the street.

I think we pediatricians should consider how large a role we may be playing in driving parental anxiety with our frequent warnings about the dangers a child can encounter outdoors whether they come in the form of accidents or exposure to the elements.

While parents have grown more hesitant to send their children outside to play, as a society we have failed to adequately acknowledge and respond to the role that unhealthy attraction of indoor alternatives to outdoor play may be contributing to indoorism. Here we’re talking about television, smartphones, and the internet.

So, what can we do as pediatricians to get our patients outside? First, we can set an example and cover our office walls with pictures of ourselves and our families enjoying the outdoors. We can be vocal advocates for creating and maintaining accessible outdoor spaces in our community. We can advocate for more outside time during recess in school and encourage the school officials to consider having more courses taught outside.

We can be more diligent in asking families about their screen use and not be afraid to express our concern when we hear how little outdoor time their child is getting. Finally, we can strive for more balance in our messaging. For example for every warning we give about playing outside on poor air quality days there should be a reminder of the health benefits of being outdoors on the other days. Every message about the importance of sunscreen should be preceded by a few sentences promoting outdoor activities in wooded environments where sun exposure is less of a concern.

We should all be looking for ways in which our communities can remove the barriers that prevent our patients for reaping the health benefits of being outdoors. Being an outsider is just as important as getting enough sleep, eating the right food and staying physically active.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at [email protected].

Our son works for a Maine-based company that produces and sells clothing and outdoor recreation equipment. One of its tag lines is “Be an Outsider.” In his role as chief marketing officer, he was recently given an app for his phone that can calculate how many minutes he spends outside each day. He assured me: “Dad, you don’t need one of these on your phone. Your weather-beaten skin says you are already logging in way more than enough minutes outdoors.”

But, it got me thinking about several avenues of research where an app like that would be useful. As luck would have it, the following week I stumbled across a paper describing just such a study.

Researchers in Shanghai, China, placed smartwatches with technology similar to my son’s phone on nearly 3000 children and found “that outdoor exposure patterns characterized by a continuous period of at least 15 minutes, accompanied by a sunlight intensity of more than 2000 lux, were associated with less myopic shift.” In other words, children getting more time outside were less likely to become nearsighted.” Whether this was an effect of being outside instead of staring at a screen indoors is an interesting question.

I have alway suspected that being outdoors was important for wellness and this paper meshed nicely with an article I had recently read in The Washington Post titled, “How time in nature builds happier, healthier and more social children” (Jamie Friedlander Serrano, 2024 Aug 4). The reporter quotes numerous experts in child health and includes links to several articles that tout the benefits of outdoor experiences, particularly ones in a natural environment. There are the vitamin D effects on growth and bone health. There are studies suggesting that being out in nature can reduce stress, anxiety, and aggression, and improve working memory and attention.

In this country there is a small but growing group of schools modeling themselves after the “Forest kindergartens” that have become popular in Europe in which a large portion of the students’ days are spent outside surrounded by nature. It will be interesting to see how robustly this trend grows here in the United States. However, in a nation like ours in which the Environmental Protection Agency estimates that the average American spends 90% of his day indoors, it’s going to require a seismic shift in our societal norms.

I think my mother always knew that being outdoors was healthy for children. I also suspect that she and most my friends’ mothers were primarily motivated by a desire to have the house to themselves. This was primarily to allow them to get the housework done unimpeded by pestering children. But, there may have been times when a busy housewife simply needed to sit down with a book in the peace and quiet of a childless environment. We kids were told to get out of the house and return for lunch and dinner, hopefully not in the tow of a police officer. There were few rules and for the most part we were left to invent our own amusement.

Yes, you’ve heard this old-fogey legend before. But it was true. Those were the halcyon days of the 1950s in a small suburban town of 5000 of a little more than 1 square mile with its own swimming pool. My particular idyll was aptly named Pleasantville but I know we were not alone as the only community where children were allowed – or let’s say “encouraged” – to be outdoors if they weren’t in school. It was a different time.

I am not so naive to believe that we will ever return to those good old days when children roamed free, but it is worth considering what has changed to drive children inside and away from all the health benefits of being outdoors. Is there anything we can do to reverse this unfortunate trend?

First, we must first face up to the reality that our society has become so focused on the potential downsides of everything that we seem to be driven primarily by risk avoidance. We hear how things can go terribly wrong in the world outside, a world we can’t control. Although the data from the pandemic don’t support it, more of us believe children are safer indoors. Parents in particular seem to worry more now than they did 75 years ago. I don’t think we can point to a single event such as the tragedies of September 11 to explain the shift.

While bad news has always traveled fast, today (with communication being almost instantaneous) a story about a child abduction at 6 in the morning in Nevada can be on my local TV channel by lunchtime here in Maine. Parents worry that if bad stuff can happen to a child in Mount Elsewhere, it could happen to my child playing in the backyard across the street.

I think we pediatricians should consider how large a role we may be playing in driving parental anxiety with our frequent warnings about the dangers a child can encounter outdoors whether they come in the form of accidents or exposure to the elements.

While parents have grown more hesitant to send their children outside to play, as a society we have failed to adequately acknowledge and respond to the role that unhealthy attraction of indoor alternatives to outdoor play may be contributing to indoorism. Here we’re talking about television, smartphones, and the internet.

So, what can we do as pediatricians to get our patients outside? First, we can set an example and cover our office walls with pictures of ourselves and our families enjoying the outdoors. We can be vocal advocates for creating and maintaining accessible outdoor spaces in our community. We can advocate for more outside time during recess in school and encourage the school officials to consider having more courses taught outside.

We can be more diligent in asking families about their screen use and not be afraid to express our concern when we hear how little outdoor time their child is getting. Finally, we can strive for more balance in our messaging. For example for every warning we give about playing outside on poor air quality days there should be a reminder of the health benefits of being outdoors on the other days. Every message about the importance of sunscreen should be preceded by a few sentences promoting outdoor activities in wooded environments where sun exposure is less of a concern.

We should all be looking for ways in which our communities can remove the barriers that prevent our patients for reaping the health benefits of being outdoors. Being an outsider is just as important as getting enough sleep, eating the right food and staying physically active.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at [email protected].

Our son works for a Maine-based company that produces and sells clothing and outdoor recreation equipment. One of its tag lines is “Be an Outsider.” In his role as chief marketing officer, he was recently given an app for his phone that can calculate how many minutes he spends outside each day. He assured me: “Dad, you don’t need one of these on your phone. Your weather-beaten skin says you are already logging in way more than enough minutes outdoors.”

But, it got me thinking about several avenues of research where an app like that would be useful. As luck would have it, the following week I stumbled across a paper describing just such a study.

Researchers in Shanghai, China, placed smartwatches with technology similar to my son’s phone on nearly 3000 children and found “that outdoor exposure patterns characterized by a continuous period of at least 15 minutes, accompanied by a sunlight intensity of more than 2000 lux, were associated with less myopic shift.” In other words, children getting more time outside were less likely to become nearsighted.” Whether this was an effect of being outside instead of staring at a screen indoors is an interesting question.

I have alway suspected that being outdoors was important for wellness and this paper meshed nicely with an article I had recently read in The Washington Post titled, “How time in nature builds happier, healthier and more social children” (Jamie Friedlander Serrano, 2024 Aug 4). The reporter quotes numerous experts in child health and includes links to several articles that tout the benefits of outdoor experiences, particularly ones in a natural environment. There are the vitamin D effects on growth and bone health. There are studies suggesting that being out in nature can reduce stress, anxiety, and aggression, and improve working memory and attention.

In this country there is a small but growing group of schools modeling themselves after the “Forest kindergartens” that have become popular in Europe in which a large portion of the students’ days are spent outside surrounded by nature. It will be interesting to see how robustly this trend grows here in the United States. However, in a nation like ours in which the Environmental Protection Agency estimates that the average American spends 90% of his day indoors, it’s going to require a seismic shift in our societal norms.

I think my mother always knew that being outdoors was healthy for children. I also suspect that she and most my friends’ mothers were primarily motivated by a desire to have the house to themselves. This was primarily to allow them to get the housework done unimpeded by pestering children. But, there may have been times when a busy housewife simply needed to sit down with a book in the peace and quiet of a childless environment. We kids were told to get out of the house and return for lunch and dinner, hopefully not in the tow of a police officer. There were few rules and for the most part we were left to invent our own amusement.

Yes, you’ve heard this old-fogey legend before. But it was true. Those were the halcyon days of the 1950s in a small suburban town of 5000 of a little more than 1 square mile with its own swimming pool. My particular idyll was aptly named Pleasantville but I know we were not alone as the only community where children were allowed – or let’s say “encouraged” – to be outdoors if they weren’t in school. It was a different time.

I am not so naive to believe that we will ever return to those good old days when children roamed free, but it is worth considering what has changed to drive children inside and away from all the health benefits of being outdoors. Is there anything we can do to reverse this unfortunate trend?

First, we must first face up to the reality that our society has become so focused on the potential downsides of everything that we seem to be driven primarily by risk avoidance. We hear how things can go terribly wrong in the world outside, a world we can’t control. Although the data from the pandemic don’t support it, more of us believe children are safer indoors. Parents in particular seem to worry more now than they did 75 years ago. I don’t think we can point to a single event such as the tragedies of September 11 to explain the shift.

While bad news has always traveled fast, today (with communication being almost instantaneous) a story about a child abduction at 6 in the morning in Nevada can be on my local TV channel by lunchtime here in Maine. Parents worry that if bad stuff can happen to a child in Mount Elsewhere, it could happen to my child playing in the backyard across the street.

I think we pediatricians should consider how large a role we may be playing in driving parental anxiety with our frequent warnings about the dangers a child can encounter outdoors whether they come in the form of accidents or exposure to the elements.

While parents have grown more hesitant to send their children outside to play, as a society we have failed to adequately acknowledge and respond to the role that unhealthy attraction of indoor alternatives to outdoor play may be contributing to indoorism. Here we’re talking about television, smartphones, and the internet.

So, what can we do as pediatricians to get our patients outside? First, we can set an example and cover our office walls with pictures of ourselves and our families enjoying the outdoors. We can be vocal advocates for creating and maintaining accessible outdoor spaces in our community. We can advocate for more outside time during recess in school and encourage the school officials to consider having more courses taught outside.

We can be more diligent in asking families about their screen use and not be afraid to express our concern when we hear how little outdoor time their child is getting. Finally, we can strive for more balance in our messaging. For example for every warning we give about playing outside on poor air quality days there should be a reminder of the health benefits of being outdoors on the other days. Every message about the importance of sunscreen should be preceded by a few sentences promoting outdoor activities in wooded environments where sun exposure is less of a concern.

We should all be looking for ways in which our communities can remove the barriers that prevent our patients for reaping the health benefits of being outdoors. Being an outsider is just as important as getting enough sleep, eating the right food and staying physically active.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at [email protected].

CARLSBAD, CALIFORNIA — Posting on social media may not be your cup of tea, but in the opinion of Jessica G. Labadie, MD, avoiding a presence on platforms like Facebook, X, Instagram, or YouTube means missing an opportunity to educate patients about dermatologic procedures and to dispel misinformation from nonmedical influencers.

“Over the past 2 decades, there has been a surge in social media use,” Dr. Labadie, a dermatologist who practices in Chestnut Hill, Massachusetts, said at the Controversies & Conversations in Laser & Cosmetic Surgery symposium. “Most of our patients use social media to find their doctors, and it plays a role in how our patients form their decision about whether to have a cosmetic procedure or not. Doctors, especially dermatologists, continue to actively participate in this ‘skinfluencer’ trend.”

courtesy Dr. Jessica G. Labadie

According to a review of social media’s impact on aesthetic medicine, use of social media by American adults increased from 5% in 2005 to 72% in 2020, and 77% of patients search for a physician online. The review’s authors cited YouTube as the most popular platform among adults and noted that social media ranks as the sixth top factor for a patient deciding whether to have a laser procedure.

Dr. Labadie, who is also an assistant professor of dermatology at the Icahn School of Medicine at Mount Sinai in New York City, said several factors should be considered when establishing and maintaining a social media presence, starting with personal ones. “Your followers are not your patients yet, and just because you may have thousands of followers does not necessarily mean that you’re busier in the clinic,” she said. “Be careful if you combine professional and personal accounts; be careful of those parasocial relationships that can form. Your followers tend to learn a lot about you. Posting can take a lot of time; it can take away from your clinical duties. Do you want to make your account private or public? There are pros and cons to both.”

Ethics also play a role. “Be transparent in your disclosure forms, especially if you’re posting ‘before’ and ‘after’ images of patients,” advised Dr. Labadie, who described herself as a social media minimalist. “Stay true to yourself in your posts, and always prioritize safety over posting.”

Don’t forget legal obligations. “Social media can facilitate a passive income, but make sure this isn’t impacting any conflicts of interest, and make sure that you meticulously follow any Health Insurance Portability and Accountability Act regulations,” she said. She also cautioned against violating intellectual property rights and making false claims about a product or procedure.

Deciding which platforms to use and what voice or tone to adopt requires some soul-searching. “What is your brand?” Dr. Labadie asked. “How do you want to portray yourself? Does your social media brand match your office brand? Does it match who you are as a provider and the type of patient you wish to attract? Would you prefer to have one collective social media presence as an office or multiple provider accounts?”

Being mindful of how your patients perceive and use social media in relation to their dermatologic concerns is also important. “What are your patients viewing on social media, and how is it affecting their decisions?” Dr. Labadie asked. “Are they coming in asking for something that is not right for what they need? At the end of the day, you are their doctor, and it’s your duty to treat the patients and not the trend.”

She encouraged dermatologists to “aim for high value and accurate posts coupled with high popularity and reach.” She added that “this is really the future of getting our research out there to the public. Academic notoriety is not enough. Our professional societies and skinfluencer colleagues need to get involved to help promote our expert research.”

Dr. Labadie reported having no financial disclosures.

A version of this article appeared on Medscape.com.

CARLSBAD, CALIFORNIA — Posting on social media may not be your cup of tea, but in the opinion of Jessica G. Labadie, MD, avoiding a presence on platforms like Facebook, X, Instagram, or YouTube means missing an opportunity to educate patients about dermatologic procedures and to dispel misinformation from nonmedical influencers.

“Over the past 2 decades, there has been a surge in social media use,” Dr. Labadie, a dermatologist who practices in Chestnut Hill, Massachusetts, said at the Controversies & Conversations in Laser & Cosmetic Surgery symposium. “Most of our patients use social media to find their doctors, and it plays a role in how our patients form their decision about whether to have a cosmetic procedure or not. Doctors, especially dermatologists, continue to actively participate in this ‘skinfluencer’ trend.”

courtesy Dr. Jessica G. Labadie

According to a review of social media’s impact on aesthetic medicine, use of social media by American adults increased from 5% in 2005 to 72% in 2020, and 77% of patients search for a physician online. The review’s authors cited YouTube as the most popular platform among adults and noted that social media ranks as the sixth top factor for a patient deciding whether to have a laser procedure.

Dr. Labadie, who is also an assistant professor of dermatology at the Icahn School of Medicine at Mount Sinai in New York City, said several factors should be considered when establishing and maintaining a social media presence, starting with personal ones. “Your followers are not your patients yet, and just because you may have thousands of followers does not necessarily mean that you’re busier in the clinic,” she said. “Be careful if you combine professional and personal accounts; be careful of those parasocial relationships that can form. Your followers tend to learn a lot about you. Posting can take a lot of time; it can take away from your clinical duties. Do you want to make your account private or public? There are pros and cons to both.”

Ethics also play a role. “Be transparent in your disclosure forms, especially if you’re posting ‘before’ and ‘after’ images of patients,” advised Dr. Labadie, who described herself as a social media minimalist. “Stay true to yourself in your posts, and always prioritize safety over posting.”

Don’t forget legal obligations. “Social media can facilitate a passive income, but make sure this isn’t impacting any conflicts of interest, and make sure that you meticulously follow any Health Insurance Portability and Accountability Act regulations,” she said. She also cautioned against violating intellectual property rights and making false claims about a product or procedure.

Deciding which platforms to use and what voice or tone to adopt requires some soul-searching. “What is your brand?” Dr. Labadie asked. “How do you want to portray yourself? Does your social media brand match your office brand? Does it match who you are as a provider and the type of patient you wish to attract? Would you prefer to have one collective social media presence as an office or multiple provider accounts?”

Being mindful of how your patients perceive and use social media in relation to their dermatologic concerns is also important. “What are your patients viewing on social media, and how is it affecting their decisions?” Dr. Labadie asked. “Are they coming in asking for something that is not right for what they need? At the end of the day, you are their doctor, and it’s your duty to treat the patients and not the trend.”

She encouraged dermatologists to “aim for high value and accurate posts coupled with high popularity and reach.” She added that “this is really the future of getting our research out there to the public. Academic notoriety is not enough. Our professional societies and skinfluencer colleagues need to get involved to help promote our expert research.”

Dr. Labadie reported having no financial disclosures.

A version of this article appeared on Medscape.com.

CARLSBAD, CALIFORNIA — Posting on social media may not be your cup of tea, but in the opinion of Jessica G. Labadie, MD, avoiding a presence on platforms like Facebook, X, Instagram, or YouTube means missing an opportunity to educate patients about dermatologic procedures and to dispel misinformation from nonmedical influencers.

“Over the past 2 decades, there has been a surge in social media use,” Dr. Labadie, a dermatologist who practices in Chestnut Hill, Massachusetts, said at the Controversies & Conversations in Laser & Cosmetic Surgery symposium. “Most of our patients use social media to find their doctors, and it plays a role in how our patients form their decision about whether to have a cosmetic procedure or not. Doctors, especially dermatologists, continue to actively participate in this ‘skinfluencer’ trend.”

courtesy Dr. Jessica G. Labadie

According to a review of social media’s impact on aesthetic medicine, use of social media by American adults increased from 5% in 2005 to 72% in 2020, and 77% of patients search for a physician online. The review’s authors cited YouTube as the most popular platform among adults and noted that social media ranks as the sixth top factor for a patient deciding whether to have a laser procedure.

Dr. Labadie, who is also an assistant professor of dermatology at the Icahn School of Medicine at Mount Sinai in New York City, said several factors should be considered when establishing and maintaining a social media presence, starting with personal ones. “Your followers are not your patients yet, and just because you may have thousands of followers does not necessarily mean that you’re busier in the clinic,” she said. “Be careful if you combine professional and personal accounts; be careful of those parasocial relationships that can form. Your followers tend to learn a lot about you. Posting can take a lot of time; it can take away from your clinical duties. Do you want to make your account private or public? There are pros and cons to both.”

Ethics also play a role. “Be transparent in your disclosure forms, especially if you’re posting ‘before’ and ‘after’ images of patients,” advised Dr. Labadie, who described herself as a social media minimalist. “Stay true to yourself in your posts, and always prioritize safety over posting.”

Don’t forget legal obligations. “Social media can facilitate a passive income, but make sure this isn’t impacting any conflicts of interest, and make sure that you meticulously follow any Health Insurance Portability and Accountability Act regulations,” she said. She also cautioned against violating intellectual property rights and making false claims about a product or procedure.

Deciding which platforms to use and what voice or tone to adopt requires some soul-searching. “What is your brand?” Dr. Labadie asked. “How do you want to portray yourself? Does your social media brand match your office brand? Does it match who you are as a provider and the type of patient you wish to attract? Would you prefer to have one collective social media presence as an office or multiple provider accounts?”

Being mindful of how your patients perceive and use social media in relation to their dermatologic concerns is also important. “What are your patients viewing on social media, and how is it affecting their decisions?” Dr. Labadie asked. “Are they coming in asking for something that is not right for what they need? At the end of the day, you are their doctor, and it’s your duty to treat the patients and not the trend.”

She encouraged dermatologists to “aim for high value and accurate posts coupled with high popularity and reach.” She added that “this is really the future of getting our research out there to the public. Academic notoriety is not enough. Our professional societies and skinfluencer colleagues need to get involved to help promote our expert research.”

Dr. Labadie reported having no financial disclosures.

A version of this article appeared on Medscape.com.

A surprising new report by the Mercer consulting firm projects that the American healthcare workforce will face a small shortfall in 2028 — a shortage of less than 1% of all employees. The report even projects a surplus of tens of thousands of registered nurses and home health aides — and even a small surplus of physicians in some states.

Mercer’s projections are rosier than federal workforce projections, which paint a grimmer picture of impending shortages.

“The labor market is a little more stabilized right now, and most healthcare systems are seeing less turnover,” Dan Lezotte, PhD, a partner with Mercer, said in an interview. But he noted “critical shortages” are still expected in some areas.

Mercer last projected workforce numbers in a 2020-2021 report released during the height of the COVID-19 pandemic. Now, “the labor market is drastically different,” Dr. Lezotte said. Health workforce shortages and surpluses have long varied significantly by region across the country.

The report forecasts a small surplus of physicians in 2028 but not in states such as California, New York, and Texas. The upper Midwest states will largely see doctor surpluses while Southern states face shortages. Some states with general physician surpluses may still experience shortages of specialists.

A surplus of nearly 30,000 registered nurses is expected, but New York, New Jersey, and Connecticut are projected to have a combined shortage of 16,000 nurses.

Overall, the report projects a shortage of more than 100,000 healthcare workers nationally by 2028. That’s less than 1% of the entire healthcare workforce of 18.6 million expected by then.

The report also predicts a shortage of nurse practitioners, especially in California and New York, and a shortage of 73,000 nursing assistants, especially in California, New York, and Texas.

“Healthcare systems are having the most difficulty hiring and hanging on to those workers who are supposed to take up the load off physicians and nurses,” Dr. Lezotte said. “They’re competing not only with other healthcare systems but with other industries like Amazon warehouses or McDonald’s in California paying $20 an hour. Healthcare was a little slow to keep up with that. In a lot of healthcare systems, that’s their biggest headache right now.”

On the other hand, the report projects a national surplus of 48,000 home health/personal care aides.

That surprised Bianca K. Frogner, PhD, director of the Center for Health Workforce Studies at the University of Washington, Seattle.

“We are seeing increasing movement of investments toward moving patients out of skilled nursing facilities and keeping them in the home and community, which requires many more home health aides,” Dr. Frogner said. “Given such high turnover in this occupation, it’s hard to know if the surplus is really a surplus or if they will quickly be employed.”

Dr. Frogner receives grants and contracts from not-for-profit entities to investigate issues related to the health workforce.

Dr. Lezotte said the report’s findings are based on data from sources such as public and private databases and job postings. According to the report, “projections were made up to 2028 based on historical data up to 2023,” and “supply projections were derived using a linear autoregressive model based on historical supply within each occupation and geography.”

It’s not clear why some states like New York are expected to have huge shortages, but migration might be a factor, along with a lack of nearby nursing schools, Dr. Lezotte said.

As for shortages, Dr. Lezotte said healthcare systems will have to understand their local workforce situation and adapt. “They’ll need to be more proactive about their employee value proposition” via competitive pay and benefits Flexibility regarding scheduling is also important.

“They’re going to have to figure out how to up their game,” he said.

What about states with surpluses? They might be target-rich environments for states facing shortages, he said.
 

Positive Outlook Not Shared by Other Researchers

Other workforce projections conflict with Mercer’s, according to Jean Moore, DrPH, and Gaetano Forte, MS, director and assistant director of the Center for Health Workforce Studies, School of Public Health, University at Albany, New York.

The National Center for Health Workforce Analysis projects a 10% shortage of registered nurses and a 13% shortage of physicians in 2031. The agency didn’t make projections for home health aides because that workforce is in flux.

Why are Mercer’s projections so different? Dr. Lezotte said other projections assume that equity efforts will bring healthcare to everyone who needs it. The report assumes this won’t happen, he said. As a result, it expects there will be fewer patients who need to be served by workers.

Other projections expect a shortage of 300,000 registered nurses by 2035, Mr. Forte said. But the number of nurse practitioners in New York is growing quickly, Dr. Moore said.

Dr. Moore said it’s difficult to interpret Mercer’s findings because the company doesn’t provide enough information about its methodology.

“At some level, it’s not particularly useful regarding what the next steps are,” she said. “Projections should make you think about what you should do to change and improve, to create more of what you need.”

The Center for Health Workforce Studies at the University of Albany has provided consulting services to multiple companies that provide healthcare workforce projections. It has no relationship with Mercer.

A version of this article first appeared on Medscape.com.

A surprising new report by the Mercer consulting firm projects that the American healthcare workforce will face a small shortfall in 2028 — a shortage of less than 1% of all employees. The report even projects a surplus of tens of thousands of registered nurses and home health aides — and even a small surplus of physicians in some states.

Mercer’s projections are rosier than federal workforce projections, which paint a grimmer picture of impending shortages.

“The labor market is a little more stabilized right now, and most healthcare systems are seeing less turnover,” Dan Lezotte, PhD, a partner with Mercer, said in an interview. But he noted “critical shortages” are still expected in some areas.

Mercer last projected workforce numbers in a 2020-2021 report released during the height of the COVID-19 pandemic. Now, “the labor market is drastically different,” Dr. Lezotte said. Health workforce shortages and surpluses have long varied significantly by region across the country.

The report forecasts a small surplus of physicians in 2028 but not in states such as California, New York, and Texas. The upper Midwest states will largely see doctor surpluses while Southern states face shortages. Some states with general physician surpluses may still experience shortages of specialists.

A surplus of nearly 30,000 registered nurses is expected, but New York, New Jersey, and Connecticut are projected to have a combined shortage of 16,000 nurses.

Overall, the report projects a shortage of more than 100,000 healthcare workers nationally by 2028. That’s less than 1% of the entire healthcare workforce of 18.6 million expected by then.

The report also predicts a shortage of nurse practitioners, especially in California and New York, and a shortage of 73,000 nursing assistants, especially in California, New York, and Texas.

“Healthcare systems are having the most difficulty hiring and hanging on to those workers who are supposed to take up the load off physicians and nurses,” Dr. Lezotte said. “They’re competing not only with other healthcare systems but with other industries like Amazon warehouses or McDonald’s in California paying $20 an hour. Healthcare was a little slow to keep up with that. In a lot of healthcare systems, that’s their biggest headache right now.”

On the other hand, the report projects a national surplus of 48,000 home health/personal care aides.

That surprised Bianca K. Frogner, PhD, director of the Center for Health Workforce Studies at the University of Washington, Seattle.

“We are seeing increasing movement of investments toward moving patients out of skilled nursing facilities and keeping them in the home and community, which requires many more home health aides,” Dr. Frogner said. “Given such high turnover in this occupation, it’s hard to know if the surplus is really a surplus or if they will quickly be employed.”

Dr. Frogner receives grants and contracts from not-for-profit entities to investigate issues related to the health workforce.

Dr. Lezotte said the report’s findings are based on data from sources such as public and private databases and job postings. According to the report, “projections were made up to 2028 based on historical data up to 2023,” and “supply projections were derived using a linear autoregressive model based on historical supply within each occupation and geography.”

It’s not clear why some states like New York are expected to have huge shortages, but migration might be a factor, along with a lack of nearby nursing schools, Dr. Lezotte said.

As for shortages, Dr. Lezotte said healthcare systems will have to understand their local workforce situation and adapt. “They’ll need to be more proactive about their employee value proposition” via competitive pay and benefits Flexibility regarding scheduling is also important.

“They’re going to have to figure out how to up their game,” he said.

What about states with surpluses? They might be target-rich environments for states facing shortages, he said.
 

Positive Outlook Not Shared by Other Researchers

Other workforce projections conflict with Mercer’s, according to Jean Moore, DrPH, and Gaetano Forte, MS, director and assistant director of the Center for Health Workforce Studies, School of Public Health, University at Albany, New York.

The National Center for Health Workforce Analysis projects a 10% shortage of registered nurses and a 13% shortage of physicians in 2031. The agency didn’t make projections for home health aides because that workforce is in flux.

Why are Mercer’s projections so different? Dr. Lezotte said other projections assume that equity efforts will bring healthcare to everyone who needs it. The report assumes this won’t happen, he said. As a result, it expects there will be fewer patients who need to be served by workers.

Other projections expect a shortage of 300,000 registered nurses by 2035, Mr. Forte said. But the number of nurse practitioners in New York is growing quickly, Dr. Moore said.

Dr. Moore said it’s difficult to interpret Mercer’s findings because the company doesn’t provide enough information about its methodology.

“At some level, it’s not particularly useful regarding what the next steps are,” she said. “Projections should make you think about what you should do to change and improve, to create more of what you need.”

The Center for Health Workforce Studies at the University of Albany has provided consulting services to multiple companies that provide healthcare workforce projections. It has no relationship with Mercer.

A version of this article first appeared on Medscape.com.

A surprising new report by the Mercer consulting firm projects that the American healthcare workforce will face a small shortfall in 2028 — a shortage of less than 1% of all employees. The report even projects a surplus of tens of thousands of registered nurses and home health aides — and even a small surplus of physicians in some states.

Mercer’s projections are rosier than federal workforce projections, which paint a grimmer picture of impending shortages.

“The labor market is a little more stabilized right now, and most healthcare systems are seeing less turnover,” Dan Lezotte, PhD, a partner with Mercer, said in an interview. But he noted “critical shortages” are still expected in some areas.

Mercer last projected workforce numbers in a 2020-2021 report released during the height of the COVID-19 pandemic. Now, “the labor market is drastically different,” Dr. Lezotte said. Health workforce shortages and surpluses have long varied significantly by region across the country.

The report forecasts a small surplus of physicians in 2028 but not in states such as California, New York, and Texas. The upper Midwest states will largely see doctor surpluses while Southern states face shortages. Some states with general physician surpluses may still experience shortages of specialists.

A surplus of nearly 30,000 registered nurses is expected, but New York, New Jersey, and Connecticut are projected to have a combined shortage of 16,000 nurses.

Overall, the report projects a shortage of more than 100,000 healthcare workers nationally by 2028. That’s less than 1% of the entire healthcare workforce of 18.6 million expected by then.

The report also predicts a shortage of nurse practitioners, especially in California and New York, and a shortage of 73,000 nursing assistants, especially in California, New York, and Texas.

“Healthcare systems are having the most difficulty hiring and hanging on to those workers who are supposed to take up the load off physicians and nurses,” Dr. Lezotte said. “They’re competing not only with other healthcare systems but with other industries like Amazon warehouses or McDonald’s in California paying $20 an hour. Healthcare was a little slow to keep up with that. In a lot of healthcare systems, that’s their biggest headache right now.”

On the other hand, the report projects a national surplus of 48,000 home health/personal care aides.

That surprised Bianca K. Frogner, PhD, director of the Center for Health Workforce Studies at the University of Washington, Seattle.

“We are seeing increasing movement of investments toward moving patients out of skilled nursing facilities and keeping them in the home and community, which requires many more home health aides,” Dr. Frogner said. “Given such high turnover in this occupation, it’s hard to know if the surplus is really a surplus or if they will quickly be employed.”

Dr. Frogner receives grants and contracts from not-for-profit entities to investigate issues related to the health workforce.

Dr. Lezotte said the report’s findings are based on data from sources such as public and private databases and job postings. According to the report, “projections were made up to 2028 based on historical data up to 2023,” and “supply projections were derived using a linear autoregressive model based on historical supply within each occupation and geography.”

It’s not clear why some states like New York are expected to have huge shortages, but migration might be a factor, along with a lack of nearby nursing schools, Dr. Lezotte said.

As for shortages, Dr. Lezotte said healthcare systems will have to understand their local workforce situation and adapt. “They’ll need to be more proactive about their employee value proposition” via competitive pay and benefits Flexibility regarding scheduling is also important.

“They’re going to have to figure out how to up their game,” he said.

What about states with surpluses? They might be target-rich environments for states facing shortages, he said.
 

Positive Outlook Not Shared by Other Researchers

Other workforce projections conflict with Mercer’s, according to Jean Moore, DrPH, and Gaetano Forte, MS, director and assistant director of the Center for Health Workforce Studies, School of Public Health, University at Albany, New York.

The National Center for Health Workforce Analysis projects a 10% shortage of registered nurses and a 13% shortage of physicians in 2031. The agency didn’t make projections for home health aides because that workforce is in flux.

Why are Mercer’s projections so different? Dr. Lezotte said other projections assume that equity efforts will bring healthcare to everyone who needs it. The report assumes this won’t happen, he said. As a result, it expects there will be fewer patients who need to be served by workers.

Other projections expect a shortage of 300,000 registered nurses by 2035, Mr. Forte said. But the number of nurse practitioners in New York is growing quickly, Dr. Moore said.

Dr. Moore said it’s difficult to interpret Mercer’s findings because the company doesn’t provide enough information about its methodology.

“At some level, it’s not particularly useful regarding what the next steps are,” she said. “Projections should make you think about what you should do to change and improve, to create more of what you need.”

The Center for Health Workforce Studies at the University of Albany has provided consulting services to multiple companies that provide healthcare workforce projections. It has no relationship with Mercer.

A version of this article first appeared on Medscape.com.

Researchers have discovered that a brain network involved in reward processing and attention to stimuli is markedly bigger in people with depression, remains stable over time, is unaffected by mood changes, and can be detected in children before onset of depression symptoms.

Using a novel brain-mapping technique, researchers found that the frontostriatal salience network was expanded nearly twofold in the brains of most individuals studied with depression compared with controls.

“This expansion in cortex was trait-like, meaning it was stable over time and did not change as symptoms changed over time,” said lead author Charles Lynch, PhD, assistant professor of neuroscience, Department of Psychiatry, Weill Cornell Medicine in New York.

It could also be detected in children who later developed depression, suggesting it may serve as a biomarker of depression risk. Investigators said the findings could aid in prevention and early detection of depression, as well as the development of more personalized treatment.

The study was published online in Nature.
 

Prewired for Depression?

Precision functional mapping is a relatively new approach to brain mapping in individuals that uses large amounts of fMRI data from hours of scans per person. The technique has been used to show differences in brain networks between and in healthy individuals but had not been used to study brain networks in people with depression.

“We leveraged our large longitudinal datasets — with many hours of functional MRI scanning per subject — to construct individual-specific maps of functional brain networks in each patient using precision functional mapping, instead of relying on group average,” Dr. Lynch said.

In the primary analysis of 141 adults with major depression and 37 healthy controls, the frontostriatal salience network — which is involved in reward processing and attention to internal and external stimuli — was markedly larger in these individuals with depression.

“This is one of the first times these kinds of personalized maps have been created in individuals with depression, and this is how we first observed of the salience network being larger in individuals with depression,” Dr. Lynch said.

In four of the six individuals, the salience network was expanded more than twofold, outside the range observed in all 37 healthy controls. On average, the salience network occupied 73% more of the cortical surface relative to the average in healthy controls.

The findings were replicated using independent samples of repeatedly sampled individuals with depression and in large-scale group average data.

The expansion of the salience network did not change over time and was unaffected by changes in mood state.

“These observations led us to propose that instead of driving changes in depressive symptoms over time, salience network expansion may be a stable marker of risk for developing depression,” the study team wrote.

An analysis of brain scans from 57 children who went on to develop depressive symptoms during adolescence and an equal number of children who did not develop depressive symptoms supports this theory.

On average, the salience network occupied roughly 36% more of cortex in the children with no current or previous symptoms of depression at the time of their fMRI scans but who subsequently developed clinically significant symptoms of depression, relative to children with no depressive symptoms at any study time point, the researchers found.
 

Immediate Clinical Impact?

Reached for comment, Shaheen Lakhan, MD, PhD, neurologist and researcher based in Miami, said this research “exemplifies the promising intersection of neurology and digital health, where advanced neuroimaging and data-driven approaches can transform mental health care into a more precise and individualized practice,” Dr. Lakhan said. “By identifying this brain network expansion, we’re unlocking new possibilities for precision medicine in mental health.”

Dr. Lakhan, who wasn’t involved in this research, said identifying the expansion of the frontostriatal salience network in individuals with depression opens new avenues for developing novel therapeutics.

“By targeting this network through neuromodulation techniques like deep brain stimulation, transcranial magnetic stimulation, and prescription digital therapeutics, treatments can be more precisely tailored to individual neurobiological profiles,” Dr. Lakhan said. “Additionally, this network expansion could serve as a biomarker for early detection, allowing for preventive strategies or personalized treatment plans, particularly for those at risk of developing depression.”

In addition, a greater understanding of the mechanisms driving salience network expansion offers potential for discovering new pharmacological targets, Dr. Lakhan noted.

“Drugs that modulate synaptic plasticity or network connectivity might be developed to reverse or mitigate these neural changes. The findings also support the use of longitudinal monitoring to predict and preempt symptom emergence, improving outcomes through timely intervention. This research paves the way for more personalized, precise, and proactive approaches in treating depression,” Dr. Lakhan concluded.

Also weighing in, Teddy Akiki, MD, with the Department of Psychiatry and Behavioral Sciences at Stanford Medicine in California, noted that the effect size of the frontostriatal salience network difference in depression is “remarkably larger than typically seen in neuroimaging studies of depression, which often describe subtle differences. The consistency across multiple datasets and across time at the individual level adds significant weight to these findings, suggesting that it is a trait marker rather than a state-dependent marker.”

“The observation that this expansion is present even before the onset of depressive symptoms in adolescence suggests its potential as a biomarker for depression risk,” Dr. Akiki said. “This approach could lead to earlier identification of at-risk individuals and potentially inform the development of targeted preventive interventions.”

He cautioned that it remains to be seen whether interventions targeting the salience network can effectively prevent or treat depression.

This research was supported in part by the National Institute of Mental Health, the National Institute on Drug Addiction, the Hope for Depression Research Foundation, and the Foundation for OCD Research. Dr. Lynch and a coauthor are listed as inventors for Cornell University patent applications on neuroimaging biomarkers for depression which are pending or in preparation. Dr. Liston has served as a scientific advisor or consultant to Compass Pathways PLC, Delix Therapeutics, and Brainify.AI. Dr. Lakhan and Dr. Akiki had no relevant disclosures.

A version of this article first appeared on Medscape.com.

Researchers have discovered that a brain network involved in reward processing and attention to stimuli is markedly bigger in people with depression, remains stable over time, is unaffected by mood changes, and can be detected in children before onset of depression symptoms.

Using a novel brain-mapping technique, researchers found that the frontostriatal salience network was expanded nearly twofold in the brains of most individuals studied with depression compared with controls.

“This expansion in cortex was trait-like, meaning it was stable over time and did not change as symptoms changed over time,” said lead author Charles Lynch, PhD, assistant professor of neuroscience, Department of Psychiatry, Weill Cornell Medicine in New York.

It could also be detected in children who later developed depression, suggesting it may serve as a biomarker of depression risk. Investigators said the findings could aid in prevention and early detection of depression, as well as the development of more personalized treatment.

The study was published online in Nature.
 

Prewired for Depression?

Precision functional mapping is a relatively new approach to brain mapping in individuals that uses large amounts of fMRI data from hours of scans per person. The technique has been used to show differences in brain networks between and in healthy individuals but had not been used to study brain networks in people with depression.

“We leveraged our large longitudinal datasets — with many hours of functional MRI scanning per subject — to construct individual-specific maps of functional brain networks in each patient using precision functional mapping, instead of relying on group average,” Dr. Lynch said.

In the primary analysis of 141 adults with major depression and 37 healthy controls, the frontostriatal salience network — which is involved in reward processing and attention to internal and external stimuli — was markedly larger in these individuals with depression.

“This is one of the first times these kinds of personalized maps have been created in individuals with depression, and this is how we first observed of the salience network being larger in individuals with depression,” Dr. Lynch said.

In four of the six individuals, the salience network was expanded more than twofold, outside the range observed in all 37 healthy controls. On average, the salience network occupied 73% more of the cortical surface relative to the average in healthy controls.

The findings were replicated using independent samples of repeatedly sampled individuals with depression and in large-scale group average data.

The expansion of the salience network did not change over time and was unaffected by changes in mood state.

“These observations led us to propose that instead of driving changes in depressive symptoms over time, salience network expansion may be a stable marker of risk for developing depression,” the study team wrote.

An analysis of brain scans from 57 children who went on to develop depressive symptoms during adolescence and an equal number of children who did not develop depressive symptoms supports this theory.

On average, the salience network occupied roughly 36% more of cortex in the children with no current or previous symptoms of depression at the time of their fMRI scans but who subsequently developed clinically significant symptoms of depression, relative to children with no depressive symptoms at any study time point, the researchers found.
 

Immediate Clinical Impact?

Reached for comment, Shaheen Lakhan, MD, PhD, neurologist and researcher based in Miami, said this research “exemplifies the promising intersection of neurology and digital health, where advanced neuroimaging and data-driven approaches can transform mental health care into a more precise and individualized practice,” Dr. Lakhan said. “By identifying this brain network expansion, we’re unlocking new possibilities for precision medicine in mental health.”

Dr. Lakhan, who wasn’t involved in this research, said identifying the expansion of the frontostriatal salience network in individuals with depression opens new avenues for developing novel therapeutics.

“By targeting this network through neuromodulation techniques like deep brain stimulation, transcranial magnetic stimulation, and prescription digital therapeutics, treatments can be more precisely tailored to individual neurobiological profiles,” Dr. Lakhan said. “Additionally, this network expansion could serve as a biomarker for early detection, allowing for preventive strategies or personalized treatment plans, particularly for those at risk of developing depression.”

In addition, a greater understanding of the mechanisms driving salience network expansion offers potential for discovering new pharmacological targets, Dr. Lakhan noted.

“Drugs that modulate synaptic plasticity or network connectivity might be developed to reverse or mitigate these neural changes. The findings also support the use of longitudinal monitoring to predict and preempt symptom emergence, improving outcomes through timely intervention. This research paves the way for more personalized, precise, and proactive approaches in treating depression,” Dr. Lakhan concluded.

Also weighing in, Teddy Akiki, MD, with the Department of Psychiatry and Behavioral Sciences at Stanford Medicine in California, noted that the effect size of the frontostriatal salience network difference in depression is “remarkably larger than typically seen in neuroimaging studies of depression, which often describe subtle differences. The consistency across multiple datasets and across time at the individual level adds significant weight to these findings, suggesting that it is a trait marker rather than a state-dependent marker.”

“The observation that this expansion is present even before the onset of depressive symptoms in adolescence suggests its potential as a biomarker for depression risk,” Dr. Akiki said. “This approach could lead to earlier identification of at-risk individuals and potentially inform the development of targeted preventive interventions.”

He cautioned that it remains to be seen whether interventions targeting the salience network can effectively prevent or treat depression.

This research was supported in part by the National Institute of Mental Health, the National Institute on Drug Addiction, the Hope for Depression Research Foundation, and the Foundation for OCD Research. Dr. Lynch and a coauthor are listed as inventors for Cornell University patent applications on neuroimaging biomarkers for depression which are pending or in preparation. Dr. Liston has served as a scientific advisor or consultant to Compass Pathways PLC, Delix Therapeutics, and Brainify.AI. Dr. Lakhan and Dr. Akiki had no relevant disclosures.

A version of this article first appeared on Medscape.com.

Researchers have discovered that a brain network involved in reward processing and attention to stimuli is markedly bigger in people with depression, remains stable over time, is unaffected by mood changes, and can be detected in children before onset of depression symptoms.

Using a novel brain-mapping technique, researchers found that the frontostriatal salience network was expanded nearly twofold in the brains of most individuals studied with depression compared with controls.

“This expansion in cortex was trait-like, meaning it was stable over time and did not change as symptoms changed over time,” said lead author Charles Lynch, PhD, assistant professor of neuroscience, Department of Psychiatry, Weill Cornell Medicine in New York.

It could also be detected in children who later developed depression, suggesting it may serve as a biomarker of depression risk. Investigators said the findings could aid in prevention and early detection of depression, as well as the development of more personalized treatment.

The study was published online in Nature.
 

Prewired for Depression?

Precision functional mapping is a relatively new approach to brain mapping in individuals that uses large amounts of fMRI data from hours of scans per person. The technique has been used to show differences in brain networks between and in healthy individuals but had not been used to study brain networks in people with depression.

“We leveraged our large longitudinal datasets — with many hours of functional MRI scanning per subject — to construct individual-specific maps of functional brain networks in each patient using precision functional mapping, instead of relying on group average,” Dr. Lynch said.

In the primary analysis of 141 adults with major depression and 37 healthy controls, the frontostriatal salience network — which is involved in reward processing and attention to internal and external stimuli — was markedly larger in these individuals with depression.

“This is one of the first times these kinds of personalized maps have been created in individuals with depression, and this is how we first observed of the salience network being larger in individuals with depression,” Dr. Lynch said.

In four of the six individuals, the salience network was expanded more than twofold, outside the range observed in all 37 healthy controls. On average, the salience network occupied 73% more of the cortical surface relative to the average in healthy controls.

The findings were replicated using independent samples of repeatedly sampled individuals with depression and in large-scale group average data.

The expansion of the salience network did not change over time and was unaffected by changes in mood state.

“These observations led us to propose that instead of driving changes in depressive symptoms over time, salience network expansion may be a stable marker of risk for developing depression,” the study team wrote.

An analysis of brain scans from 57 children who went on to develop depressive symptoms during adolescence and an equal number of children who did not develop depressive symptoms supports this theory.

On average, the salience network occupied roughly 36% more of cortex in the children with no current or previous symptoms of depression at the time of their fMRI scans but who subsequently developed clinically significant symptoms of depression, relative to children with no depressive symptoms at any study time point, the researchers found.
 

Immediate Clinical Impact?

Reached for comment, Shaheen Lakhan, MD, PhD, neurologist and researcher based in Miami, said this research “exemplifies the promising intersection of neurology and digital health, where advanced neuroimaging and data-driven approaches can transform mental health care into a more precise and individualized practice,” Dr. Lakhan said. “By identifying this brain network expansion, we’re unlocking new possibilities for precision medicine in mental health.”

Dr. Lakhan, who wasn’t involved in this research, said identifying the expansion of the frontostriatal salience network in individuals with depression opens new avenues for developing novel therapeutics.

“By targeting this network through neuromodulation techniques like deep brain stimulation, transcranial magnetic stimulation, and prescription digital therapeutics, treatments can be more precisely tailored to individual neurobiological profiles,” Dr. Lakhan said. “Additionally, this network expansion could serve as a biomarker for early detection, allowing for preventive strategies or personalized treatment plans, particularly for those at risk of developing depression.”

In addition, a greater understanding of the mechanisms driving salience network expansion offers potential for discovering new pharmacological targets, Dr. Lakhan noted.

“Drugs that modulate synaptic plasticity or network connectivity might be developed to reverse or mitigate these neural changes. The findings also support the use of longitudinal monitoring to predict and preempt symptom emergence, improving outcomes through timely intervention. This research paves the way for more personalized, precise, and proactive approaches in treating depression,” Dr. Lakhan concluded.

Also weighing in, Teddy Akiki, MD, with the Department of Psychiatry and Behavioral Sciences at Stanford Medicine in California, noted that the effect size of the frontostriatal salience network difference in depression is “remarkably larger than typically seen in neuroimaging studies of depression, which often describe subtle differences. The consistency across multiple datasets and across time at the individual level adds significant weight to these findings, suggesting that it is a trait marker rather than a state-dependent marker.”

“The observation that this expansion is present even before the onset of depressive symptoms in adolescence suggests its potential as a biomarker for depression risk,” Dr. Akiki said. “This approach could lead to earlier identification of at-risk individuals and potentially inform the development of targeted preventive interventions.”

He cautioned that it remains to be seen whether interventions targeting the salience network can effectively prevent or treat depression.

This research was supported in part by the National Institute of Mental Health, the National Institute on Drug Addiction, the Hope for Depression Research Foundation, and the Foundation for OCD Research. Dr. Lynch and a coauthor are listed as inventors for Cornell University patent applications on neuroimaging biomarkers for depression which are pending or in preparation. Dr. Liston has served as a scientific advisor or consultant to Compass Pathways PLC, Delix Therapeutics, and Brainify.AI. Dr. Lakhan and Dr. Akiki had no relevant disclosures.

A version of this article first appeared on Medscape.com.

TOPLINE:

A self-guided mobile application for cognitive behavioral therapy (CBT) is associated with significant reductions in anxiety in young adults with anxiety disorders after 3 weeks, with continued improvement through week 12, a new randomized clinical trial shows.

METHODOLOGY:

• The study included 59 adults aged 18-25 years (mean age, 23 years; 78% women) with anxiety disorders (56% with generalized anxiety disorder; 41% with social anxiety disorder).
• Participants received a 6-week CBT program with a self-guided mobile application called Maya and were assigned to one of three incentive strategies to encourage engagement: Loss-framed (lose points for incomplete sessions), gain-framed (earn points for completed sessions), or gain-social support (gain points with added social support from a designated person).
• The primary end point was change in anxiety at week 6, measured with the Hamilton Anxiety Rating Scale.
• The researchers also evaluated change in anxiety at 3 and 12 weeks, change in anxiety sensitivity, social anxiety symptoms, and engagement and satisfaction with the app.

TAKEAWAY:

• Anxiety decreased significantly from baseline at week 3, 6, and 12 (mean differences, −3.20, −5.64, and −5.67, respectively; all P < .001), with similar reductions in anxiety among the three incentive conditions.
• Use of the CBT app was also associated with significant reductions in anxiety sensitivity and social anxiety symptoms over time, with moderate to large effect sizes.
• A total of 98% of participants completed the 6-week assessment and 93% the 12-week follow-up. On average, the participants completed 10.8 of 12 sessions and 64% completed all sessions.
• The participants reported high satisfaction with the app across all time points, with no significant differences based on time or incentive condition.

IN PRACTICE:

“We hear a lot about the negative impact of technology use on mental health in this age group,” senior study author Faith M. Gunning, PhD, said in a press release. “But the ubiquitous use of cell phones for information may provide a way of addressing anxiety for some people who, even if they have access to mental health providers, may not go. If the app helps reduce symptoms, they may then be able to take the next step of seeing a mental health professional when needed.”

SOURCE:

The study was led by Jennifer N. Bress, PhD, Department of Psychiatry, Weill Cornell Medicine, New York City. It was published online in JAMA Network Open.

LIMITATIONS:

This study lacked a control group, and the unbalanced allocation of participants to the three incentive groups due to the COVID-19 pandemic may have influenced the results. The study sample, which predominantly consisted of female and college-educated participants, may not have accurately represented the broader population of young adults with anxiety.

DISCLOSURES:

This study was funded by the NewYork-Presbyterian Center for Youth Mental Health, the Khoury Foundation, the Paul and Jenna Segal Family Foundation, the Saks Fifth Avenue Foundation, Mary and Jonathan Rather, Weill Cornell Medicine, the Pritzker Neuropsychiatric Disorders Research Consortium, and the National Institutes of Health. Some authors reported obtaining grants, receiving personal fees, serving on speaker’s bureaus, and having other ties with multiple pharmaceutical companies and institutions. Full disclosures are available in the original article.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.

A version of this article first appeared on Medscape.com.

TOPLINE:

A self-guided mobile application for cognitive behavioral therapy (CBT) is associated with significant reductions in anxiety in young adults with anxiety disorders after 3 weeks, with continued improvement through week 12, a new randomized clinical trial shows.

METHODOLOGY:

• The study included 59 adults aged 18-25 years (mean age, 23 years; 78% women) with anxiety disorders (56% with generalized anxiety disorder; 41% with social anxiety disorder).
• Participants received a 6-week CBT program with a self-guided mobile application called Maya and were assigned to one of three incentive strategies to encourage engagement: Loss-framed (lose points for incomplete sessions), gain-framed (earn points for completed sessions), or gain-social support (gain points with added social support from a designated person).
• The primary end point was change in anxiety at week 6, measured with the Hamilton Anxiety Rating Scale.
• The researchers also evaluated change in anxiety at 3 and 12 weeks, change in anxiety sensitivity, social anxiety symptoms, and engagement and satisfaction with the app.

TAKEAWAY:

• Anxiety decreased significantly from baseline at week 3, 6, and 12 (mean differences, −3.20, −5.64, and −5.67, respectively; all P < .001), with similar reductions in anxiety among the three incentive conditions.
• Use of the CBT app was also associated with significant reductions in anxiety sensitivity and social anxiety symptoms over time, with moderate to large effect sizes.
• A total of 98% of participants completed the 6-week assessment and 93% the 12-week follow-up. On average, the participants completed 10.8 of 12 sessions and 64% completed all sessions.
• The participants reported high satisfaction with the app across all time points, with no significant differences based on time or incentive condition.

IN PRACTICE:

“We hear a lot about the negative impact of technology use on mental health in this age group,” senior study author Faith M. Gunning, PhD, said in a press release. “But the ubiquitous use of cell phones for information may provide a way of addressing anxiety for some people who, even if they have access to mental health providers, may not go. If the app helps reduce symptoms, they may then be able to take the next step of seeing a mental health professional when needed.”

SOURCE:

The study was led by Jennifer N. Bress, PhD, Department of Psychiatry, Weill Cornell Medicine, New York City. It was published online in JAMA Network Open.

LIMITATIONS:

This study lacked a control group, and the unbalanced allocation of participants to the three incentive groups due to the COVID-19 pandemic may have influenced the results. The study sample, which predominantly consisted of female and college-educated participants, may not have accurately represented the broader population of young adults with anxiety.

DISCLOSURES:

This study was funded by the NewYork-Presbyterian Center for Youth Mental Health, the Khoury Foundation, the Paul and Jenna Segal Family Foundation, the Saks Fifth Avenue Foundation, Mary and Jonathan Rather, Weill Cornell Medicine, the Pritzker Neuropsychiatric Disorders Research Consortium, and the National Institutes of Health. Some authors reported obtaining grants, receiving personal fees, serving on speaker’s bureaus, and having other ties with multiple pharmaceutical companies and institutions. Full disclosures are available in the original article.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.

A version of this article first appeared on Medscape.com.

TOPLINE:

A self-guided mobile application for cognitive behavioral therapy (CBT) is associated with significant reductions in anxiety in young adults with anxiety disorders after 3 weeks, with continued improvement through week 12, a new randomized clinical trial shows.

METHODOLOGY:

• The study included 59 adults aged 18-25 years (mean age, 23 years; 78% women) with anxiety disorders (56% with generalized anxiety disorder; 41% with social anxiety disorder).
• Participants received a 6-week CBT program with a self-guided mobile application called Maya and were assigned to one of three incentive strategies to encourage engagement: Loss-framed (lose points for incomplete sessions), gain-framed (earn points for completed sessions), or gain-social support (gain points with added social support from a designated person).
• The primary end point was change in anxiety at week 6, measured with the Hamilton Anxiety Rating Scale.
• The researchers also evaluated change in anxiety at 3 and 12 weeks, change in anxiety sensitivity, social anxiety symptoms, and engagement and satisfaction with the app.

TAKEAWAY:

• Anxiety decreased significantly from baseline at week 3, 6, and 12 (mean differences, −3.20, −5.64, and −5.67, respectively; all P < .001), with similar reductions in anxiety among the three incentive conditions.
• Use of the CBT app was also associated with significant reductions in anxiety sensitivity and social anxiety symptoms over time, with moderate to large effect sizes.
• A total of 98% of participants completed the 6-week assessment and 93% the 12-week follow-up. On average, the participants completed 10.8 of 12 sessions and 64% completed all sessions.
• The participants reported high satisfaction with the app across all time points, with no significant differences based on time or incentive condition.

IN PRACTICE:

“We hear a lot about the negative impact of technology use on mental health in this age group,” senior study author Faith M. Gunning, PhD, said in a press release. “But the ubiquitous use of cell phones for information may provide a way of addressing anxiety for some people who, even if they have access to mental health providers, may not go. If the app helps reduce symptoms, they may then be able to take the next step of seeing a mental health professional when needed.”

SOURCE:

The study was led by Jennifer N. Bress, PhD, Department of Psychiatry, Weill Cornell Medicine, New York City. It was published online in JAMA Network Open.

LIMITATIONS:

This study lacked a control group, and the unbalanced allocation of participants to the three incentive groups due to the COVID-19 pandemic may have influenced the results. The study sample, which predominantly consisted of female and college-educated participants, may not have accurately represented the broader population of young adults with anxiety.

DISCLOSURES:

This study was funded by the NewYork-Presbyterian Center for Youth Mental Health, the Khoury Foundation, the Paul and Jenna Segal Family Foundation, the Saks Fifth Avenue Foundation, Mary and Jonathan Rather, Weill Cornell Medicine, the Pritzker Neuropsychiatric Disorders Research Consortium, and the National Institutes of Health. Some authors reported obtaining grants, receiving personal fees, serving on speaker’s bureaus, and having other ties with multiple pharmaceutical companies and institutions. Full disclosures are available in the original article.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.

A version of this article first appeared on Medscape.com.

When pediatrician Eric Ball, MD, opened a refrigerator full of childhood vaccines, all the expected shots were there — DTaP, polio, pneumococcal vaccine — except one.

“This is where we usually store our COVID vaccines, but we don’t have any right now because they all expired at the end of last year and we had to dispose of them,” said Dr. Ball, who is part of a pediatric practice in Orange County, California.

“We thought demand would be way higher than it was.”

Pediatricians across the country are preordering the updated and reformulated COVID-19 vaccine for the fall and winter respiratory virus season, but some doctors said they’re struggling to predict whether parents will be interested. Providers like Dr. Ball don’t want to waste money ordering doses that won’t be used, but they need enough on hand to vaccinate vulnerable children.

The Centers for Disease Control and Prevention recommends that anyone 6 months or older get the updated COVID vaccination, but in the 2023-24 vaccination season only about 15% of eligible children in the United States got a shot.

Dr. Ball said it was difficult to let vaccines go to waste in 2023. It was the first time the federal government was no longer picking up the tab for the shots, and providers had to pay upfront for the vaccines. Parents would often skip the COVID shot, which can have a very short shelf life, compared with other vaccines.

“Watching it sitting on our shelves expiring every 30 days, that’s like throwing away $150 repeatedly every day, multiple times a month,” Dr. Ball said.

in 2024, Dr. Ball slashed his fall vaccine order to the bare minimum to avoid another costly mistake.

“We took the number of flu vaccines that we order, and then we ordered 5% of that in COVID vaccines,” Dr. Ball said. “It’s a guess.”

That small vaccine order cost more than $63,000, he said.

Pharmacists, pharmacy interns, and techs are allowed to give COVID vaccines only to children age 3 and up, meaning babies and toddlers would need to visit a doctor’s office for inoculation.

It’s difficult to predict how parents will feel about the shots this fall, said Chicago pediatrician Scott Goldstein, MD. Unlike other vaccinations, COVID shots aren’t required for kids to attend school, and parental interest seems to wane with each new formulation. For a physician-owned practice such as Dr. Goldstein’s, the upfront cost of the vaccine can be a gamble.

“The cost of vaccines, that’s far and away our biggest expense. But it’s also the most important thing we do, you could argue, is vaccinating kids,” Dr. Goldstein said.

Insurance doesn’t necessarily cover vaccine storage accidents, which can put the practice at risk of financial ruin.

“We’ve had things happen like a refrigerator gets unplugged. And then we’re all of a sudden out $80,000 overnight,” Dr. Goldstein said.

South Carolina pediatrician Deborah Greenhouse, MD, said she would order more COVID vaccines for older children if the pharmaceutical companies that she buys from had a more forgiving return policy.

“Pfizer is creating that situation. If you’re only going to let us return 30%, we’re not going to buy much,” she said. “We can’t.”

Greenhouse owns her practice, so the remaining 70% of leftover shots would come out of her pocket.

Vaccine maker Pfizer will take back all unused COVID shots for young children, but only 30% of doses for people 12 and older.

Pfizer said in an Aug. 20 emailed statement, “The return policy was instituted as we recognize both the importance and the complexity of pediatric vaccination and wanted to ensure that pediatric offices did not have hurdles to providing vaccine to their young patients.”

Pfizer’s return policy is similar to policies from other drugmakers for pediatric flu vaccines, also recommended during the fall season. Physicians who are worried about unwanted COVID vaccines expiring on the shelves said flu shots cost them about $20 per dose, while COVID shots cost around $150 per dose.

“We run on a very thin margin. If we get stuck holding a ton of vaccine that we cannot return, we can’t absorb that kind of cost,” Dr. Greenhouse said.

Vaccine maker Moderna will accept COVID vaccine returns, but the amount depends on the individual contract with a provider. Novavax will accept the return of only unopened vaccines and doesn’t specify the amount they’ll accept.

Dr. Greenhouse wants to vaccinate as many children as possible but said she can’t afford to stock shots with a short shelf life. Once she runs out of the doses she’s ordered, Dr. Greenhouse plans to tell families to go to a pharmacy to get older children vaccinated. If pediatricians around the country are making the same calculations, doses for very small children could be harder to find at doctors’ offices.

“Frankly, it’s not an ideal situation, but it’s what we have to do to stay in business,” she said.

Dr. Ball worries that parents’ limited interest has caused pediatricians to minimize their vaccine orders, in turn making the newest COVID shots difficult to find once they become available.

“I think there’s just a misperception that it’s less of a big deal to get COVID, but I’m still sending babies to the hospital with COVID,” Dr. Ball said. “We’re still seeing kids with long COVID. This is with us forever.”

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF — the independent source for health policy research, polling, and journalism.

When pediatrician Eric Ball, MD, opened a refrigerator full of childhood vaccines, all the expected shots were there — DTaP, polio, pneumococcal vaccine — except one.

“This is where we usually store our COVID vaccines, but we don’t have any right now because they all expired at the end of last year and we had to dispose of them,” said Dr. Ball, who is part of a pediatric practice in Orange County, California.

“We thought demand would be way higher than it was.”

Pediatricians across the country are preordering the updated and reformulated COVID-19 vaccine for the fall and winter respiratory virus season, but some doctors said they’re struggling to predict whether parents will be interested. Providers like Dr. Ball don’t want to waste money ordering doses that won’t be used, but they need enough on hand to vaccinate vulnerable children.

The Centers for Disease Control and Prevention recommends that anyone 6 months or older get the updated COVID vaccination, but in the 2023-24 vaccination season only about 15% of eligible children in the United States got a shot.

Dr. Ball said it was difficult to let vaccines go to waste in 2023. It was the first time the federal government was no longer picking up the tab for the shots, and providers had to pay upfront for the vaccines. Parents would often skip the COVID shot, which can have a very short shelf life, compared with other vaccines.

“Watching it sitting on our shelves expiring every 30 days, that’s like throwing away $150 repeatedly every day, multiple times a month,” Dr. Ball said.

in 2024, Dr. Ball slashed his fall vaccine order to the bare minimum to avoid another costly mistake.

“We took the number of flu vaccines that we order, and then we ordered 5% of that in COVID vaccines,” Dr. Ball said. “It’s a guess.”

That small vaccine order cost more than $63,000, he said.

Pharmacists, pharmacy interns, and techs are allowed to give COVID vaccines only to children age 3 and up, meaning babies and toddlers would need to visit a doctor’s office for inoculation.

It’s difficult to predict how parents will feel about the shots this fall, said Chicago pediatrician Scott Goldstein, MD. Unlike other vaccinations, COVID shots aren’t required for kids to attend school, and parental interest seems to wane with each new formulation. For a physician-owned practice such as Dr. Goldstein’s, the upfront cost of the vaccine can be a gamble.

“The cost of vaccines, that’s far and away our biggest expense. But it’s also the most important thing we do, you could argue, is vaccinating kids,” Dr. Goldstein said.

Insurance doesn’t necessarily cover vaccine storage accidents, which can put the practice at risk of financial ruin.

“We’ve had things happen like a refrigerator gets unplugged. And then we’re all of a sudden out $80,000 overnight,” Dr. Goldstein said.

South Carolina pediatrician Deborah Greenhouse, MD, said she would order more COVID vaccines for older children if the pharmaceutical companies that she buys from had a more forgiving return policy.

“Pfizer is creating that situation. If you’re only going to let us return 30%, we’re not going to buy much,” she said. “We can’t.”

Greenhouse owns her practice, so the remaining 70% of leftover shots would come out of her pocket.

Vaccine maker Pfizer will take back all unused COVID shots for young children, but only 30% of doses for people 12 and older.

Pfizer said in an Aug. 20 emailed statement, “The return policy was instituted as we recognize both the importance and the complexity of pediatric vaccination and wanted to ensure that pediatric offices did not have hurdles to providing vaccine to their young patients.”

Pfizer’s return policy is similar to policies from other drugmakers for pediatric flu vaccines, also recommended during the fall season. Physicians who are worried about unwanted COVID vaccines expiring on the shelves said flu shots cost them about $20 per dose, while COVID shots cost around $150 per dose.

“We run on a very thin margin. If we get stuck holding a ton of vaccine that we cannot return, we can’t absorb that kind of cost,” Dr. Greenhouse said.

Vaccine maker Moderna will accept COVID vaccine returns, but the amount depends on the individual contract with a provider. Novavax will accept the return of only unopened vaccines and doesn’t specify the amount they’ll accept.

Dr. Greenhouse wants to vaccinate as many children as possible but said she can’t afford to stock shots with a short shelf life. Once she runs out of the doses she’s ordered, Dr. Greenhouse plans to tell families to go to a pharmacy to get older children vaccinated. If pediatricians around the country are making the same calculations, doses for very small children could be harder to find at doctors’ offices.

“Frankly, it’s not an ideal situation, but it’s what we have to do to stay in business,” she said.

Dr. Ball worries that parents’ limited interest has caused pediatricians to minimize their vaccine orders, in turn making the newest COVID shots difficult to find once they become available.

“I think there’s just a misperception that it’s less of a big deal to get COVID, but I’m still sending babies to the hospital with COVID,” Dr. Ball said. “We’re still seeing kids with long COVID. This is with us forever.”

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF — the independent source for health policy research, polling, and journalism.

When pediatrician Eric Ball, MD, opened a refrigerator full of childhood vaccines, all the expected shots were there — DTaP, polio, pneumococcal vaccine — except one.

“This is where we usually store our COVID vaccines, but we don’t have any right now because they all expired at the end of last year and we had to dispose of them,” said Dr. Ball, who is part of a pediatric practice in Orange County, California.

“We thought demand would be way higher than it was.”

Pediatricians across the country are preordering the updated and reformulated COVID-19 vaccine for the fall and winter respiratory virus season, but some doctors said they’re struggling to predict whether parents will be interested. Providers like Dr. Ball don’t want to waste money ordering doses that won’t be used, but they need enough on hand to vaccinate vulnerable children.

The Centers for Disease Control and Prevention recommends that anyone 6 months or older get the updated COVID vaccination, but in the 2023-24 vaccination season only about 15% of eligible children in the United States got a shot.

Dr. Ball said it was difficult to let vaccines go to waste in 2023. It was the first time the federal government was no longer picking up the tab for the shots, and providers had to pay upfront for the vaccines. Parents would often skip the COVID shot, which can have a very short shelf life, compared with other vaccines.

“Watching it sitting on our shelves expiring every 30 days, that’s like throwing away $150 repeatedly every day, multiple times a month,” Dr. Ball said.

in 2024, Dr. Ball slashed his fall vaccine order to the bare minimum to avoid another costly mistake.

“We took the number of flu vaccines that we order, and then we ordered 5% of that in COVID vaccines,” Dr. Ball said. “It’s a guess.”

That small vaccine order cost more than $63,000, he said.

Pharmacists, pharmacy interns, and techs are allowed to give COVID vaccines only to children age 3 and up, meaning babies and toddlers would need to visit a doctor’s office for inoculation.

It’s difficult to predict how parents will feel about the shots this fall, said Chicago pediatrician Scott Goldstein, MD. Unlike other vaccinations, COVID shots aren’t required for kids to attend school, and parental interest seems to wane with each new formulation. For a physician-owned practice such as Dr. Goldstein’s, the upfront cost of the vaccine can be a gamble.

“The cost of vaccines, that’s far and away our biggest expense. But it’s also the most important thing we do, you could argue, is vaccinating kids,” Dr. Goldstein said.

Insurance doesn’t necessarily cover vaccine storage accidents, which can put the practice at risk of financial ruin.

“We’ve had things happen like a refrigerator gets unplugged. And then we’re all of a sudden out $80,000 overnight,” Dr. Goldstein said.

South Carolina pediatrician Deborah Greenhouse, MD, said she would order more COVID vaccines for older children if the pharmaceutical companies that she buys from had a more forgiving return policy.

“Pfizer is creating that situation. If you’re only going to let us return 30%, we’re not going to buy much,” she said. “We can’t.”

Greenhouse owns her practice, so the remaining 70% of leftover shots would come out of her pocket.

Vaccine maker Pfizer will take back all unused COVID shots for young children, but only 30% of doses for people 12 and older.

Pfizer said in an Aug. 20 emailed statement, “The return policy was instituted as we recognize both the importance and the complexity of pediatric vaccination and wanted to ensure that pediatric offices did not have hurdles to providing vaccine to their young patients.”

Pfizer’s return policy is similar to policies from other drugmakers for pediatric flu vaccines, also recommended during the fall season. Physicians who are worried about unwanted COVID vaccines expiring on the shelves said flu shots cost them about $20 per dose, while COVID shots cost around $150 per dose.

“We run on a very thin margin. If we get stuck holding a ton of vaccine that we cannot return, we can’t absorb that kind of cost,” Dr. Greenhouse said.

Vaccine maker Moderna will accept COVID vaccine returns, but the amount depends on the individual contract with a provider. Novavax will accept the return of only unopened vaccines and doesn’t specify the amount they’ll accept.

Dr. Greenhouse wants to vaccinate as many children as possible but said she can’t afford to stock shots with a short shelf life. Once she runs out of the doses she’s ordered, Dr. Greenhouse plans to tell families to go to a pharmacy to get older children vaccinated. If pediatricians around the country are making the same calculations, doses for very small children could be harder to find at doctors’ offices.

“Frankly, it’s not an ideal situation, but it’s what we have to do to stay in business,” she said.

Dr. Ball worries that parents’ limited interest has caused pediatricians to minimize their vaccine orders, in turn making the newest COVID shots difficult to find once they become available.

“I think there’s just a misperception that it’s less of a big deal to get COVID, but I’m still sending babies to the hospital with COVID,” Dr. Ball said. “We’re still seeing kids with long COVID. This is with us forever.”

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF — the independent source for health policy research, polling, and journalism.

A new analysis suggests one reason doctors are wary of value-based care arrangements: Overkill.

Researchers found that primary care physicians in one large integrated health system were required to track an average of 57 different quality measures across multiple insurers that linked outcomes to payments under value-based contracts.

Medicare contracts were the most likely to pile quality measures on physicians with an average of 13.42 measures vs 10.07 for commercial insurer contracts and 5.37 for Medicaid contracts, reported Claire Boone, PhD, of the University of Chicago in Illinois and Providence Research Network, Portland, Oregon, and colleagues in JAMA Health Forum. The analysis, which may be the first of its kind, tracked 890 primary care physicians from 2020 to 2022.

The average of 57 quality measures per physician was unexpectedly high, Dr. Boone said in an interview.

“The magnitude of that number surprised us,” Dr. Boone said. “Primary care physicians and their practices have a lot on their plate. Now we know that one of those things is a very large number of different quality metrics to pay attention to, measure, report on, and implement.

Value-based care programs use quality measures to evaluate how well clinicians are doing their jobs and adjust reimbursement accordingly. A payer, for example, may raise reimbursements if a clinician has higher numbers of patients who meet quality measure standards for depression screening or blood pressure.

Dr. Boone said her research group is studying the impact of quality measures and was surprised that data showed individual primary care physicians had to deal with a high number of value-based contracts.

The researchers tracked value-based contracts for 890 physicians (58.3% women, 41.7% men) in an unidentified West Coast Health system. (Several study authors work for the Providence Health System, which serves several Western States and Texas.) The average number of patients per physician was 1309.

The physicians were part of an average of 11.18 value-based contracts (commercial insurers, 49.50%; Medicaid, 21.49%; and Medicare, 29.01%). This number grew from 9.39 in 2020 to 12.26 in 2022. Quality measure data weren’t available for 29% of contracts.

Quality measures were considered unique if they referenced different conditions.

For example, colorectal cancer screening is unique from depression screening. The researchers also considered measures for the same condition unique if the target value differed — for example, blood pressure control defined as < 140/90 vs blood pressure control defined as < 130/80, Dr. Boone said.

Dr. Boone said she expected payers to coordinate quality measures.

“The fact that they largely are not is really the main finding of this paper. Without coordination, the use of value-based contracts and quality measures at scale leads to many unique measures being used. This may reflect the fact that there are so many important tasks to do in primary care, and there’s no consensus on which ones should be included in quality-based contracts.”

Ronald N. Adler, MD, an associate professor in the Department of Family Medicine and Community Health at UMass Chan Medical School, Worcester, Massachusetts, who’s familiar with the findings but didn’t take part in the research, said the study offers something new — the quantification of quality measures.

He said in an interview that physicians deal with quality measures in different ways. Some clinicians “don’t really care,” and have an attitude of “this is not why I got into medicine.” But others “are very competitive around this, and it leads to a lot of a lot of stress. Trying to address 50-plus measures is impossible and demoralizing.”

The metrics may measure things like mammogram screening that are out of the physician’s control, Dr. Adler said. “I can recommend a mammogram, and my patient can choose not to do it. Or maybe my patient is homeless; she doesn’t have transportation, and it’s not a priority for her, even though she wants to do it.”

Patients may not take medication as prescribed, or they may be unable to afford it, he said. “Can they afford to eat healthy foods? Or is ramen all they can afford, and their sugars are through the roof? There are a lot of factors at play here that are independent of the quality of care provided by the doctor.”

As for his own approach, Dr. Adler said he worries about some measures more than others. “I’m very proactive about screening my patients for colon cancer and maybe a little less so about mammography.”

For colon cancer screening, “there are a lot of benefits and not that many harms as opposed to mammography, which has harms such as false positives and overdiagnosis of breast cancer.”

Dr. Adler is a member of the Quality Measure Alignment Taskforce in Massachusetts, which is trying to establish consensus on appropriate quality measures. But payer participation is voluntary. “Our health systems are too siloed ... so there is no readily available mechanism for enforcing such recommendations.”

Wayne Altman, MD, chair of Family Medicine at Tufts University School of Medicine, Boston, Massachusetts, is also familiar with the study findings but didn’t take part in the research. He said in an interview that clinicians shouldn’t have to deal with more than 5-10 quality measures in total.

He pointed out that many measures don’t make sense in certain populations. Titrating blood pressure to < 140/90 isn’t ideal for elderly patients because aggressive control can send their blood pressure dangerously low. “They’re going to fall down, break a hip, and likely die within a year. You have to have the right population and be aware of unintended consequences.”

Still, Dr. Adler noted, there’s an important role for quality measures in healthcare.

“We need data to inform our quality improvement activities, but they need to be the right measures. People can’t respond reasonably to improve on 50-plus measures,” he said. “They need to be consolidated and prioritized. It would be really helpful if we could have a much lower number of measures that are meaningful, safe, and connect to things that matter.”

No funding has been reported. Dr. Boone disclosed a grant from the National Institute on Aging. Dr. Adler and Dr. Altman had no disclosures.

A version of this article first appeared on Medscape.com.

A new analysis suggests one reason doctors are wary of value-based care arrangements: Overkill.

Researchers found that primary care physicians in one large integrated health system were required to track an average of 57 different quality measures across multiple insurers that linked outcomes to payments under value-based contracts.

Medicare contracts were the most likely to pile quality measures on physicians with an average of 13.42 measures vs 10.07 for commercial insurer contracts and 5.37 for Medicaid contracts, reported Claire Boone, PhD, of the University of Chicago in Illinois and Providence Research Network, Portland, Oregon, and colleagues in JAMA Health Forum. The analysis, which may be the first of its kind, tracked 890 primary care physicians from 2020 to 2022.

The average of 57 quality measures per physician was unexpectedly high, Dr. Boone said in an interview.

“The magnitude of that number surprised us,” Dr. Boone said. “Primary care physicians and their practices have a lot on their plate. Now we know that one of those things is a very large number of different quality metrics to pay attention to, measure, report on, and implement.

Value-based care programs use quality measures to evaluate how well clinicians are doing their jobs and adjust reimbursement accordingly. A payer, for example, may raise reimbursements if a clinician has higher numbers of patients who meet quality measure standards for depression screening or blood pressure.

Dr. Boone said her research group is studying the impact of quality measures and was surprised that data showed individual primary care physicians had to deal with a high number of value-based contracts.

The researchers tracked value-based contracts for 890 physicians (58.3% women, 41.7% men) in an unidentified West Coast Health system. (Several study authors work for the Providence Health System, which serves several Western States and Texas.) The average number of patients per physician was 1309.

The physicians were part of an average of 11.18 value-based contracts (commercial insurers, 49.50%; Medicaid, 21.49%; and Medicare, 29.01%). This number grew from 9.39 in 2020 to 12.26 in 2022. Quality measure data weren’t available for 29% of contracts.

Quality measures were considered unique if they referenced different conditions.

For example, colorectal cancer screening is unique from depression screening. The researchers also considered measures for the same condition unique if the target value differed — for example, blood pressure control defined as < 140/90 vs blood pressure control defined as < 130/80, Dr. Boone said.

Dr. Boone said she expected payers to coordinate quality measures.

“The fact that they largely are not is really the main finding of this paper. Without coordination, the use of value-based contracts and quality measures at scale leads to many unique measures being used. This may reflect the fact that there are so many important tasks to do in primary care, and there’s no consensus on which ones should be included in quality-based contracts.”

Ronald N. Adler, MD, an associate professor in the Department of Family Medicine and Community Health at UMass Chan Medical School, Worcester, Massachusetts, who’s familiar with the findings but didn’t take part in the research, said the study offers something new — the quantification of quality measures.

He said in an interview that physicians deal with quality measures in different ways. Some clinicians “don’t really care,” and have an attitude of “this is not why I got into medicine.” But others “are very competitive around this, and it leads to a lot of a lot of stress. Trying to address 50-plus measures is impossible and demoralizing.”

The metrics may measure things like mammogram screening that are out of the physician’s control, Dr. Adler said. “I can recommend a mammogram, and my patient can choose not to do it. Or maybe my patient is homeless; she doesn’t have transportation, and it’s not a priority for her, even though she wants to do it.”

Patients may not take medication as prescribed, or they may be unable to afford it, he said. “Can they afford to eat healthy foods? Or is ramen all they can afford, and their sugars are through the roof? There are a lot of factors at play here that are independent of the quality of care provided by the doctor.”

As for his own approach, Dr. Adler said he worries about some measures more than others. “I’m very proactive about screening my patients for colon cancer and maybe a little less so about mammography.”

For colon cancer screening, “there are a lot of benefits and not that many harms as opposed to mammography, which has harms such as false positives and overdiagnosis of breast cancer.”

Dr. Adler is a member of the Quality Measure Alignment Taskforce in Massachusetts, which is trying to establish consensus on appropriate quality measures. But payer participation is voluntary. “Our health systems are too siloed ... so there is no readily available mechanism for enforcing such recommendations.”

Wayne Altman, MD, chair of Family Medicine at Tufts University School of Medicine, Boston, Massachusetts, is also familiar with the study findings but didn’t take part in the research. He said in an interview that clinicians shouldn’t have to deal with more than 5-10 quality measures in total.

He pointed out that many measures don’t make sense in certain populations. Titrating blood pressure to < 140/90 isn’t ideal for elderly patients because aggressive control can send their blood pressure dangerously low. “They’re going to fall down, break a hip, and likely die within a year. You have to have the right population and be aware of unintended consequences.”

Still, Dr. Adler noted, there’s an important role for quality measures in healthcare.

“We need data to inform our quality improvement activities, but they need to be the right measures. People can’t respond reasonably to improve on 50-plus measures,” he said. “They need to be consolidated and prioritized. It would be really helpful if we could have a much lower number of measures that are meaningful, safe, and connect to things that matter.”

No funding has been reported. Dr. Boone disclosed a grant from the National Institute on Aging. Dr. Adler and Dr. Altman had no disclosures.

A version of this article first appeared on Medscape.com.

A new analysis suggests one reason doctors are wary of value-based care arrangements: Overkill.

Researchers found that primary care physicians in one large integrated health system were required to track an average of 57 different quality measures across multiple insurers that linked outcomes to payments under value-based contracts.

Medicare contracts were the most likely to pile quality measures on physicians with an average of 13.42 measures vs 10.07 for commercial insurer contracts and 5.37 for Medicaid contracts, reported Claire Boone, PhD, of the University of Chicago in Illinois and Providence Research Network, Portland, Oregon, and colleagues in JAMA Health Forum. The analysis, which may be the first of its kind, tracked 890 primary care physicians from 2020 to 2022.

The average of 57 quality measures per physician was unexpectedly high, Dr. Boone said in an interview.

“The magnitude of that number surprised us,” Dr. Boone said. “Primary care physicians and their practices have a lot on their plate. Now we know that one of those things is a very large number of different quality metrics to pay attention to, measure, report on, and implement.

Value-based care programs use quality measures to evaluate how well clinicians are doing their jobs and adjust reimbursement accordingly. A payer, for example, may raise reimbursements if a clinician has higher numbers of patients who meet quality measure standards for depression screening or blood pressure.

Dr. Boone said her research group is studying the impact of quality measures and was surprised that data showed individual primary care physicians had to deal with a high number of value-based contracts.

The researchers tracked value-based contracts for 890 physicians (58.3% women, 41.7% men) in an unidentified West Coast Health system. (Several study authors work for the Providence Health System, which serves several Western States and Texas.) The average number of patients per physician was 1309.

The physicians were part of an average of 11.18 value-based contracts (commercial insurers, 49.50%; Medicaid, 21.49%; and Medicare, 29.01%). This number grew from 9.39 in 2020 to 12.26 in 2022. Quality measure data weren’t available for 29% of contracts.

Quality measures were considered unique if they referenced different conditions.

For example, colorectal cancer screening is unique from depression screening. The researchers also considered measures for the same condition unique if the target value differed — for example, blood pressure control defined as < 140/90 vs blood pressure control defined as < 130/80, Dr. Boone said.

Dr. Boone said she expected payers to coordinate quality measures.

“The fact that they largely are not is really the main finding of this paper. Without coordination, the use of value-based contracts and quality measures at scale leads to many unique measures being used. This may reflect the fact that there are so many important tasks to do in primary care, and there’s no consensus on which ones should be included in quality-based contracts.”

Ronald N. Adler, MD, an associate professor in the Department of Family Medicine and Community Health at UMass Chan Medical School, Worcester, Massachusetts, who’s familiar with the findings but didn’t take part in the research, said the study offers something new — the quantification of quality measures.

He said in an interview that physicians deal with quality measures in different ways. Some clinicians “don’t really care,” and have an attitude of “this is not why I got into medicine.” But others “are very competitive around this, and it leads to a lot of a lot of stress. Trying to address 50-plus measures is impossible and demoralizing.”

The metrics may measure things like mammogram screening that are out of the physician’s control, Dr. Adler said. “I can recommend a mammogram, and my patient can choose not to do it. Or maybe my patient is homeless; she doesn’t have transportation, and it’s not a priority for her, even though she wants to do it.”

Patients may not take medication as prescribed, or they may be unable to afford it, he said. “Can they afford to eat healthy foods? Or is ramen all they can afford, and their sugars are through the roof? There are a lot of factors at play here that are independent of the quality of care provided by the doctor.”

As for his own approach, Dr. Adler said he worries about some measures more than others. “I’m very proactive about screening my patients for colon cancer and maybe a little less so about mammography.”

For colon cancer screening, “there are a lot of benefits and not that many harms as opposed to mammography, which has harms such as false positives and overdiagnosis of breast cancer.”

Dr. Adler is a member of the Quality Measure Alignment Taskforce in Massachusetts, which is trying to establish consensus on appropriate quality measures. But payer participation is voluntary. “Our health systems are too siloed ... so there is no readily available mechanism for enforcing such recommendations.”

Wayne Altman, MD, chair of Family Medicine at Tufts University School of Medicine, Boston, Massachusetts, is also familiar with the study findings but didn’t take part in the research. He said in an interview that clinicians shouldn’t have to deal with more than 5-10 quality measures in total.

He pointed out that many measures don’t make sense in certain populations. Titrating blood pressure to < 140/90 isn’t ideal for elderly patients because aggressive control can send their blood pressure dangerously low. “They’re going to fall down, break a hip, and likely die within a year. You have to have the right population and be aware of unintended consequences.”

Still, Dr. Adler noted, there’s an important role for quality measures in healthcare.

“We need data to inform our quality improvement activities, but they need to be the right measures. People can’t respond reasonably to improve on 50-plus measures,” he said. “They need to be consolidated and prioritized. It would be really helpful if we could have a much lower number of measures that are meaningful, safe, and connect to things that matter.”

No funding has been reported. Dr. Boone disclosed a grant from the National Institute on Aging. Dr. Adler and Dr. Altman had no disclosures.

A version of this article first appeared on Medscape.com.

You see it all the time. It’s the family at the table next to you in the restaurant where the two teenage children are texting away on their phones. Or the playground, where a 3-year-old is playing with his toy truck and bulldozer in the sand and his father, immersed in his laptop, hasn’t said a word to his child.

It may trouble you when you witness social situations like that in which an electronic device is preventing or certainly interfering with interpersonal interactions. Or at least I hope it troubles you. Maybe it is so ubiquitous that you have come to accept it as the norm. It’s likely you may even be a participant. But, do you have a name for it?

It’s called “technoference,” a word coined by a doctoral student in human development and family studies at Penn State a decade ago “to describe the everyday intrusions and interruptions in couple interactions that take place due to technology devices and their always-on, ever-present nature.” Although, the original research that triggered the coinage was about couples, obviously the phenomenon occurs whenever people of any age are together in social situations.

While the word may not have crept into common parlance, we all know it when we see it. Technoference may not appear in the paper’s title, but it is a subject being investigated across a broad array of disciplines. One phone tracking study found that parents of young infants spend more than 5 hours each day on their smartphones. More than a quarter of that time the infant is engaged with the parent’s digital device. Technoference has been associated with decreased parent-child interaction during early childhood. It has been associated with more negative responses to children’s behavior, as well as an increased risk of child injury.

There are numerous studies suggesting an association between parental technoference and mental health difficulties in children. I have recently reviewed one of these studies that looks at the relationship of perceived parental technoference and the mental health of children entering adolescents. The authors collected longitudinal data of more than 1300 emerging adolescents, hoping to determine if the relationship between parental distraction and mental health was bidirectional. In other words, could a child’s mental health be contributing to his parents’ perceived distraction? Or was it primarily the parents’ technoference that was playing a role in the child’s mental health problems?

What investigators found was that higher levels of parental distraction were associated with higher levels of inattention and hyperactivity in the emerging adolescents, but not vice versa. On the other hand, higher levels of adolescent anxiety was associated with higher levels of perceived parental technoference, but not vice versa.

I know this sounds a bit confusing and a bit chicken-egg-chicken-eggish. The study was not designed to determine causation in these associations. However, the authors offer some possible scenarios that may provide a bit of clarity. It could be that parents who are concerned about their anxious child respond by retreating into the cyberspace to avoid tense situations or for support or information.

On the other hand, emerging adolescents who are exhibiting hyperactivity and inattention may be responding to an environment infused with their parents’ higher level of technoference. This explanation meshes with other studies demonstrating an association between parental distraction and aggression and attention problems in early childhood.

While one could spend more time imagining other factors that could be driving these bidirectional relationships, I’m not sure that it makes a heckuva lot of difference. Whether the child’s mental illness is the primary driver or the parent’s device-associated distraction is the dominant force isn’t the point. These are bidirectional relationships. If we are interested in pointing fingers, the common denominator is the device and our failure as a society to keep it in proper perspective. We all know that smartphones, tablets, and computers create an unhealthy distraction in personal relationships. The parents know and most of the children know. It’s time for us all to demonstrate some self-discipline. And that can begin for us as health care providers as we sit behind our computers spending more time looking at the screen than we do engaging the patient with our eyes.
 

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at [email protected].

You see it all the time. It’s the family at the table next to you in the restaurant where the two teenage children are texting away on their phones. Or the playground, where a 3-year-old is playing with his toy truck and bulldozer in the sand and his father, immersed in his laptop, hasn’t said a word to his child.

It may trouble you when you witness social situations like that in which an electronic device is preventing or certainly interfering with interpersonal interactions. Or at least I hope it troubles you. Maybe it is so ubiquitous that you have come to accept it as the norm. It’s likely you may even be a participant. But, do you have a name for it?

It’s called “technoference,” a word coined by a doctoral student in human development and family studies at Penn State a decade ago “to describe the everyday intrusions and interruptions in couple interactions that take place due to technology devices and their always-on, ever-present nature.” Although, the original research that triggered the coinage was about couples, obviously the phenomenon occurs whenever people of any age are together in social situations.

While the word may not have crept into common parlance, we all know it when we see it. Technoference may not appear in the paper’s title, but it is a subject being investigated across a broad array of disciplines. One phone tracking study found that parents of young infants spend more than 5 hours each day on their smartphones. More than a quarter of that time the infant is engaged with the parent’s digital device. Technoference has been associated with decreased parent-child interaction during early childhood. It has been associated with more negative responses to children’s behavior, as well as an increased risk of child injury.

There are numerous studies suggesting an association between parental technoference and mental health difficulties in children. I have recently reviewed one of these studies that looks at the relationship of perceived parental technoference and the mental health of children entering adolescents. The authors collected longitudinal data of more than 1300 emerging adolescents, hoping to determine if the relationship between parental distraction and mental health was bidirectional. In other words, could a child’s mental health be contributing to his parents’ perceived distraction? Or was it primarily the parents’ technoference that was playing a role in the child’s mental health problems?

What investigators found was that higher levels of parental distraction were associated with higher levels of inattention and hyperactivity in the emerging adolescents, but not vice versa. On the other hand, higher levels of adolescent anxiety was associated with higher levels of perceived parental technoference, but not vice versa.

I know this sounds a bit confusing and a bit chicken-egg-chicken-eggish. The study was not designed to determine causation in these associations. However, the authors offer some possible scenarios that may provide a bit of clarity. It could be that parents who are concerned about their anxious child respond by retreating into the cyberspace to avoid tense situations or for support or information.

On the other hand, emerging adolescents who are exhibiting hyperactivity and inattention may be responding to an environment infused with their parents’ higher level of technoference. This explanation meshes with other studies demonstrating an association between parental distraction and aggression and attention problems in early childhood.

While one could spend more time imagining other factors that could be driving these bidirectional relationships, I’m not sure that it makes a heckuva lot of difference. Whether the child’s mental illness is the primary driver or the parent’s device-associated distraction is the dominant force isn’t the point. These are bidirectional relationships. If we are interested in pointing fingers, the common denominator is the device and our failure as a society to keep it in proper perspective. We all know that smartphones, tablets, and computers create an unhealthy distraction in personal relationships. The parents know and most of the children know. It’s time for us all to demonstrate some self-discipline. And that can begin for us as health care providers as we sit behind our computers spending more time looking at the screen than we do engaging the patient with our eyes.
 

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at [email protected].

You see it all the time. It’s the family at the table next to you in the restaurant where the two teenage children are texting away on their phones. Or the playground, where a 3-year-old is playing with his toy truck and bulldozer in the sand and his father, immersed in his laptop, hasn’t said a word to his child.

It may trouble you when you witness social situations like that in which an electronic device is preventing or certainly interfering with interpersonal interactions. Or at least I hope it troubles you. Maybe it is so ubiquitous that you have come to accept it as the norm. It’s likely you may even be a participant. But, do you have a name for it?

It’s called “technoference,” a word coined by a doctoral student in human development and family studies at Penn State a decade ago “to describe the everyday intrusions and interruptions in couple interactions that take place due to technology devices and their always-on, ever-present nature.” Although, the original research that triggered the coinage was about couples, obviously the phenomenon occurs whenever people of any age are together in social situations.

While the word may not have crept into common parlance, we all know it when we see it. Technoference may not appear in the paper’s title, but it is a subject being investigated across a broad array of disciplines. One phone tracking study found that parents of young infants spend more than 5 hours each day on their smartphones. More than a quarter of that time the infant is engaged with the parent’s digital device. Technoference has been associated with decreased parent-child interaction during early childhood. It has been associated with more negative responses to children’s behavior, as well as an increased risk of child injury.

There are numerous studies suggesting an association between parental technoference and mental health difficulties in children. I have recently reviewed one of these studies that looks at the relationship of perceived parental technoference and the mental health of children entering adolescents. The authors collected longitudinal data of more than 1300 emerging adolescents, hoping to determine if the relationship between parental distraction and mental health was bidirectional. In other words, could a child’s mental health be contributing to his parents’ perceived distraction? Or was it primarily the parents’ technoference that was playing a role in the child’s mental health problems?

What investigators found was that higher levels of parental distraction were associated with higher levels of inattention and hyperactivity in the emerging adolescents, but not vice versa. On the other hand, higher levels of adolescent anxiety was associated with higher levels of perceived parental technoference, but not vice versa.

I know this sounds a bit confusing and a bit chicken-egg-chicken-eggish. The study was not designed to determine causation in these associations. However, the authors offer some possible scenarios that may provide a bit of clarity. It could be that parents who are concerned about their anxious child respond by retreating into the cyberspace to avoid tense situations or for support or information.

On the other hand, emerging adolescents who are exhibiting hyperactivity and inattention may be responding to an environment infused with their parents’ higher level of technoference. This explanation meshes with other studies demonstrating an association between parental distraction and aggression and attention problems in early childhood.

While one could spend more time imagining other factors that could be driving these bidirectional relationships, I’m not sure that it makes a heckuva lot of difference. Whether the child’s mental illness is the primary driver or the parent’s device-associated distraction is the dominant force isn’t the point. These are bidirectional relationships. If we are interested in pointing fingers, the common denominator is the device and our failure as a society to keep it in proper perspective. We all know that smartphones, tablets, and computers create an unhealthy distraction in personal relationships. The parents know and most of the children know. It’s time for us all to demonstrate some self-discipline. And that can begin for us as health care providers as we sit behind our computers spending more time looking at the screen than we do engaging the patient with our eyes.
 

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at [email protected].

TOPLINE: 

Compared with other urine analysis methods, urine Gram stain has a moderate predictive value for detecting gram-negative bacteria in urine culture but does not significantly improve urinary tract infection (UTI) diagnosis in the emergency department (ED).

METHODOLOGY:

• Researchers conducted an observational cohort study at the University Medical Center Groningen in the Netherlands, encompassing 1358 episodes across 1136 patients suspected of having a UTI.
• The study included the following predefined subgroups: patients using urinary catheters and patients with leukopenia (< 4.0×10⁹ leucocytes/L). Urine dipstick nitrite, automated urinalysis, Gram stain, and urine cultures were performed on urine samples collected from patients presenting at the ED.
• The sensitivity and specificity of Gram stain for “many” bacteria (quantified as > 15/high power field) were compared with those of urine dipstick nitrite and automated bacterial counting in urinalysis.

TAKEAWAY:

• The sensitivity and specificity of Gram stain for “many” bacteria were 51.3% and 91.0%, respectively, with an accuracy of 76.8%.
• Gram stain showed a positive predictive value (PPV) of 84.7% for gram-negative rods in urine culture; however, the PPV was only 38.4% for gram-positive cocci.
• In the catheter subgroup, the presence of monomorphic bacteria quantified as “many” had a higher PPV for diagnosing a UTI than the presence of polymorphic bacteria with the same quantification.
• The overall performance of Gram stain in diagnosing a UTI in the ED was comparable to that of automated bacterial counting in urinalysis but better than that of urine dipstick nitrite.

IN PRACTICE:

“With the exception of a moderate prediction of gram-negative bacteria in the UC [urine culture], urine GS [Gram stain] does not improve UTI diagnosis at the ED compared to other urine parameters,” the authors wrote.

SOURCE:

The study was led by Stephanie J.M. Middelkoop, University of Groningen, University Medical Center Groningen, the Netherlands. It was published online on August 16, 2024, in Infectious Diseases.

LIMITATIONS: 

The study’s limitations included a small sample size within the leukopenia subgroup, which may have affected the generalizability of the findings. Additionally, the potential influence of refrigeration of urine samples on bacterial growth could have affected the results. In this study, indwelling catheters were not replaced before urine sample collection, which may have affected the accuracy of UTI diagnosis in patients using catheters.
 

DISCLOSURES:

No conflicts of interest were disclosed by the authors.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication. A version of this article first appeared on Medscape.com.

TOPLINE: 

Compared with other urine analysis methods, urine Gram stain has a moderate predictive value for detecting gram-negative bacteria in urine culture but does not significantly improve urinary tract infection (UTI) diagnosis in the emergency department (ED).

METHODOLOGY:

• Researchers conducted an observational cohort study at the University Medical Center Groningen in the Netherlands, encompassing 1358 episodes across 1136 patients suspected of having a UTI.
• The study included the following predefined subgroups: patients using urinary catheters and patients with leukopenia (< 4.0×10⁹ leucocytes/L). Urine dipstick nitrite, automated urinalysis, Gram stain, and urine cultures were performed on urine samples collected from patients presenting at the ED.
• The sensitivity and specificity of Gram stain for “many” bacteria (quantified as > 15/high power field) were compared with those of urine dipstick nitrite and automated bacterial counting in urinalysis.

TAKEAWAY:

• The sensitivity and specificity of Gram stain for “many” bacteria were 51.3% and 91.0%, respectively, with an accuracy of 76.8%.
• Gram stain showed a positive predictive value (PPV) of 84.7% for gram-negative rods in urine culture; however, the PPV was only 38.4% for gram-positive cocci.
• In the catheter subgroup, the presence of monomorphic bacteria quantified as “many” had a higher PPV for diagnosing a UTI than the presence of polymorphic bacteria with the same quantification.
• The overall performance of Gram stain in diagnosing a UTI in the ED was comparable to that of automated bacterial counting in urinalysis but better than that of urine dipstick nitrite.

IN PRACTICE:

“With the exception of a moderate prediction of gram-negative bacteria in the UC [urine culture], urine GS [Gram stain] does not improve UTI diagnosis at the ED compared to other urine parameters,” the authors wrote.

SOURCE:

The study was led by Stephanie J.M. Middelkoop, University of Groningen, University Medical Center Groningen, the Netherlands. It was published online on August 16, 2024, in Infectious Diseases.

LIMITATIONS: 

The study’s limitations included a small sample size within the leukopenia subgroup, which may have affected the generalizability of the findings. Additionally, the potential influence of refrigeration of urine samples on bacterial growth could have affected the results. In this study, indwelling catheters were not replaced before urine sample collection, which may have affected the accuracy of UTI diagnosis in patients using catheters.
 

DISCLOSURES:

No conflicts of interest were disclosed by the authors.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication. A version of this article first appeared on Medscape.com.

TOPLINE: 

Compared with other urine analysis methods, urine Gram stain has a moderate predictive value for detecting gram-negative bacteria in urine culture but does not significantly improve urinary tract infection (UTI) diagnosis in the emergency department (ED).

METHODOLOGY:

• Researchers conducted an observational cohort study at the University Medical Center Groningen in the Netherlands, encompassing 1358 episodes across 1136 patients suspected of having a UTI.
• The study included the following predefined subgroups: patients using urinary catheters and patients with leukopenia (< 4.0×10⁹ leucocytes/L). Urine dipstick nitrite, automated urinalysis, Gram stain, and urine cultures were performed on urine samples collected from patients presenting at the ED.
• The sensitivity and specificity of Gram stain for “many” bacteria (quantified as > 15/high power field) were compared with those of urine dipstick nitrite and automated bacterial counting in urinalysis.

TAKEAWAY:

• The sensitivity and specificity of Gram stain for “many” bacteria were 51.3% and 91.0%, respectively, with an accuracy of 76.8%.
• Gram stain showed a positive predictive value (PPV) of 84.7% for gram-negative rods in urine culture; however, the PPV was only 38.4% for gram-positive cocci.
• In the catheter subgroup, the presence of monomorphic bacteria quantified as “many” had a higher PPV for diagnosing a UTI than the presence of polymorphic bacteria with the same quantification.
• The overall performance of Gram stain in diagnosing a UTI in the ED was comparable to that of automated bacterial counting in urinalysis but better than that of urine dipstick nitrite.

IN PRACTICE:

“With the exception of a moderate prediction of gram-negative bacteria in the UC [urine culture], urine GS [Gram stain] does not improve UTI diagnosis at the ED compared to other urine parameters,” the authors wrote.

SOURCE:

The study was led by Stephanie J.M. Middelkoop, University of Groningen, University Medical Center Groningen, the Netherlands. It was published online on August 16, 2024, in Infectious Diseases.

LIMITATIONS: 

The study’s limitations included a small sample size within the leukopenia subgroup, which may have affected the generalizability of the findings. Additionally, the potential influence of refrigeration of urine samples on bacterial growth could have affected the results. In this study, indwelling catheters were not replaced before urine sample collection, which may have affected the accuracy of UTI diagnosis in patients using catheters.
 

DISCLOSURES:

No conflicts of interest were disclosed by the authors.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication. A version of this article first appeared on Medscape.com.