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Voice recognition software errors: Often silly, sometimes serious
How much is 15%?
Not that much, on paper. With any drug, at least 15% of people will get some kind of side effect. Usually they all list dizziness and headaches at the top.
Could the same be true of a seemingly harmless technology?
Voice recognition software has become pretty commonplace in modern medicine but is far from perfect. I try to be pretty careful about proofreading my dictations, but many docs, especially those in emergency room, don’t have the time to. So VR errors slip by, persisting in 71% of notes.
Most of these errors are just silly and obvious for what they are. But a recent study at a level I ER found that 15% of dictations contained one or more errors deemed as “critical,” with the potential to adversely affect patient care (Int J Med Inform. 2016 Sep;93:70-3).
Communication among doctors, nurses, and all the other key players in the hospital environment is one of the most critical areas in modern medicine. So many people often rely on the initial dictation for an idea of what’s going on that a critical error can affect the way they think about the case from the get-go.
Another issue, sadly, in today’s hospital is that no one takes (or has) the time to get a patient’s past medical history. It’s commonplace to pull the history out of previous admission notes. (Admittedly, sometimes in a demented or unconscious patient you don’t have a choice.) As a result, errors of this sort tend to propagate down the line, from an admission, to the consults, to the discharge summary, and into the next admission.
So let’s get back to that 15%.
I have to assume that 15% of people being admitted aren’t having catastrophic events from medical errors, hopefully because the doctors and nurses handling patient care are thinking for themselves, recognizing dictation errors, and addressing them appropriately.
But even if we dial it down to a tenth of that, say 1.5%, it’s still a serious concern. Bad outcomes in medicine are never entirely avoidable. That’s the nature of the job.
But bad outcomes caused by too much trust in a still-faulty technology are avoidable.
If 15% of people had a serious outcome from a medication, you’d be very cautious about using it. We need to treat these technological gadgets with the same concerns we extend to drugs and procedures. Avoidable bad outcomes, regardless of cause, are never good.
Dr. Block has a solo neurology practice in Scottsdale, Ariz.
How much is 15%?
Not that much, on paper. With any drug, at least 15% of people will get some kind of side effect. Usually they all list dizziness and headaches at the top.
Could the same be true of a seemingly harmless technology?
Voice recognition software has become pretty commonplace in modern medicine but is far from perfect. I try to be pretty careful about proofreading my dictations, but many docs, especially those in emergency room, don’t have the time to. So VR errors slip by, persisting in 71% of notes.
Most of these errors are just silly and obvious for what they are. But a recent study at a level I ER found that 15% of dictations contained one or more errors deemed as “critical,” with the potential to adversely affect patient care (Int J Med Inform. 2016 Sep;93:70-3).
Communication among doctors, nurses, and all the other key players in the hospital environment is one of the most critical areas in modern medicine. So many people often rely on the initial dictation for an idea of what’s going on that a critical error can affect the way they think about the case from the get-go.
Another issue, sadly, in today’s hospital is that no one takes (or has) the time to get a patient’s past medical history. It’s commonplace to pull the history out of previous admission notes. (Admittedly, sometimes in a demented or unconscious patient you don’t have a choice.) As a result, errors of this sort tend to propagate down the line, from an admission, to the consults, to the discharge summary, and into the next admission.
So let’s get back to that 15%.
I have to assume that 15% of people being admitted aren’t having catastrophic events from medical errors, hopefully because the doctors and nurses handling patient care are thinking for themselves, recognizing dictation errors, and addressing them appropriately.
But even if we dial it down to a tenth of that, say 1.5%, it’s still a serious concern. Bad outcomes in medicine are never entirely avoidable. That’s the nature of the job.
But bad outcomes caused by too much trust in a still-faulty technology are avoidable.
If 15% of people had a serious outcome from a medication, you’d be very cautious about using it. We need to treat these technological gadgets with the same concerns we extend to drugs and procedures. Avoidable bad outcomes, regardless of cause, are never good.
Dr. Block has a solo neurology practice in Scottsdale, Ariz.
How much is 15%?
Not that much, on paper. With any drug, at least 15% of people will get some kind of side effect. Usually they all list dizziness and headaches at the top.
Could the same be true of a seemingly harmless technology?
Voice recognition software has become pretty commonplace in modern medicine but is far from perfect. I try to be pretty careful about proofreading my dictations, but many docs, especially those in emergency room, don’t have the time to. So VR errors slip by, persisting in 71% of notes.
Most of these errors are just silly and obvious for what they are. But a recent study at a level I ER found that 15% of dictations contained one or more errors deemed as “critical,” with the potential to adversely affect patient care (Int J Med Inform. 2016 Sep;93:70-3).
Communication among doctors, nurses, and all the other key players in the hospital environment is one of the most critical areas in modern medicine. So many people often rely on the initial dictation for an idea of what’s going on that a critical error can affect the way they think about the case from the get-go.
Another issue, sadly, in today’s hospital is that no one takes (or has) the time to get a patient’s past medical history. It’s commonplace to pull the history out of previous admission notes. (Admittedly, sometimes in a demented or unconscious patient you don’t have a choice.) As a result, errors of this sort tend to propagate down the line, from an admission, to the consults, to the discharge summary, and into the next admission.
So let’s get back to that 15%.
I have to assume that 15% of people being admitted aren’t having catastrophic events from medical errors, hopefully because the doctors and nurses handling patient care are thinking for themselves, recognizing dictation errors, and addressing them appropriately.
But even if we dial it down to a tenth of that, say 1.5%, it’s still a serious concern. Bad outcomes in medicine are never entirely avoidable. That’s the nature of the job.
But bad outcomes caused by too much trust in a still-faulty technology are avoidable.
If 15% of people had a serious outcome from a medication, you’d be very cautious about using it. We need to treat these technological gadgets with the same concerns we extend to drugs and procedures. Avoidable bad outcomes, regardless of cause, are never good.
Dr. Block has a solo neurology practice in Scottsdale, Ariz.
A tool to assess comportment and communication for hospitalists
With the rise of hospital medicine in the United States, the lion’s share of inpatient care is delivered by hospitalists. Both hospitals and hospitalist providers are committed to delivering excellent patient care, but to accomplish this goal, specific feedback is essential.
Patient satisfaction surveys that assess provider performance, such as Press Ganey (PG)1 and Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS),2 do not truly provide feedback at the encounter level with valid attribution, and these data are not sent to providers in a timely manner.
In the analyses, the HMCCOT scores were moderately correlated with the hospitalists’ PG scores. Higher scores on the HMCCOT took an average of 13 minutes per patient encounter, giving further credence to the fact that excellent communication and comportment can be rapidly established at the bedside.
Patients’ complaints about doctors often relate to comportment and communication; the grievances are most commonly about feeling rushed, not being heard, and that information was not conveyed in a clear manner.4 Patient-centeredness has been shown to improve patient satisfaction as well as clinical outcomes, in part because they feel like partners in the mutually agreed upon treatment plans.5 Many of the components of the HMCCOT are at the heart of patient-centered care. While comportment may not be a frequently used term in patient care, respectful behaviors performed at the opening of any encounter [etiquette-based medicine which includes introducing oneself to patients and smiling] set the tone for the doctor-patient interaction.
Demonstrating genuine interest in the patient as a person is a core component of excellent patient care. Sir William Osler famously observed “It is much more important to know what sort of a patient has a disease than what sort of a disease a patient has.”6 A common method of “demonstrating interest in the patient as a person” recorded by the HMCCOT was physicians asking about patient’s personal history and of their interests. It is not difficult to fathom how knowing about patients’ personal interests and perspectives can help to most effectively engage them in establishing their goals of care and with therapeutic decisions.
Because hospitalists spend only a small proportion of their clinical time in direct patient care at the bedside, they need to make every moment count. HMCCOT allows for the identification of providers who are excellent in communication and comportment. Once identified, these exemplars can watch their peers and become the trainers to establish a culture of excellence.
Larger studies will be needed in the future to assess whether interventions that translate into improved comportment and communication among hospitalists will definitively augment patient satisfaction and ameliorate clinical outcomes.
1. Press Ganey. Accessed Dec. 15, 2015.
2. HCAHPS. Accessed Feb. 2, 2016.
3. Kotwal S, Khaliq W, Landis R, Wright S. Developing a comportment and communication tool for use in hospital medicine. J Hosp Med. 2016 Aug 13. doi: 10.1002/jhm.2647.
4. Hickson GB, Clayton EW, Entman SS, Miller CS, Githens PB, Whetten-Goldstein K, Sloan FA. Obstetricians’ prior malpractice experience and patients’ satisfaction with care. JAMA. 1994 Nov 23-30;272(20):1583-7.
5. Epstein RM, Street RL. Patient-centered communication in cancer care: promoting healing and reducing suffering. National Cancer Institute, NIH Publication No. 07-6225. Bethesda, MD, 2007.
6. Taylor RB. White Coat Tales: Medicine’s Heroes, Heritage, and Misadventure. New York: Springer; 2007:126.
Susrutha Kotwal, MD, and Scott Wright, MD, are based in the department of medicine, division of hospital medicine, Johns Hopkins Bayview Medical Center and Johns Hopkins University, Baltimore.
With the rise of hospital medicine in the United States, the lion’s share of inpatient care is delivered by hospitalists. Both hospitals and hospitalist providers are committed to delivering excellent patient care, but to accomplish this goal, specific feedback is essential.
Patient satisfaction surveys that assess provider performance, such as Press Ganey (PG)1 and Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS),2 do not truly provide feedback at the encounter level with valid attribution, and these data are not sent to providers in a timely manner.
In the analyses, the HMCCOT scores were moderately correlated with the hospitalists’ PG scores. Higher scores on the HMCCOT took an average of 13 minutes per patient encounter, giving further credence to the fact that excellent communication and comportment can be rapidly established at the bedside.
Patients’ complaints about doctors often relate to comportment and communication; the grievances are most commonly about feeling rushed, not being heard, and that information was not conveyed in a clear manner.4 Patient-centeredness has been shown to improve patient satisfaction as well as clinical outcomes, in part because they feel like partners in the mutually agreed upon treatment plans.5 Many of the components of the HMCCOT are at the heart of patient-centered care. While comportment may not be a frequently used term in patient care, respectful behaviors performed at the opening of any encounter [etiquette-based medicine which includes introducing oneself to patients and smiling] set the tone for the doctor-patient interaction.
Demonstrating genuine interest in the patient as a person is a core component of excellent patient care. Sir William Osler famously observed “It is much more important to know what sort of a patient has a disease than what sort of a disease a patient has.”6 A common method of “demonstrating interest in the patient as a person” recorded by the HMCCOT was physicians asking about patient’s personal history and of their interests. It is not difficult to fathom how knowing about patients’ personal interests and perspectives can help to most effectively engage them in establishing their goals of care and with therapeutic decisions.
Because hospitalists spend only a small proportion of their clinical time in direct patient care at the bedside, they need to make every moment count. HMCCOT allows for the identification of providers who are excellent in communication and comportment. Once identified, these exemplars can watch their peers and become the trainers to establish a culture of excellence.
Larger studies will be needed in the future to assess whether interventions that translate into improved comportment and communication among hospitalists will definitively augment patient satisfaction and ameliorate clinical outcomes.
1. Press Ganey. Accessed Dec. 15, 2015.
2. HCAHPS. Accessed Feb. 2, 2016.
3. Kotwal S, Khaliq W, Landis R, Wright S. Developing a comportment and communication tool for use in hospital medicine. J Hosp Med. 2016 Aug 13. doi: 10.1002/jhm.2647.
4. Hickson GB, Clayton EW, Entman SS, Miller CS, Githens PB, Whetten-Goldstein K, Sloan FA. Obstetricians’ prior malpractice experience and patients’ satisfaction with care. JAMA. 1994 Nov 23-30;272(20):1583-7.
5. Epstein RM, Street RL. Patient-centered communication in cancer care: promoting healing and reducing suffering. National Cancer Institute, NIH Publication No. 07-6225. Bethesda, MD, 2007.
6. Taylor RB. White Coat Tales: Medicine’s Heroes, Heritage, and Misadventure. New York: Springer; 2007:126.
Susrutha Kotwal, MD, and Scott Wright, MD, are based in the department of medicine, division of hospital medicine, Johns Hopkins Bayview Medical Center and Johns Hopkins University, Baltimore.
With the rise of hospital medicine in the United States, the lion’s share of inpatient care is delivered by hospitalists. Both hospitals and hospitalist providers are committed to delivering excellent patient care, but to accomplish this goal, specific feedback is essential.
Patient satisfaction surveys that assess provider performance, such as Press Ganey (PG)1 and Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS),2 do not truly provide feedback at the encounter level with valid attribution, and these data are not sent to providers in a timely manner.
In the analyses, the HMCCOT scores were moderately correlated with the hospitalists’ PG scores. Higher scores on the HMCCOT took an average of 13 minutes per patient encounter, giving further credence to the fact that excellent communication and comportment can be rapidly established at the bedside.
Patients’ complaints about doctors often relate to comportment and communication; the grievances are most commonly about feeling rushed, not being heard, and that information was not conveyed in a clear manner.4 Patient-centeredness has been shown to improve patient satisfaction as well as clinical outcomes, in part because they feel like partners in the mutually agreed upon treatment plans.5 Many of the components of the HMCCOT are at the heart of patient-centered care. While comportment may not be a frequently used term in patient care, respectful behaviors performed at the opening of any encounter [etiquette-based medicine which includes introducing oneself to patients and smiling] set the tone for the doctor-patient interaction.
Demonstrating genuine interest in the patient as a person is a core component of excellent patient care. Sir William Osler famously observed “It is much more important to know what sort of a patient has a disease than what sort of a disease a patient has.”6 A common method of “demonstrating interest in the patient as a person” recorded by the HMCCOT was physicians asking about patient’s personal history and of their interests. It is not difficult to fathom how knowing about patients’ personal interests and perspectives can help to most effectively engage them in establishing their goals of care and with therapeutic decisions.
Because hospitalists spend only a small proportion of their clinical time in direct patient care at the bedside, they need to make every moment count. HMCCOT allows for the identification of providers who are excellent in communication and comportment. Once identified, these exemplars can watch their peers and become the trainers to establish a culture of excellence.
Larger studies will be needed in the future to assess whether interventions that translate into improved comportment and communication among hospitalists will definitively augment patient satisfaction and ameliorate clinical outcomes.
1. Press Ganey. Accessed Dec. 15, 2015.
2. HCAHPS. Accessed Feb. 2, 2016.
3. Kotwal S, Khaliq W, Landis R, Wright S. Developing a comportment and communication tool for use in hospital medicine. J Hosp Med. 2016 Aug 13. doi: 10.1002/jhm.2647.
4. Hickson GB, Clayton EW, Entman SS, Miller CS, Githens PB, Whetten-Goldstein K, Sloan FA. Obstetricians’ prior malpractice experience and patients’ satisfaction with care. JAMA. 1994 Nov 23-30;272(20):1583-7.
5. Epstein RM, Street RL. Patient-centered communication in cancer care: promoting healing and reducing suffering. National Cancer Institute, NIH Publication No. 07-6225. Bethesda, MD, 2007.
6. Taylor RB. White Coat Tales: Medicine’s Heroes, Heritage, and Misadventure. New York: Springer; 2007:126.
Susrutha Kotwal, MD, and Scott Wright, MD, are based in the department of medicine, division of hospital medicine, Johns Hopkins Bayview Medical Center and Johns Hopkins University, Baltimore.
Enhanced recovery pathways in gynecology
Enhanced recovery surgical principles were first described in the 1990s.1 These principles postulate that the body’s stress response to surgical injury and deviation from normal physiology is the source of postoperative morbidity. Thus, enhanced recovery programs are designed around perioperative interventions that mitigate and help the body cope with the surgical stress response.
Many of these interventions run counter to traditional perioperative care paradigms. Enhanced recovery protocols are diverse but have common themes of avoiding preoperative fasting and bowel preparation, early oral intake, limiting use of drains and catheters, multimodal analgesia, early ambulation, and prioritizing euvolemia and normothermia. Individual interventions in these areas are combined to create a master protocol, which is implemented as a bundle to improve surgical outcomes.
Current components
Minimizing preoperative fasting, early postoperative refeeding, and preoperative carbohydrate-loading drinks are all key aspects of enhanced recovery protocols. “NPO after midnight” has been a longstanding rule due to the risk of aspiration with intubation. However, a Cochrane review found no evidence that a shortened period of fasting was associated with an increased risk of aspiration or related morbidity. Currently, the American Society of Anesthesiologists recommends only a 6-hour fast for solid foods and 2 hours for clear liquids.2,3
Preoperative fasting causes depletion of glycogen stores leading to insulin resistance and hyperglycemia, which are both associated with postoperative complications and morbidity.4 Preoperative carbohydrate-loading drinks can reverse some of the effects of limited preoperative fasting including preventing insulin resistance and hyperglycemia.5
Postoperative fasting should also be avoided. Early enteral intake is very important to decrease time spent in a catabolic state and decrease insulin resistance. In gynecology patients, early refeeding is associated with a faster return of bowel function and a decreased length of stay without an increase in postoperative complications.6 Notably, patients undergoing early feeding consistently experience more nausea and vomiting, but this is not associated with complications.7
The fluid management goal in enhanced recovery is to maintain perioperative euvolemia, as both hypovolemia and hypervolemia have negative physiologic consequences. When studied, fluid protocols designed to minimize the use of postoperative fluids have resulted in decreased cardiopulmonary complications, decreased postoperative morbidity, faster return of bowel function, and shorter hospital stays.8 Given the morbidity associated with fluid overload, enhanced recovery protocols recommend that minimal fluids be given in the operating room and intravenous fluids be removed as quickly as possible, often with first oral intake or postoperative day 1 at the latest.
Engagement of the patient in their perioperative recovery with patient education materials and expectations for postoperative tasks, such as early refeeding, spirometry, and ambulation are all important components of enhanced recovery. Patients become partners in achieving postoperative milestones, and this results in improved outcomes such as decreased pain scores and shorter recoveries.
Evidence in gynecology
Enhanced recovery has been studied in many surgical disciplines including urology, colorectal surgery, hepatobiliary surgery, and gynecology. High-quality studies of abdominal and vaginal hysterectomy patients have consistently found a decrease in length of stay with no difference in readmission or postoperative complication rates.9 An interesting study also found that an enhanced recovery program was associated with decreased nursing time required for patient care.10
For ovarian cancer patients, enhanced recovery is associated with decreased length of stay, decreased time to return of bowel function, and improved quality of life. Enhanced recovery is also cost saving, saving $257-$697 per vaginal hysterectomy patient and $5,410-$7,600 per ovarian cancer patient.11
Enhanced recovery protocols are safe, evidenced based, cost saving, and are increasingly being adopted as clinicians and health systems become aware of their benefits.
References
1. Br J Anaesth. 1997 May;78(5):606-17.
2. Cochrane Database Syst Rev. 2003 Oct 20;(4):CD004423.
3. Anesthesiology. 1999 Mar;90(3):896-905.
4. J Am Coll Surg. 2012 Jan;214(1):68-80.
5. Clin Nutr. 1998 Apr;17(2):65-71.
6. Cochrane Database Syst Rev. 2007 Oct 17;(4):CD004508.
7. Obstet Gynecol. 1998 Jul;92(1):94-7.
8. Br J Surg. 2009 Apr;96(4):331-41.
9. Obstet Gynecol. 2013 Aug;122(2 Pt 1):319-28.
10. Qual Saf Health Care. 2009 Jun;18(3):236-40.
11. Gynecol Oncol. 2008 Feb;108(2):282-6.
Dr. Gehrig is professor and director of gynecologic oncology at the University of North Carolina at Chapel Hill. Dr. Barber is a third-year fellow in gynecologic oncology at the university. They reported having no financial disclosures relevant to this column. Email them at [email protected].
Enhanced recovery surgical principles were first described in the 1990s.1 These principles postulate that the body’s stress response to surgical injury and deviation from normal physiology is the source of postoperative morbidity. Thus, enhanced recovery programs are designed around perioperative interventions that mitigate and help the body cope with the surgical stress response.
Many of these interventions run counter to traditional perioperative care paradigms. Enhanced recovery protocols are diverse but have common themes of avoiding preoperative fasting and bowel preparation, early oral intake, limiting use of drains and catheters, multimodal analgesia, early ambulation, and prioritizing euvolemia and normothermia. Individual interventions in these areas are combined to create a master protocol, which is implemented as a bundle to improve surgical outcomes.
Current components
Minimizing preoperative fasting, early postoperative refeeding, and preoperative carbohydrate-loading drinks are all key aspects of enhanced recovery protocols. “NPO after midnight” has been a longstanding rule due to the risk of aspiration with intubation. However, a Cochrane review found no evidence that a shortened period of fasting was associated with an increased risk of aspiration or related morbidity. Currently, the American Society of Anesthesiologists recommends only a 6-hour fast for solid foods and 2 hours for clear liquids.2,3
Preoperative fasting causes depletion of glycogen stores leading to insulin resistance and hyperglycemia, which are both associated with postoperative complications and morbidity.4 Preoperative carbohydrate-loading drinks can reverse some of the effects of limited preoperative fasting including preventing insulin resistance and hyperglycemia.5
Postoperative fasting should also be avoided. Early enteral intake is very important to decrease time spent in a catabolic state and decrease insulin resistance. In gynecology patients, early refeeding is associated with a faster return of bowel function and a decreased length of stay without an increase in postoperative complications.6 Notably, patients undergoing early feeding consistently experience more nausea and vomiting, but this is not associated with complications.7
The fluid management goal in enhanced recovery is to maintain perioperative euvolemia, as both hypovolemia and hypervolemia have negative physiologic consequences. When studied, fluid protocols designed to minimize the use of postoperative fluids have resulted in decreased cardiopulmonary complications, decreased postoperative morbidity, faster return of bowel function, and shorter hospital stays.8 Given the morbidity associated with fluid overload, enhanced recovery protocols recommend that minimal fluids be given in the operating room and intravenous fluids be removed as quickly as possible, often with first oral intake or postoperative day 1 at the latest.
Engagement of the patient in their perioperative recovery with patient education materials and expectations for postoperative tasks, such as early refeeding, spirometry, and ambulation are all important components of enhanced recovery. Patients become partners in achieving postoperative milestones, and this results in improved outcomes such as decreased pain scores and shorter recoveries.
Evidence in gynecology
Enhanced recovery has been studied in many surgical disciplines including urology, colorectal surgery, hepatobiliary surgery, and gynecology. High-quality studies of abdominal and vaginal hysterectomy patients have consistently found a decrease in length of stay with no difference in readmission or postoperative complication rates.9 An interesting study also found that an enhanced recovery program was associated with decreased nursing time required for patient care.10
For ovarian cancer patients, enhanced recovery is associated with decreased length of stay, decreased time to return of bowel function, and improved quality of life. Enhanced recovery is also cost saving, saving $257-$697 per vaginal hysterectomy patient and $5,410-$7,600 per ovarian cancer patient.11
Enhanced recovery protocols are safe, evidenced based, cost saving, and are increasingly being adopted as clinicians and health systems become aware of their benefits.
References
1. Br J Anaesth. 1997 May;78(5):606-17.
2. Cochrane Database Syst Rev. 2003 Oct 20;(4):CD004423.
3. Anesthesiology. 1999 Mar;90(3):896-905.
4. J Am Coll Surg. 2012 Jan;214(1):68-80.
5. Clin Nutr. 1998 Apr;17(2):65-71.
6. Cochrane Database Syst Rev. 2007 Oct 17;(4):CD004508.
7. Obstet Gynecol. 1998 Jul;92(1):94-7.
8. Br J Surg. 2009 Apr;96(4):331-41.
9. Obstet Gynecol. 2013 Aug;122(2 Pt 1):319-28.
10. Qual Saf Health Care. 2009 Jun;18(3):236-40.
11. Gynecol Oncol. 2008 Feb;108(2):282-6.
Dr. Gehrig is professor and director of gynecologic oncology at the University of North Carolina at Chapel Hill. Dr. Barber is a third-year fellow in gynecologic oncology at the university. They reported having no financial disclosures relevant to this column. Email them at [email protected].
Enhanced recovery surgical principles were first described in the 1990s.1 These principles postulate that the body’s stress response to surgical injury and deviation from normal physiology is the source of postoperative morbidity. Thus, enhanced recovery programs are designed around perioperative interventions that mitigate and help the body cope with the surgical stress response.
Many of these interventions run counter to traditional perioperative care paradigms. Enhanced recovery protocols are diverse but have common themes of avoiding preoperative fasting and bowel preparation, early oral intake, limiting use of drains and catheters, multimodal analgesia, early ambulation, and prioritizing euvolemia and normothermia. Individual interventions in these areas are combined to create a master protocol, which is implemented as a bundle to improve surgical outcomes.
Current components
Minimizing preoperative fasting, early postoperative refeeding, and preoperative carbohydrate-loading drinks are all key aspects of enhanced recovery protocols. “NPO after midnight” has been a longstanding rule due to the risk of aspiration with intubation. However, a Cochrane review found no evidence that a shortened period of fasting was associated with an increased risk of aspiration or related morbidity. Currently, the American Society of Anesthesiologists recommends only a 6-hour fast for solid foods and 2 hours for clear liquids.2,3
Preoperative fasting causes depletion of glycogen stores leading to insulin resistance and hyperglycemia, which are both associated with postoperative complications and morbidity.4 Preoperative carbohydrate-loading drinks can reverse some of the effects of limited preoperative fasting including preventing insulin resistance and hyperglycemia.5
Postoperative fasting should also be avoided. Early enteral intake is very important to decrease time spent in a catabolic state and decrease insulin resistance. In gynecology patients, early refeeding is associated with a faster return of bowel function and a decreased length of stay without an increase in postoperative complications.6 Notably, patients undergoing early feeding consistently experience more nausea and vomiting, but this is not associated with complications.7
The fluid management goal in enhanced recovery is to maintain perioperative euvolemia, as both hypovolemia and hypervolemia have negative physiologic consequences. When studied, fluid protocols designed to minimize the use of postoperative fluids have resulted in decreased cardiopulmonary complications, decreased postoperative morbidity, faster return of bowel function, and shorter hospital stays.8 Given the morbidity associated with fluid overload, enhanced recovery protocols recommend that minimal fluids be given in the operating room and intravenous fluids be removed as quickly as possible, often with first oral intake or postoperative day 1 at the latest.
Engagement of the patient in their perioperative recovery with patient education materials and expectations for postoperative tasks, such as early refeeding, spirometry, and ambulation are all important components of enhanced recovery. Patients become partners in achieving postoperative milestones, and this results in improved outcomes such as decreased pain scores and shorter recoveries.
Evidence in gynecology
Enhanced recovery has been studied in many surgical disciplines including urology, colorectal surgery, hepatobiliary surgery, and gynecology. High-quality studies of abdominal and vaginal hysterectomy patients have consistently found a decrease in length of stay with no difference in readmission or postoperative complication rates.9 An interesting study also found that an enhanced recovery program was associated with decreased nursing time required for patient care.10
For ovarian cancer patients, enhanced recovery is associated with decreased length of stay, decreased time to return of bowel function, and improved quality of life. Enhanced recovery is also cost saving, saving $257-$697 per vaginal hysterectomy patient and $5,410-$7,600 per ovarian cancer patient.11
Enhanced recovery protocols are safe, evidenced based, cost saving, and are increasingly being adopted as clinicians and health systems become aware of their benefits.
References
1. Br J Anaesth. 1997 May;78(5):606-17.
2. Cochrane Database Syst Rev. 2003 Oct 20;(4):CD004423.
3. Anesthesiology. 1999 Mar;90(3):896-905.
4. J Am Coll Surg. 2012 Jan;214(1):68-80.
5. Clin Nutr. 1998 Apr;17(2):65-71.
6. Cochrane Database Syst Rev. 2007 Oct 17;(4):CD004508.
7. Obstet Gynecol. 1998 Jul;92(1):94-7.
8. Br J Surg. 2009 Apr;96(4):331-41.
9. Obstet Gynecol. 2013 Aug;122(2 Pt 1):319-28.
10. Qual Saf Health Care. 2009 Jun;18(3):236-40.
11. Gynecol Oncol. 2008 Feb;108(2):282-6.
Dr. Gehrig is professor and director of gynecologic oncology at the University of North Carolina at Chapel Hill. Dr. Barber is a third-year fellow in gynecologic oncology at the university. They reported having no financial disclosures relevant to this column. Email them at [email protected].
Navigating the ambiguity around whether to admit or discharge
In my first week of intern year, I learned the criteria for admission to an inpatient psychiatric unit: imminent harm to self, imminent harm to others, or the inability to care for self.1 The standard risk assessment. In residency training, each patient encounter trains us in the challenging practice of risk assessment in potentially dangerous situations. One quickly learns the anxiety a moderate risk patient will cause.
Less discussed than the risk assessment, but certainly, a frequent challenge facing psychiatry residents is whether an admission is “good” or “bad.” The bad admission reflects the type of patient and situation, when you, the psychiatrist, basically know that inpatient admission is likely inappropriate.2 Usually, these occur when your hands are tied by structural and systemic pressures. Perhaps the patient is a known “high utilizer” whose admission is primarily motivated by homelessness or lack of community mental health resources.3 Or maybe the bad admission is a patient with a personality disorder who is consistently readmitted by each resident in the program with seemingly little improvement after each admission.4 Bad admissions are the type of patient who, as the overnight resident, you feel a touch embarrassed signing out to the fresh resident there to relieve you in the morning. In these cases, I find myself making various justifications: It was a busy night; there was no collateral; no family; no friends; no outpatient support. I tell myself, I just couldn’t manage a safe enough discharge. I couldn’t mitigate the risk enough.
If the situation allows in the midst of the tumult, I create an intimate space to interview my patient. I pull up a chair and lean in to listen. To maintain an empathetic stance, I must recognize and control my biases toward high utilizers, drug use, homelessness, noncompliance, and the other host of factors that may influence my judgment. Between the hours of 1 a.m. and 6 a.m., fatigue, in particular, will breed negative countertransference. Before I sit down to listen, I repeat my mantra to myself: The least I can offer is kindness. Then the assessment and the decision-making process that leads to an admission or a discharge begins.
When I’m on call, I am torn by my obligations: to the patient, their safety and well-being; to the health care system and distributive justice; to making the “right” decision to admit or discharge; to my nursing staff and their safety; to my supervisors and my fellow residents who will judge and must deal with my clinical decision to admit or discharge. Some of these obligations that I struggle to balance are outlined as core competencies by the Accreditation Council for Graduate Medical Education and the American Board of Psychiatry and Neurology, and called the Psychiatry Milestone Project.5 I am supposed to be thinking about these issues as I work up a patient, evaluating, and making purposeful trade-offs. The educational language of these core competencies does not capture the tensions of these complicated on-call experiences.
The most useful thing I have learned this year is that the decision to admit or discharge is not a binary decision. The very act of assessment through an interview and making a plan with the patient is valuable in itself as risk mitigation. Only recently as a second-year resident have I fully realized how my presence could have therapeutic effects. Even a brief interview in the emergency department can be generative. I try to bring calm to the chaos around the patient. I listen, elicit protective factors and coping skills, and try to mobilize hope and internal strength building capabilities just as we are taught in my residency program.
However, I admittedly continue to dread my overnight calls. As a second-year resident, I am still uncomfortable with the ambiguity in some decisions to admit or discharge. Nonetheless, I recognize these experiences are only helping me become a better psychiatrist with every night I spend running between the ED and the psychiatric unit. To get through this process of residency, I have formulated another mantra: Every call and every patient is a learning experience.
References
1. BMC Health Serv Res. 2006;6:150.
2. Health Policy. 2000 Oct;53(3):157-84.
3. Adm Policy Ment Health. 2012 May;39(3):200-9.
4. Psychiatr Serv. 2015 Jan 1;66(1):15-20.
5. “The Psychiatry Milestone Project”: Assessment Tools. A Joint Initiative of the Accreditation Council for Graduate Medical Education and the American Board of Psychiatry and Neurology.
Dr. Posada is a second-year resident in the psychiatry & behavioral sciences department at George Washington University, Washington. She completed a bachelor’s degree at the George Washington University. For 2 years after her undergraduate education, she worked at the National Institutes of Allergy and Infectious Diseases studying HIV pathogenesis. Dr. Posada completed her medical degree at the University of Texas Medical Branch in Galveston. Her interests include public psychiatry, health care policy, health disparities, and psychosomatic medicine.
In my first week of intern year, I learned the criteria for admission to an inpatient psychiatric unit: imminent harm to self, imminent harm to others, or the inability to care for self.1 The standard risk assessment. In residency training, each patient encounter trains us in the challenging practice of risk assessment in potentially dangerous situations. One quickly learns the anxiety a moderate risk patient will cause.
Less discussed than the risk assessment, but certainly, a frequent challenge facing psychiatry residents is whether an admission is “good” or “bad.” The bad admission reflects the type of patient and situation, when you, the psychiatrist, basically know that inpatient admission is likely inappropriate.2 Usually, these occur when your hands are tied by structural and systemic pressures. Perhaps the patient is a known “high utilizer” whose admission is primarily motivated by homelessness or lack of community mental health resources.3 Or maybe the bad admission is a patient with a personality disorder who is consistently readmitted by each resident in the program with seemingly little improvement after each admission.4 Bad admissions are the type of patient who, as the overnight resident, you feel a touch embarrassed signing out to the fresh resident there to relieve you in the morning. In these cases, I find myself making various justifications: It was a busy night; there was no collateral; no family; no friends; no outpatient support. I tell myself, I just couldn’t manage a safe enough discharge. I couldn’t mitigate the risk enough.
If the situation allows in the midst of the tumult, I create an intimate space to interview my patient. I pull up a chair and lean in to listen. To maintain an empathetic stance, I must recognize and control my biases toward high utilizers, drug use, homelessness, noncompliance, and the other host of factors that may influence my judgment. Between the hours of 1 a.m. and 6 a.m., fatigue, in particular, will breed negative countertransference. Before I sit down to listen, I repeat my mantra to myself: The least I can offer is kindness. Then the assessment and the decision-making process that leads to an admission or a discharge begins.
When I’m on call, I am torn by my obligations: to the patient, their safety and well-being; to the health care system and distributive justice; to making the “right” decision to admit or discharge; to my nursing staff and their safety; to my supervisors and my fellow residents who will judge and must deal with my clinical decision to admit or discharge. Some of these obligations that I struggle to balance are outlined as core competencies by the Accreditation Council for Graduate Medical Education and the American Board of Psychiatry and Neurology, and called the Psychiatry Milestone Project.5 I am supposed to be thinking about these issues as I work up a patient, evaluating, and making purposeful trade-offs. The educational language of these core competencies does not capture the tensions of these complicated on-call experiences.
The most useful thing I have learned this year is that the decision to admit or discharge is not a binary decision. The very act of assessment through an interview and making a plan with the patient is valuable in itself as risk mitigation. Only recently as a second-year resident have I fully realized how my presence could have therapeutic effects. Even a brief interview in the emergency department can be generative. I try to bring calm to the chaos around the patient. I listen, elicit protective factors and coping skills, and try to mobilize hope and internal strength building capabilities just as we are taught in my residency program.
However, I admittedly continue to dread my overnight calls. As a second-year resident, I am still uncomfortable with the ambiguity in some decisions to admit or discharge. Nonetheless, I recognize these experiences are only helping me become a better psychiatrist with every night I spend running between the ED and the psychiatric unit. To get through this process of residency, I have formulated another mantra: Every call and every patient is a learning experience.
References
1. BMC Health Serv Res. 2006;6:150.
2. Health Policy. 2000 Oct;53(3):157-84.
3. Adm Policy Ment Health. 2012 May;39(3):200-9.
4. Psychiatr Serv. 2015 Jan 1;66(1):15-20.
5. “The Psychiatry Milestone Project”: Assessment Tools. A Joint Initiative of the Accreditation Council for Graduate Medical Education and the American Board of Psychiatry and Neurology.
Dr. Posada is a second-year resident in the psychiatry & behavioral sciences department at George Washington University, Washington. She completed a bachelor’s degree at the George Washington University. For 2 years after her undergraduate education, she worked at the National Institutes of Allergy and Infectious Diseases studying HIV pathogenesis. Dr. Posada completed her medical degree at the University of Texas Medical Branch in Galveston. Her interests include public psychiatry, health care policy, health disparities, and psychosomatic medicine.
In my first week of intern year, I learned the criteria for admission to an inpatient psychiatric unit: imminent harm to self, imminent harm to others, or the inability to care for self.1 The standard risk assessment. In residency training, each patient encounter trains us in the challenging practice of risk assessment in potentially dangerous situations. One quickly learns the anxiety a moderate risk patient will cause.
Less discussed than the risk assessment, but certainly, a frequent challenge facing psychiatry residents is whether an admission is “good” or “bad.” The bad admission reflects the type of patient and situation, when you, the psychiatrist, basically know that inpatient admission is likely inappropriate.2 Usually, these occur when your hands are tied by structural and systemic pressures. Perhaps the patient is a known “high utilizer” whose admission is primarily motivated by homelessness or lack of community mental health resources.3 Or maybe the bad admission is a patient with a personality disorder who is consistently readmitted by each resident in the program with seemingly little improvement after each admission.4 Bad admissions are the type of patient who, as the overnight resident, you feel a touch embarrassed signing out to the fresh resident there to relieve you in the morning. In these cases, I find myself making various justifications: It was a busy night; there was no collateral; no family; no friends; no outpatient support. I tell myself, I just couldn’t manage a safe enough discharge. I couldn’t mitigate the risk enough.
If the situation allows in the midst of the tumult, I create an intimate space to interview my patient. I pull up a chair and lean in to listen. To maintain an empathetic stance, I must recognize and control my biases toward high utilizers, drug use, homelessness, noncompliance, and the other host of factors that may influence my judgment. Between the hours of 1 a.m. and 6 a.m., fatigue, in particular, will breed negative countertransference. Before I sit down to listen, I repeat my mantra to myself: The least I can offer is kindness. Then the assessment and the decision-making process that leads to an admission or a discharge begins.
When I’m on call, I am torn by my obligations: to the patient, their safety and well-being; to the health care system and distributive justice; to making the “right” decision to admit or discharge; to my nursing staff and their safety; to my supervisors and my fellow residents who will judge and must deal with my clinical decision to admit or discharge. Some of these obligations that I struggle to balance are outlined as core competencies by the Accreditation Council for Graduate Medical Education and the American Board of Psychiatry and Neurology, and called the Psychiatry Milestone Project.5 I am supposed to be thinking about these issues as I work up a patient, evaluating, and making purposeful trade-offs. The educational language of these core competencies does not capture the tensions of these complicated on-call experiences.
The most useful thing I have learned this year is that the decision to admit or discharge is not a binary decision. The very act of assessment through an interview and making a plan with the patient is valuable in itself as risk mitigation. Only recently as a second-year resident have I fully realized how my presence could have therapeutic effects. Even a brief interview in the emergency department can be generative. I try to bring calm to the chaos around the patient. I listen, elicit protective factors and coping skills, and try to mobilize hope and internal strength building capabilities just as we are taught in my residency program.
However, I admittedly continue to dread my overnight calls. As a second-year resident, I am still uncomfortable with the ambiguity in some decisions to admit or discharge. Nonetheless, I recognize these experiences are only helping me become a better psychiatrist with every night I spend running between the ED and the psychiatric unit. To get through this process of residency, I have formulated another mantra: Every call and every patient is a learning experience.
References
1. BMC Health Serv Res. 2006;6:150.
2. Health Policy. 2000 Oct;53(3):157-84.
3. Adm Policy Ment Health. 2012 May;39(3):200-9.
4. Psychiatr Serv. 2015 Jan 1;66(1):15-20.
5. “The Psychiatry Milestone Project”: Assessment Tools. A Joint Initiative of the Accreditation Council for Graduate Medical Education and the American Board of Psychiatry and Neurology.
Dr. Posada is a second-year resident in the psychiatry & behavioral sciences department at George Washington University, Washington. She completed a bachelor’s degree at the George Washington University. For 2 years after her undergraduate education, she worked at the National Institutes of Allergy and Infectious Diseases studying HIV pathogenesis. Dr. Posada completed her medical degree at the University of Texas Medical Branch in Galveston. Her interests include public psychiatry, health care policy, health disparities, and psychosomatic medicine.
MACRA
Given the copious amount of printed and blog space that has been devoted in recent months to MACRA – the Medicare Access and CHIP Reauthorization Act of 2015 – I felt no particular obligation to add to the din. Then I was startled to read a recent poll from Deloitte that found that half of all private-practice physicians had never heard of MACRA. Furthermore, only 21% of solo or small-group physicians, and 9% of those employed by hospitals or larger groups, were even somewhat familiar with its financial implications.
Since yet another significant percentage of your Medicare reimbursements will be at risk under this new bureaucracy, an introduction is in order.
When the new system is implemented in 2019, physicians must choose between two payment tracks: the Merit-Based Incentive System (MIPS) or one of the so-called Alternate Payment Models (APM).
The MIPS track will use the four reporting programs just mentioned to compile a composite score between 0 and 100 each year for every practitioner, based on four performance metrics: quality measures listed in Qualified Clinical Data Registries, such as Approved Quality Improvement; total resources used by each practitioner, as measured by VBM; “improvement activities” (MOC); and MU, in some new, as-yet-undefined form. You can earn a bonus of 4% of reimbursement in 2019, rising to 5% in 2020, 7% in 2021, and 9% in 2022 – or you can be penalized those amounts (“negative adjustments”) if your performance doesn’t measure up.
The Centers for Medicare & Medicaid Services initially estimated that most physicians in groups of 24 or fewer on the MIPS track would incur a penalty in 2019; but the final MACRA regulations, issued in mid-October, allow a more gradual implementation that should decrease the penalty burden for small practices, at least initially. For example, you can avoid a penalty – but not qualify for a bonus – in 2019 by reporting your performance in only one quality-of-care or practice-improvement category, or by reporting for only a portion of the year. A decrease in penalties, however, means a smaller pot for bonuses – and reprieves will be temporary.
The alternative, APM, is difficult to discuss at present as very few models have been presented, or even defined, to date. Only Accountable Care Organizations (ACOs) have been introduced in any quantity, and most have failed miserably in real-world settings. The Episode of Care model, which pays providers a fixed amount for all services rendered in a bundle (“episode”) of care, has been discussed at some length, but remains untested, and in the end, may turn out to be just another variant of capitation.
So, which to choose? Long term, I strongly suggest that everyone prepare for the APM track as soon as better, more efficient APMs become available, as it appears that there will be more financial security, with less risk of penalties; but you will probably need to start in the MIPS program, as most projections indicate that the great majority of practitioners, particularly those in smaller operations, will do.
While some may be prompted to join a larger organization or network to decrease their risk of MIPS penalties and gain quicker access to the APM track – which may well be one of CMS’ surreptitious goals in introducing MACRA in the first place – there are steps that those individuals and small groups who choose to remain independent can take now to maximize their chances of landing on the bonus side of the MIPS ledger.
First, make sure your practice data is accurate on the Medicare Provider Enrollment, Chain, and Ownership System (PECOS) – where CMS will gather data for the VBM and Physician Feedback Reports. Study the quality benchmarks, and review your Quality Resource and Use Report (QRUR), which gathers information about each practice’s quality and performance rates for the VBM. (Both PECOS and QRUR can be downloaded at CMS.gov.) And, of course, report successfully for PQRS, which will avoid an automatic penalty of 4% 2 years hence.
If the alphabet soup above has your head swimming, join the club – you’re far from alone; but don’t be discouraged. CMS has already indicated its willingness to make changes aimed at decreasing the administrative burden and, in its words, “making the transition to MACRA as simple and as flexible as possible.”
Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters, and is a longtime monthly columnist for Dermatology News. Write to him at [email protected] .
Given the copious amount of printed and blog space that has been devoted in recent months to MACRA – the Medicare Access and CHIP Reauthorization Act of 2015 – I felt no particular obligation to add to the din. Then I was startled to read a recent poll from Deloitte that found that half of all private-practice physicians had never heard of MACRA. Furthermore, only 21% of solo or small-group physicians, and 9% of those employed by hospitals or larger groups, were even somewhat familiar with its financial implications.
Since yet another significant percentage of your Medicare reimbursements will be at risk under this new bureaucracy, an introduction is in order.
When the new system is implemented in 2019, physicians must choose between two payment tracks: the Merit-Based Incentive System (MIPS) or one of the so-called Alternate Payment Models (APM).
The MIPS track will use the four reporting programs just mentioned to compile a composite score between 0 and 100 each year for every practitioner, based on four performance metrics: quality measures listed in Qualified Clinical Data Registries, such as Approved Quality Improvement; total resources used by each practitioner, as measured by VBM; “improvement activities” (MOC); and MU, in some new, as-yet-undefined form. You can earn a bonus of 4% of reimbursement in 2019, rising to 5% in 2020, 7% in 2021, and 9% in 2022 – or you can be penalized those amounts (“negative adjustments”) if your performance doesn’t measure up.
The Centers for Medicare & Medicaid Services initially estimated that most physicians in groups of 24 or fewer on the MIPS track would incur a penalty in 2019; but the final MACRA regulations, issued in mid-October, allow a more gradual implementation that should decrease the penalty burden for small practices, at least initially. For example, you can avoid a penalty – but not qualify for a bonus – in 2019 by reporting your performance in only one quality-of-care or practice-improvement category, or by reporting for only a portion of the year. A decrease in penalties, however, means a smaller pot for bonuses – and reprieves will be temporary.
The alternative, APM, is difficult to discuss at present as very few models have been presented, or even defined, to date. Only Accountable Care Organizations (ACOs) have been introduced in any quantity, and most have failed miserably in real-world settings. The Episode of Care model, which pays providers a fixed amount for all services rendered in a bundle (“episode”) of care, has been discussed at some length, but remains untested, and in the end, may turn out to be just another variant of capitation.
So, which to choose? Long term, I strongly suggest that everyone prepare for the APM track as soon as better, more efficient APMs become available, as it appears that there will be more financial security, with less risk of penalties; but you will probably need to start in the MIPS program, as most projections indicate that the great majority of practitioners, particularly those in smaller operations, will do.
While some may be prompted to join a larger organization or network to decrease their risk of MIPS penalties and gain quicker access to the APM track – which may well be one of CMS’ surreptitious goals in introducing MACRA in the first place – there are steps that those individuals and small groups who choose to remain independent can take now to maximize their chances of landing on the bonus side of the MIPS ledger.
First, make sure your practice data is accurate on the Medicare Provider Enrollment, Chain, and Ownership System (PECOS) – where CMS will gather data for the VBM and Physician Feedback Reports. Study the quality benchmarks, and review your Quality Resource and Use Report (QRUR), which gathers information about each practice’s quality and performance rates for the VBM. (Both PECOS and QRUR can be downloaded at CMS.gov.) And, of course, report successfully for PQRS, which will avoid an automatic penalty of 4% 2 years hence.
If the alphabet soup above has your head swimming, join the club – you’re far from alone; but don’t be discouraged. CMS has already indicated its willingness to make changes aimed at decreasing the administrative burden and, in its words, “making the transition to MACRA as simple and as flexible as possible.”
Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters, and is a longtime monthly columnist for Dermatology News. Write to him at [email protected] .
Given the copious amount of printed and blog space that has been devoted in recent months to MACRA – the Medicare Access and CHIP Reauthorization Act of 2015 – I felt no particular obligation to add to the din. Then I was startled to read a recent poll from Deloitte that found that half of all private-practice physicians had never heard of MACRA. Furthermore, only 21% of solo or small-group physicians, and 9% of those employed by hospitals or larger groups, were even somewhat familiar with its financial implications.
Since yet another significant percentage of your Medicare reimbursements will be at risk under this new bureaucracy, an introduction is in order.
When the new system is implemented in 2019, physicians must choose between two payment tracks: the Merit-Based Incentive System (MIPS) or one of the so-called Alternate Payment Models (APM).
The MIPS track will use the four reporting programs just mentioned to compile a composite score between 0 and 100 each year for every practitioner, based on four performance metrics: quality measures listed in Qualified Clinical Data Registries, such as Approved Quality Improvement; total resources used by each practitioner, as measured by VBM; “improvement activities” (MOC); and MU, in some new, as-yet-undefined form. You can earn a bonus of 4% of reimbursement in 2019, rising to 5% in 2020, 7% in 2021, and 9% in 2022 – or you can be penalized those amounts (“negative adjustments”) if your performance doesn’t measure up.
The Centers for Medicare & Medicaid Services initially estimated that most physicians in groups of 24 or fewer on the MIPS track would incur a penalty in 2019; but the final MACRA regulations, issued in mid-October, allow a more gradual implementation that should decrease the penalty burden for small practices, at least initially. For example, you can avoid a penalty – but not qualify for a bonus – in 2019 by reporting your performance in only one quality-of-care or practice-improvement category, or by reporting for only a portion of the year. A decrease in penalties, however, means a smaller pot for bonuses – and reprieves will be temporary.
The alternative, APM, is difficult to discuss at present as very few models have been presented, or even defined, to date. Only Accountable Care Organizations (ACOs) have been introduced in any quantity, and most have failed miserably in real-world settings. The Episode of Care model, which pays providers a fixed amount for all services rendered in a bundle (“episode”) of care, has been discussed at some length, but remains untested, and in the end, may turn out to be just another variant of capitation.
So, which to choose? Long term, I strongly suggest that everyone prepare for the APM track as soon as better, more efficient APMs become available, as it appears that there will be more financial security, with less risk of penalties; but you will probably need to start in the MIPS program, as most projections indicate that the great majority of practitioners, particularly those in smaller operations, will do.
While some may be prompted to join a larger organization or network to decrease their risk of MIPS penalties and gain quicker access to the APM track – which may well be one of CMS’ surreptitious goals in introducing MACRA in the first place – there are steps that those individuals and small groups who choose to remain independent can take now to maximize their chances of landing on the bonus side of the MIPS ledger.
First, make sure your practice data is accurate on the Medicare Provider Enrollment, Chain, and Ownership System (PECOS) – where CMS will gather data for the VBM and Physician Feedback Reports. Study the quality benchmarks, and review your Quality Resource and Use Report (QRUR), which gathers information about each practice’s quality and performance rates for the VBM. (Both PECOS and QRUR can be downloaded at CMS.gov.) And, of course, report successfully for PQRS, which will avoid an automatic penalty of 4% 2 years hence.
If the alphabet soup above has your head swimming, join the club – you’re far from alone; but don’t be discouraged. CMS has already indicated its willingness to make changes aimed at decreasing the administrative burden and, in its words, “making the transition to MACRA as simple and as flexible as possible.”
Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters, and is a longtime monthly columnist for Dermatology News. Write to him at [email protected] .
Myth of the Month: Does nitroglycerin response predict coronary artery disease?
A 55-year-old man presents to the emergency department with substernal chest pain. The pain has occurred off and on over the past 2 hours. He has no family history of coronary artery disease. He has no history of diabetes, hypertension, or cigarette smoking. His most recent total cholesterol was 220 mg/dL (HDL, 40; LDL, 155). Blood pressure is 130/70. An ECG obtained on arrival is unremarkable. When he reached the ED, he received a nitroglycerin tablet with resolution of his pain within 4 minutes.
What is the most accurate statement?
A. The chance of CAD in this man over the next 10 years was 8% before his symptoms and is now greater than 20%.
B. The chance of CAD in this man over the next 10 years was 8% and is still 8%.
C. The chance of CAD in this man over the next 10 years was 15% before his symptoms and is now close to 100%.
D. The chance of CAD in this man over the next 10 years was 15% before his symptoms and is now close to 50%.
For years, giving nitroglycerin to patients who present with chest pain has been considered a good therapy, and the response to the medication has been considered a sign that the pain was likely due to cardiac ischemia. Is there evidence that this is true?
The study was a retrospective review of 223 patients who presented to the ED over a 5-month period with ongoing chest pain. They looked at patients who had ongoing chest pain in the ED, received nitroglycerin, and did not receive any therapy other than aspirin within 10 minutes of receiving nitroglycerin. Nitroglycerin response was compared with the final diagnosis of cardiac versus noncardiac chest pain.
Of the patients with a final determination of cardiac chest pain, 88% had a nitroglycerin response, whereas 92% of the patients with noncardiac chest pain had a nitroglycerin response (P = .50).
Deborah B. Diercks, MD, and her colleagues looked at improvement in chest pain scores in the ED in patients treated with nitroglycerin and whether it correlated with a cardiac etiology of chest pain.2 The study was a prospective, observational study of 664 patients in an urban tertiary care ED over a 16-month period. An 11-point numeric chest pain scale was assessed and recorded by research assistants before and 5 minutes after receiving nitroglycerin. The scale ranged from 0 (no pain) to 10 (worst pain imaginable).
A final diagnosis of a cardiac etiology for chest pain was found in 18% of the patients in the study. Of the patients who had cardiac-related chest pain, 20% had no reduction in pain with nitroglycerin, compared with 19% of the patients without cardiac-related chest pain. Complete or significant reduction in chest pain occurred with nitroglycerin in 31% of patients with cardiac chest pain and 27% of the patients without cardiac chest pain (P = .76).
Two other studies with similar designs showed similar results. Robert Steele, MD, and his colleagues studied 270 patients in a prospective observational cohort study of patients with chest pain presenting to an urban ED.3 Patients presenting to the ED with active chest pain who received nitroglycerin were enrolled.
The sensitivity in this study for nitroglycerin relief determining cardiac chest pain was 72%, and the specificity was 37%, with a positive likelihood ratio for coronary artery disease if nitroglycerin response of 1.1 (0.96-1.34).
In another prospective, observational cohort study, 459 patients who presented to an ED with chest pain were evaluated for response to nitroglycerin as a marker for ischemic cardiac disease.4 In this study, presence of ischemic cardiac disease was defined as diagnosis in the ED or during a 4-month follow-up period. Nitroglycerin relieved chest pain in 35% of patients who had coronary disease, whereas 41% of patients without coronary disease had a nitroglycerin response. This study had a much lower overall nitroglycerin response rate than any of the other studies.
Katherine Grailey, MD, and Paul Glasziou, MD, PhD, published a meta-analysis of nitroglycerin use for the diagnosis of chest pain, using the above referenced studies. They concluded that in the acute setting, nitroglycerin is not a reliable test of treatment for use in diagnosis of coronary artery disease.5
High response rate for nitroglycerin in the noncoronary artery groups in the studies may be due to a strong placebo effect and/or that nitroglycerin may help with pain caused by esophageal spasm. The lack of specificity in the pain relief response for nitroglycerin makes it not a helpful test. Note that all the studies have been in the acute, ED setting for chest pain. In the case presented at the beginning of the article, the response the patient had to nitroglycerin would not change the probability that he has coronary artery disease.
References
1. Am J Cardiol. 2002 Dec 1;90(11):1264-6.
2. Ann Emerg Med. 2005 Jun;45(6):581-5.
3. CJEM. 2006 May;8(3):164-9.
4. Ann Intern Med. 2003 Dec 16;139(12):979-86.
5. Emerg Med J. 2012 Mar;29(3):173-6.
Dr. Paauw is professor of medicine in the division of general internal medicine at the University of Washington, Seattle, and he serves as third-year medical student clerkship director at the University of Washington. Contact Dr. Paauw at [email protected] .
A 55-year-old man presents to the emergency department with substernal chest pain. The pain has occurred off and on over the past 2 hours. He has no family history of coronary artery disease. He has no history of diabetes, hypertension, or cigarette smoking. His most recent total cholesterol was 220 mg/dL (HDL, 40; LDL, 155). Blood pressure is 130/70. An ECG obtained on arrival is unremarkable. When he reached the ED, he received a nitroglycerin tablet with resolution of his pain within 4 minutes.
What is the most accurate statement?
A. The chance of CAD in this man over the next 10 years was 8% before his symptoms and is now greater than 20%.
B. The chance of CAD in this man over the next 10 years was 8% and is still 8%.
C. The chance of CAD in this man over the next 10 years was 15% before his symptoms and is now close to 100%.
D. The chance of CAD in this man over the next 10 years was 15% before his symptoms and is now close to 50%.
For years, giving nitroglycerin to patients who present with chest pain has been considered a good therapy, and the response to the medication has been considered a sign that the pain was likely due to cardiac ischemia. Is there evidence that this is true?
The study was a retrospective review of 223 patients who presented to the ED over a 5-month period with ongoing chest pain. They looked at patients who had ongoing chest pain in the ED, received nitroglycerin, and did not receive any therapy other than aspirin within 10 minutes of receiving nitroglycerin. Nitroglycerin response was compared with the final diagnosis of cardiac versus noncardiac chest pain.
Of the patients with a final determination of cardiac chest pain, 88% had a nitroglycerin response, whereas 92% of the patients with noncardiac chest pain had a nitroglycerin response (P = .50).
Deborah B. Diercks, MD, and her colleagues looked at improvement in chest pain scores in the ED in patients treated with nitroglycerin and whether it correlated with a cardiac etiology of chest pain.2 The study was a prospective, observational study of 664 patients in an urban tertiary care ED over a 16-month period. An 11-point numeric chest pain scale was assessed and recorded by research assistants before and 5 minutes after receiving nitroglycerin. The scale ranged from 0 (no pain) to 10 (worst pain imaginable).
A final diagnosis of a cardiac etiology for chest pain was found in 18% of the patients in the study. Of the patients who had cardiac-related chest pain, 20% had no reduction in pain with nitroglycerin, compared with 19% of the patients without cardiac-related chest pain. Complete or significant reduction in chest pain occurred with nitroglycerin in 31% of patients with cardiac chest pain and 27% of the patients without cardiac chest pain (P = .76).
Two other studies with similar designs showed similar results. Robert Steele, MD, and his colleagues studied 270 patients in a prospective observational cohort study of patients with chest pain presenting to an urban ED.3 Patients presenting to the ED with active chest pain who received nitroglycerin were enrolled.
The sensitivity in this study for nitroglycerin relief determining cardiac chest pain was 72%, and the specificity was 37%, with a positive likelihood ratio for coronary artery disease if nitroglycerin response of 1.1 (0.96-1.34).
In another prospective, observational cohort study, 459 patients who presented to an ED with chest pain were evaluated for response to nitroglycerin as a marker for ischemic cardiac disease.4 In this study, presence of ischemic cardiac disease was defined as diagnosis in the ED or during a 4-month follow-up period. Nitroglycerin relieved chest pain in 35% of patients who had coronary disease, whereas 41% of patients without coronary disease had a nitroglycerin response. This study had a much lower overall nitroglycerin response rate than any of the other studies.
Katherine Grailey, MD, and Paul Glasziou, MD, PhD, published a meta-analysis of nitroglycerin use for the diagnosis of chest pain, using the above referenced studies. They concluded that in the acute setting, nitroglycerin is not a reliable test of treatment for use in diagnosis of coronary artery disease.5
High response rate for nitroglycerin in the noncoronary artery groups in the studies may be due to a strong placebo effect and/or that nitroglycerin may help with pain caused by esophageal spasm. The lack of specificity in the pain relief response for nitroglycerin makes it not a helpful test. Note that all the studies have been in the acute, ED setting for chest pain. In the case presented at the beginning of the article, the response the patient had to nitroglycerin would not change the probability that he has coronary artery disease.
References
1. Am J Cardiol. 2002 Dec 1;90(11):1264-6.
2. Ann Emerg Med. 2005 Jun;45(6):581-5.
3. CJEM. 2006 May;8(3):164-9.
4. Ann Intern Med. 2003 Dec 16;139(12):979-86.
5. Emerg Med J. 2012 Mar;29(3):173-6.
Dr. Paauw is professor of medicine in the division of general internal medicine at the University of Washington, Seattle, and he serves as third-year medical student clerkship director at the University of Washington. Contact Dr. Paauw at [email protected] .
A 55-year-old man presents to the emergency department with substernal chest pain. The pain has occurred off and on over the past 2 hours. He has no family history of coronary artery disease. He has no history of diabetes, hypertension, or cigarette smoking. His most recent total cholesterol was 220 mg/dL (HDL, 40; LDL, 155). Blood pressure is 130/70. An ECG obtained on arrival is unremarkable. When he reached the ED, he received a nitroglycerin tablet with resolution of his pain within 4 minutes.
What is the most accurate statement?
A. The chance of CAD in this man over the next 10 years was 8% before his symptoms and is now greater than 20%.
B. The chance of CAD in this man over the next 10 years was 8% and is still 8%.
C. The chance of CAD in this man over the next 10 years was 15% before his symptoms and is now close to 100%.
D. The chance of CAD in this man over the next 10 years was 15% before his symptoms and is now close to 50%.
For years, giving nitroglycerin to patients who present with chest pain has been considered a good therapy, and the response to the medication has been considered a sign that the pain was likely due to cardiac ischemia. Is there evidence that this is true?
The study was a retrospective review of 223 patients who presented to the ED over a 5-month period with ongoing chest pain. They looked at patients who had ongoing chest pain in the ED, received nitroglycerin, and did not receive any therapy other than aspirin within 10 minutes of receiving nitroglycerin. Nitroglycerin response was compared with the final diagnosis of cardiac versus noncardiac chest pain.
Of the patients with a final determination of cardiac chest pain, 88% had a nitroglycerin response, whereas 92% of the patients with noncardiac chest pain had a nitroglycerin response (P = .50).
Deborah B. Diercks, MD, and her colleagues looked at improvement in chest pain scores in the ED in patients treated with nitroglycerin and whether it correlated with a cardiac etiology of chest pain.2 The study was a prospective, observational study of 664 patients in an urban tertiary care ED over a 16-month period. An 11-point numeric chest pain scale was assessed and recorded by research assistants before and 5 minutes after receiving nitroglycerin. The scale ranged from 0 (no pain) to 10 (worst pain imaginable).
A final diagnosis of a cardiac etiology for chest pain was found in 18% of the patients in the study. Of the patients who had cardiac-related chest pain, 20% had no reduction in pain with nitroglycerin, compared with 19% of the patients without cardiac-related chest pain. Complete or significant reduction in chest pain occurred with nitroglycerin in 31% of patients with cardiac chest pain and 27% of the patients without cardiac chest pain (P = .76).
Two other studies with similar designs showed similar results. Robert Steele, MD, and his colleagues studied 270 patients in a prospective observational cohort study of patients with chest pain presenting to an urban ED.3 Patients presenting to the ED with active chest pain who received nitroglycerin were enrolled.
The sensitivity in this study for nitroglycerin relief determining cardiac chest pain was 72%, and the specificity was 37%, with a positive likelihood ratio for coronary artery disease if nitroglycerin response of 1.1 (0.96-1.34).
In another prospective, observational cohort study, 459 patients who presented to an ED with chest pain were evaluated for response to nitroglycerin as a marker for ischemic cardiac disease.4 In this study, presence of ischemic cardiac disease was defined as diagnosis in the ED or during a 4-month follow-up period. Nitroglycerin relieved chest pain in 35% of patients who had coronary disease, whereas 41% of patients without coronary disease had a nitroglycerin response. This study had a much lower overall nitroglycerin response rate than any of the other studies.
Katherine Grailey, MD, and Paul Glasziou, MD, PhD, published a meta-analysis of nitroglycerin use for the diagnosis of chest pain, using the above referenced studies. They concluded that in the acute setting, nitroglycerin is not a reliable test of treatment for use in diagnosis of coronary artery disease.5
High response rate for nitroglycerin in the noncoronary artery groups in the studies may be due to a strong placebo effect and/or that nitroglycerin may help with pain caused by esophageal spasm. The lack of specificity in the pain relief response for nitroglycerin makes it not a helpful test. Note that all the studies have been in the acute, ED setting for chest pain. In the case presented at the beginning of the article, the response the patient had to nitroglycerin would not change the probability that he has coronary artery disease.
References
1. Am J Cardiol. 2002 Dec 1;90(11):1264-6.
2. Ann Emerg Med. 2005 Jun;45(6):581-5.
3. CJEM. 2006 May;8(3):164-9.
4. Ann Intern Med. 2003 Dec 16;139(12):979-86.
5. Emerg Med J. 2012 Mar;29(3):173-6.
Dr. Paauw is professor of medicine in the division of general internal medicine at the University of Washington, Seattle, and he serves as third-year medical student clerkship director at the University of Washington. Contact Dr. Paauw at [email protected] .
Addressing sex and gender inequality in biomedical research
in two general areas. Not only are biologic sex and gender insufficiently reported within research studies, but women are also underrepresented as basic and clinical researchers in academic medicine. While these issues may seem unrelated, addressing both will diversify knowledge and interdisciplinary research teams, as well as improve the value of the science produced and ultimately the quality of health care provided.
In 1986, the National Institutes of Health instituted a policy urging the inclusion of women as subjects in clinical trials. This policy became law when Congress passed the NIH Revitalization Act of 1993, which requires that NIH-supported clinical research include women and minorities as subjects “in approximately equal numbers of both sexes … unless different proportions are appropriate because of known prevalence, incidence, morbidity, mortality rates, or expected intervention effect.” Women of childbearing potential cannot be routinely excluded without a strong scientific rationale.
Despite these initiatives, evidence suggests that sex/gender is still not sufficiently considered as a biologic variable in federally funded research, and studies oftentimes fail to account for the cultural and societal influences of gender in health outcomes. Women comprise more than half of clinical trial participants, yet 75% of federally funded studies published in 2009 failed to report any outcomes by sex/gender. Recent events, such as the Food and Drug Administration’s updated Ambien dosage recommendation for men versus women, demonstrate the harmful effects of failing to account for sex as a biologic variable.
In recognition of the slow progress, the NIH required that research grants submitted after Jan. 25, 2016, address biologic sex within their research design and added reviewer criteria related to consideration of biologic sex in the research proposal. Ensuring enhanced inclusion, analysis, and reporting of sex and gender goes beyond NIH policy to include NIH enforcement of its own policies. In addition, journal editors should add review criteria related to sex and gender, and researchers themselves should examine potential sex/gender differences in their research.
The NIH and ORWH have implemented various programs to diversify the sciences; however, change has been less than desired. Studies indicate that females have lower publication rates throughout their careers, and are less likely to receive an R01 than men, despite reporting equal likelihood of applying for R01 awards. Additionally, the intraorganizational and network reach of female scientists is smaller than that of men, hindering opportunities for collaboration and publication. Even in the instance of equally qualified men and women conducting comparable work, investigators find differential pay between male and female researchers, as well as differential promotion to leadership positions. These factors, both in part caused by and exacerbated by unconscious or implicit interpersonal and institutional biases, lead to higher female attrition within the sciences and academia.
Addressing disparities and promoting greater inclusion includes unmasking unconscious bias and putting greater efforts toward mentoring and leadership initiatives for women. Only by partnering efforts to increase inclusion of sex/gender within research design with efforts to diversify the biomedical workforce can we adequately consider the role of sex and gender in biomedical research.
Dr. Geller is the G. William Arends Professor of Obstetrics and Gynecology at the University of Illinois College of Medicine, and the Director of the UIC Center for Research on Women and Gender. Ms. Koch is a senior research specialist at the Center for Research on Women and Gender. They reported having no financial disclosures.
in two general areas. Not only are biologic sex and gender insufficiently reported within research studies, but women are also underrepresented as basic and clinical researchers in academic medicine. While these issues may seem unrelated, addressing both will diversify knowledge and interdisciplinary research teams, as well as improve the value of the science produced and ultimately the quality of health care provided.
In 1986, the National Institutes of Health instituted a policy urging the inclusion of women as subjects in clinical trials. This policy became law when Congress passed the NIH Revitalization Act of 1993, which requires that NIH-supported clinical research include women and minorities as subjects “in approximately equal numbers of both sexes … unless different proportions are appropriate because of known prevalence, incidence, morbidity, mortality rates, or expected intervention effect.” Women of childbearing potential cannot be routinely excluded without a strong scientific rationale.
Despite these initiatives, evidence suggests that sex/gender is still not sufficiently considered as a biologic variable in federally funded research, and studies oftentimes fail to account for the cultural and societal influences of gender in health outcomes. Women comprise more than half of clinical trial participants, yet 75% of federally funded studies published in 2009 failed to report any outcomes by sex/gender. Recent events, such as the Food and Drug Administration’s updated Ambien dosage recommendation for men versus women, demonstrate the harmful effects of failing to account for sex as a biologic variable.
In recognition of the slow progress, the NIH required that research grants submitted after Jan. 25, 2016, address biologic sex within their research design and added reviewer criteria related to consideration of biologic sex in the research proposal. Ensuring enhanced inclusion, analysis, and reporting of sex and gender goes beyond NIH policy to include NIH enforcement of its own policies. In addition, journal editors should add review criteria related to sex and gender, and researchers themselves should examine potential sex/gender differences in their research.
The NIH and ORWH have implemented various programs to diversify the sciences; however, change has been less than desired. Studies indicate that females have lower publication rates throughout their careers, and are less likely to receive an R01 than men, despite reporting equal likelihood of applying for R01 awards. Additionally, the intraorganizational and network reach of female scientists is smaller than that of men, hindering opportunities for collaboration and publication. Even in the instance of equally qualified men and women conducting comparable work, investigators find differential pay between male and female researchers, as well as differential promotion to leadership positions. These factors, both in part caused by and exacerbated by unconscious or implicit interpersonal and institutional biases, lead to higher female attrition within the sciences and academia.
Addressing disparities and promoting greater inclusion includes unmasking unconscious bias and putting greater efforts toward mentoring and leadership initiatives for women. Only by partnering efforts to increase inclusion of sex/gender within research design with efforts to diversify the biomedical workforce can we adequately consider the role of sex and gender in biomedical research.
Dr. Geller is the G. William Arends Professor of Obstetrics and Gynecology at the University of Illinois College of Medicine, and the Director of the UIC Center for Research on Women and Gender. Ms. Koch is a senior research specialist at the Center for Research on Women and Gender. They reported having no financial disclosures.
in two general areas. Not only are biologic sex and gender insufficiently reported within research studies, but women are also underrepresented as basic and clinical researchers in academic medicine. While these issues may seem unrelated, addressing both will diversify knowledge and interdisciplinary research teams, as well as improve the value of the science produced and ultimately the quality of health care provided.
In 1986, the National Institutes of Health instituted a policy urging the inclusion of women as subjects in clinical trials. This policy became law when Congress passed the NIH Revitalization Act of 1993, which requires that NIH-supported clinical research include women and minorities as subjects “in approximately equal numbers of both sexes … unless different proportions are appropriate because of known prevalence, incidence, morbidity, mortality rates, or expected intervention effect.” Women of childbearing potential cannot be routinely excluded without a strong scientific rationale.
Despite these initiatives, evidence suggests that sex/gender is still not sufficiently considered as a biologic variable in federally funded research, and studies oftentimes fail to account for the cultural and societal influences of gender in health outcomes. Women comprise more than half of clinical trial participants, yet 75% of federally funded studies published in 2009 failed to report any outcomes by sex/gender. Recent events, such as the Food and Drug Administration’s updated Ambien dosage recommendation for men versus women, demonstrate the harmful effects of failing to account for sex as a biologic variable.
In recognition of the slow progress, the NIH required that research grants submitted after Jan. 25, 2016, address biologic sex within their research design and added reviewer criteria related to consideration of biologic sex in the research proposal. Ensuring enhanced inclusion, analysis, and reporting of sex and gender goes beyond NIH policy to include NIH enforcement of its own policies. In addition, journal editors should add review criteria related to sex and gender, and researchers themselves should examine potential sex/gender differences in their research.
The NIH and ORWH have implemented various programs to diversify the sciences; however, change has been less than desired. Studies indicate that females have lower publication rates throughout their careers, and are less likely to receive an R01 than men, despite reporting equal likelihood of applying for R01 awards. Additionally, the intraorganizational and network reach of female scientists is smaller than that of men, hindering opportunities for collaboration and publication. Even in the instance of equally qualified men and women conducting comparable work, investigators find differential pay between male and female researchers, as well as differential promotion to leadership positions. These factors, both in part caused by and exacerbated by unconscious or implicit interpersonal and institutional biases, lead to higher female attrition within the sciences and academia.
Addressing disparities and promoting greater inclusion includes unmasking unconscious bias and putting greater efforts toward mentoring and leadership initiatives for women. Only by partnering efforts to increase inclusion of sex/gender within research design with efforts to diversify the biomedical workforce can we adequately consider the role of sex and gender in biomedical research.
Dr. Geller is the G. William Arends Professor of Obstetrics and Gynecology at the University of Illinois College of Medicine, and the Director of the UIC Center for Research on Women and Gender. Ms. Koch is a senior research specialist at the Center for Research on Women and Gender. They reported having no financial disclosures.
Change in end-of-life cancer care imperative
With the passage of the Medicare Access and CHIP Reauthorization Act, changes to how cancer care is delivered are fast approaching. This legislation aims to reward value-based care and incentivize alternative payment models that prize quality. The shift from quantity-based to value-based reimbursement is motivated in part by the rising cost of health care as well as the growing demand from patients, employers, and payers to better understand the quality of care being delivered. In cancer care, one area of high-cost and questionable value being examined is aggressive care at the end of life.
The scientific pace of progress in cancer care is exciting, with 19 therapies approved or granted a new indication in 2015. New categories of drugs, such as immunotherapies, are changing how we treat patients. It is also a time of great change in how cancer care is being delivered in our clinics, hospitals, and academic institutions. We must be vigilant in learning from these experiments in care delivery to ensure that they deliver on their promise of value to patients.
Dr. Bobby Daly, Dr. Andrew Hantel, and Dr. Blase Polite are with the University of Chicago.
With the passage of the Medicare Access and CHIP Reauthorization Act, changes to how cancer care is delivered are fast approaching. This legislation aims to reward value-based care and incentivize alternative payment models that prize quality. The shift from quantity-based to value-based reimbursement is motivated in part by the rising cost of health care as well as the growing demand from patients, employers, and payers to better understand the quality of care being delivered. In cancer care, one area of high-cost and questionable value being examined is aggressive care at the end of life.
The scientific pace of progress in cancer care is exciting, with 19 therapies approved or granted a new indication in 2015. New categories of drugs, such as immunotherapies, are changing how we treat patients. It is also a time of great change in how cancer care is being delivered in our clinics, hospitals, and academic institutions. We must be vigilant in learning from these experiments in care delivery to ensure that they deliver on their promise of value to patients.
Dr. Bobby Daly, Dr. Andrew Hantel, and Dr. Blase Polite are with the University of Chicago.
With the passage of the Medicare Access and CHIP Reauthorization Act, changes to how cancer care is delivered are fast approaching. This legislation aims to reward value-based care and incentivize alternative payment models that prize quality. The shift from quantity-based to value-based reimbursement is motivated in part by the rising cost of health care as well as the growing demand from patients, employers, and payers to better understand the quality of care being delivered. In cancer care, one area of high-cost and questionable value being examined is aggressive care at the end of life.
The scientific pace of progress in cancer care is exciting, with 19 therapies approved or granted a new indication in 2015. New categories of drugs, such as immunotherapies, are changing how we treat patients. It is also a time of great change in how cancer care is being delivered in our clinics, hospitals, and academic institutions. We must be vigilant in learning from these experiments in care delivery to ensure that they deliver on their promise of value to patients.
Dr. Bobby Daly, Dr. Andrew Hantel, and Dr. Blase Polite are with the University of Chicago.
Clown therapy is community psychiatry in disguise
Ever had a patient who not only got better but used the insights she gained from talking with you to help others in distress? I have just such a patient in the Peruvian Amazon.
I’ve previously written about an annual clown trip to Peru that I make with my friend Patch Adams, MD, and 100 other humanitarian clowns from all over the world. We have been going there for a decade to spread cheer, and revitalize the impoverished community of Belén, which is situated in the Amazon floodplain in the city of Iquitos. We conduct workshops, perform street theater, create community art installations, visit hospitals, and work with local grass-roots organizations. For the last 5 years, we also have been conducting mental health clinics in the streets.
To provide a brief overview ... we go to a neighborhood, set up our space, and walk the streets with a bull horn. We announce our presence – “we are mental health professionals, and we’re meeting over at” ... and we talk with anybody, young and old, who wants to discuss health problems, family issues, or other concerns.
We sit in a public place and speak to individuals/couples/families for 20 minutes, while around us, support clowns entertain the kids. We neither make diagnoses nor give drugs; we come with a clown nose and an open heart, and we listen actively without judgment and focus on solutions. We help people identify their strengths and resilience, and give them practical advice. This is community psychiatry disguised as “clown therapy,” which is just another phrase for solution-oriented therapy/ positive psychology/reality therapy/resilience-based therapy, logotherapy, existential psychotherapy, or kitchen table wisdom. These street clinics have had a profound impact on patients and clinicians.
Three years ago, I met a middle-aged woman who was suicidally depressed, and together we negotiated a successful intervention. In summary, she emerged from a church that happened to be across the street from where we were setting up our clinic. A clown saw her weeping and approached her, and after talking with her assured her that there was somebody here right now – a mental health professional – who would talk with her.
Maria sat down and told an unbelievably painful story that was happening within her family. On that day, after 8 months of prayer and receiving no sign from God, she had decided to kill herself. After listening to her, I actually believed she could do it.
There are no treatment centers or emergency shelters for the poor in Belén, so at our closure, I made her promise that she would not try to kill herself until I could see her again at our next clinic 2 days away, and close by. I gave her an amulet that was blessed and told her it was a reminder of her promise, and that my smiling face would be with her until she saw me again. She returned with her daughters to the next clinic, and together, they found a way to take a step forward.
Last year, I made my first home visit, and met with Maria, her daughters, and new grandson in their “new” home where they were happily sustaining themselves . When I left, the love and appreciation was so overwhelming that I told them as long as I returned I would come visit every year.
I just got back from this year’s annual visit, and was again greeted with passionate tears of joy. We sat and talked, and Maria told me her story. It seems that people in the community were now coming to her as a resource when they were deeply depressed. People know that she had walked a similar path and moved beyond it.
She is a warm, good listener, and tells them a story about walking out of church and deciding she wanted to kill herself, and meeting with a tall gringo, a clown/doctor who miraculously saved her life. She gives them simple, practical advice, tells them how important it is to stay connected to their children, speak your truth with them openly; to pray for miracles and recognize them when they occur. She tells them to reach out for help, and people will reach out to them. She is a credible, inspiring friend who gives hope.
For those who remember when community psychiatry was actually a subspecialty, this is my vision of community mental health: People talking to credible witnesses/healers/resources in their community, whom they respect, who will listen without judgment, and maybe even say something that inspires a light in the darkness. It’s at least as effective as psychotropic drugs, and all its benefits come without side effects.
Once a year we come together, listen to each other’s stories, and continue our healing work together. Maria tells me her friends want to meet me. “They want to steal you away,” she says, “but I tell them I am not afraid.”
Maria, a lay therapist of sorts, is the community mental health consultant. Once a year, she consults with her gringo, the clown/doctor, to compare notes. We laugh and love, hug and cry, and give each other hope. No matter how divisive and polarizing the times, it is possible to come together in community and promote healing.
Dr. Hammerschlag is chief of community mental health of the Gesundheit! Institute and a faculty member at the University of Arizona, Phoenix. He is the author of several books on healing and spirituality, including “Kindling Spirit: Healing from Within” (New York: Turtle Island Press, 2010) and “The Dancing Healers: A Doctor’s Journey of Healing With Native Americans” (San Francisco: Harper, 1988). Dr. Hammerschlag’s website is healingdoc.com.
Ever had a patient who not only got better but used the insights she gained from talking with you to help others in distress? I have just such a patient in the Peruvian Amazon.
I’ve previously written about an annual clown trip to Peru that I make with my friend Patch Adams, MD, and 100 other humanitarian clowns from all over the world. We have been going there for a decade to spread cheer, and revitalize the impoverished community of Belén, which is situated in the Amazon floodplain in the city of Iquitos. We conduct workshops, perform street theater, create community art installations, visit hospitals, and work with local grass-roots organizations. For the last 5 years, we also have been conducting mental health clinics in the streets.
To provide a brief overview ... we go to a neighborhood, set up our space, and walk the streets with a bull horn. We announce our presence – “we are mental health professionals, and we’re meeting over at” ... and we talk with anybody, young and old, who wants to discuss health problems, family issues, or other concerns.
We sit in a public place and speak to individuals/couples/families for 20 minutes, while around us, support clowns entertain the kids. We neither make diagnoses nor give drugs; we come with a clown nose and an open heart, and we listen actively without judgment and focus on solutions. We help people identify their strengths and resilience, and give them practical advice. This is community psychiatry disguised as “clown therapy,” which is just another phrase for solution-oriented therapy/ positive psychology/reality therapy/resilience-based therapy, logotherapy, existential psychotherapy, or kitchen table wisdom. These street clinics have had a profound impact on patients and clinicians.
Three years ago, I met a middle-aged woman who was suicidally depressed, and together we negotiated a successful intervention. In summary, she emerged from a church that happened to be across the street from where we were setting up our clinic. A clown saw her weeping and approached her, and after talking with her assured her that there was somebody here right now – a mental health professional – who would talk with her.
Maria sat down and told an unbelievably painful story that was happening within her family. On that day, after 8 months of prayer and receiving no sign from God, she had decided to kill herself. After listening to her, I actually believed she could do it.
There are no treatment centers or emergency shelters for the poor in Belén, so at our closure, I made her promise that she would not try to kill herself until I could see her again at our next clinic 2 days away, and close by. I gave her an amulet that was blessed and told her it was a reminder of her promise, and that my smiling face would be with her until she saw me again. She returned with her daughters to the next clinic, and together, they found a way to take a step forward.
Last year, I made my first home visit, and met with Maria, her daughters, and new grandson in their “new” home where they were happily sustaining themselves . When I left, the love and appreciation was so overwhelming that I told them as long as I returned I would come visit every year.
I just got back from this year’s annual visit, and was again greeted with passionate tears of joy. We sat and talked, and Maria told me her story. It seems that people in the community were now coming to her as a resource when they were deeply depressed. People know that she had walked a similar path and moved beyond it.
She is a warm, good listener, and tells them a story about walking out of church and deciding she wanted to kill herself, and meeting with a tall gringo, a clown/doctor who miraculously saved her life. She gives them simple, practical advice, tells them how important it is to stay connected to their children, speak your truth with them openly; to pray for miracles and recognize them when they occur. She tells them to reach out for help, and people will reach out to them. She is a credible, inspiring friend who gives hope.
For those who remember when community psychiatry was actually a subspecialty, this is my vision of community mental health: People talking to credible witnesses/healers/resources in their community, whom they respect, who will listen without judgment, and maybe even say something that inspires a light in the darkness. It’s at least as effective as psychotropic drugs, and all its benefits come without side effects.
Once a year we come together, listen to each other’s stories, and continue our healing work together. Maria tells me her friends want to meet me. “They want to steal you away,” she says, “but I tell them I am not afraid.”
Maria, a lay therapist of sorts, is the community mental health consultant. Once a year, she consults with her gringo, the clown/doctor, to compare notes. We laugh and love, hug and cry, and give each other hope. No matter how divisive and polarizing the times, it is possible to come together in community and promote healing.
Dr. Hammerschlag is chief of community mental health of the Gesundheit! Institute and a faculty member at the University of Arizona, Phoenix. He is the author of several books on healing and spirituality, including “Kindling Spirit: Healing from Within” (New York: Turtle Island Press, 2010) and “The Dancing Healers: A Doctor’s Journey of Healing With Native Americans” (San Francisco: Harper, 1988). Dr. Hammerschlag’s website is healingdoc.com.
Ever had a patient who not only got better but used the insights she gained from talking with you to help others in distress? I have just such a patient in the Peruvian Amazon.
I’ve previously written about an annual clown trip to Peru that I make with my friend Patch Adams, MD, and 100 other humanitarian clowns from all over the world. We have been going there for a decade to spread cheer, and revitalize the impoverished community of Belén, which is situated in the Amazon floodplain in the city of Iquitos. We conduct workshops, perform street theater, create community art installations, visit hospitals, and work with local grass-roots organizations. For the last 5 years, we also have been conducting mental health clinics in the streets.
To provide a brief overview ... we go to a neighborhood, set up our space, and walk the streets with a bull horn. We announce our presence – “we are mental health professionals, and we’re meeting over at” ... and we talk with anybody, young and old, who wants to discuss health problems, family issues, or other concerns.
We sit in a public place and speak to individuals/couples/families for 20 minutes, while around us, support clowns entertain the kids. We neither make diagnoses nor give drugs; we come with a clown nose and an open heart, and we listen actively without judgment and focus on solutions. We help people identify their strengths and resilience, and give them practical advice. This is community psychiatry disguised as “clown therapy,” which is just another phrase for solution-oriented therapy/ positive psychology/reality therapy/resilience-based therapy, logotherapy, existential psychotherapy, or kitchen table wisdom. These street clinics have had a profound impact on patients and clinicians.
Three years ago, I met a middle-aged woman who was suicidally depressed, and together we negotiated a successful intervention. In summary, she emerged from a church that happened to be across the street from where we were setting up our clinic. A clown saw her weeping and approached her, and after talking with her assured her that there was somebody here right now – a mental health professional – who would talk with her.
Maria sat down and told an unbelievably painful story that was happening within her family. On that day, after 8 months of prayer and receiving no sign from God, she had decided to kill herself. After listening to her, I actually believed she could do it.
There are no treatment centers or emergency shelters for the poor in Belén, so at our closure, I made her promise that she would not try to kill herself until I could see her again at our next clinic 2 days away, and close by. I gave her an amulet that was blessed and told her it was a reminder of her promise, and that my smiling face would be with her until she saw me again. She returned with her daughters to the next clinic, and together, they found a way to take a step forward.
Last year, I made my first home visit, and met with Maria, her daughters, and new grandson in their “new” home where they were happily sustaining themselves . When I left, the love and appreciation was so overwhelming that I told them as long as I returned I would come visit every year.
I just got back from this year’s annual visit, and was again greeted with passionate tears of joy. We sat and talked, and Maria told me her story. It seems that people in the community were now coming to her as a resource when they were deeply depressed. People know that she had walked a similar path and moved beyond it.
She is a warm, good listener, and tells them a story about walking out of church and deciding she wanted to kill herself, and meeting with a tall gringo, a clown/doctor who miraculously saved her life. She gives them simple, practical advice, tells them how important it is to stay connected to their children, speak your truth with them openly; to pray for miracles and recognize them when they occur. She tells them to reach out for help, and people will reach out to them. She is a credible, inspiring friend who gives hope.
For those who remember when community psychiatry was actually a subspecialty, this is my vision of community mental health: People talking to credible witnesses/healers/resources in their community, whom they respect, who will listen without judgment, and maybe even say something that inspires a light in the darkness. It’s at least as effective as psychotropic drugs, and all its benefits come without side effects.
Once a year we come together, listen to each other’s stories, and continue our healing work together. Maria tells me her friends want to meet me. “They want to steal you away,” she says, “but I tell them I am not afraid.”
Maria, a lay therapist of sorts, is the community mental health consultant. Once a year, she consults with her gringo, the clown/doctor, to compare notes. We laugh and love, hug and cry, and give each other hope. No matter how divisive and polarizing the times, it is possible to come together in community and promote healing.
Dr. Hammerschlag is chief of community mental health of the Gesundheit! Institute and a faculty member at the University of Arizona, Phoenix. He is the author of several books on healing and spirituality, including “Kindling Spirit: Healing from Within” (New York: Turtle Island Press, 2010) and “The Dancing Healers: A Doctor’s Journey of Healing With Native Americans” (San Francisco: Harper, 1988). Dr. Hammerschlag’s website is healingdoc.com.
When is it time to stop hormone therapy?
Extended use of systemic hormone therapy represents one area that clinicians commonly encounter. However, because randomized trial data are not available, helping women make decisions regarding long-term use of hormone therapy is controversial. When it is finalized, the 2016 hormone therapy position statement from the North American Menopause Society will address this topic.
Here I’m referring to the patient who likely started systemic hormone therapy when she was a younger, or more recently menopausal, woman (perhaps in her early 50s), but now she’s in her 60s. In my practice, a patient in this age range would likely be on a lower-than-standard dose of hormone therapy than what she began with originally.
And now the question is, Should she continue, or should she stop, hormone therapy? The median duration of bothersome symptoms is about 10 or 11 years, from the best available data – far longer than what many physicians assume.
And risk stratification also becomes relevant. Let’s say the patient is a slender white or Asian woman with a low body mass index , or she has a parent who had a hip fracture. Continuing low-dose systemic hormone therapy in this case, particularly for osteoporosis prevention when vasomotor symptoms are no longer present, might make sense. However, if the patient is obese, and, therefore has a lower risk for osteoporosis, it may be that ongoing use of systemic hormone therapy would not be indicated, and that patient should be encouraged to discontinue at that point.
Also, if a uterus is not present – and we’re talking only about estrogen therapy, given its greater safety profile with long-term use with respect to breast cancer – clinicians and women can be more comfortable with continued use of low-dose systemic hormone therapy for osteoporosis prevention. If a uterus is present, then women making decisions about long-term use of hormone therapy need to be aware of the small, but I believe real, elevated risk of breast cancer. With each office visit and when decisions about refilling prescriptions or continuing hormone therapy are made, this is an important issue to discuss, particularly if there’s an intact uterus. These discussions also need to be documented in the record.
What about the route of estrogen? Age, BMI, and oral estrogen therapy each represent independent risk factors for venous thromboembolism. For older, as well as obese menopausal women, who are candidates for systemic hormone therapy, I prefer transdermal over oral estrogen therapy.
Finally, I counsel women that although vasomotor symptoms/hot flashes improve as women age, the same is not true for genitourinary syndrome of menopause (GSM, also known as genital atrophy). If vaginal dryness, pain with sex, or other manifestations of GSM occur in women tapering their dose of systemic hormone therapy or in women who have discontinued systemic hormone therapy, initiation and long-term use of low-dose vaginal estrogen should be considered.
References
1. Menopause. 2014 Jun;21(6):679-81.
Dr. Kaunitz is a professor and associate chair of the department of obstetrics and gynecology, University of Florida in Jacksonville. He is on the board of trustees of the North American Menopause Society. He reports being a consultant or on the advisory board or review panel of several pharmaceutical companies, and receiving grant support from several pharmaceutical companies. He receives royalties from UpToDate.
Extended use of systemic hormone therapy represents one area that clinicians commonly encounter. However, because randomized trial data are not available, helping women make decisions regarding long-term use of hormone therapy is controversial. When it is finalized, the 2016 hormone therapy position statement from the North American Menopause Society will address this topic.
Here I’m referring to the patient who likely started systemic hormone therapy when she was a younger, or more recently menopausal, woman (perhaps in her early 50s), but now she’s in her 60s. In my practice, a patient in this age range would likely be on a lower-than-standard dose of hormone therapy than what she began with originally.
And now the question is, Should she continue, or should she stop, hormone therapy? The median duration of bothersome symptoms is about 10 or 11 years, from the best available data – far longer than what many physicians assume.
And risk stratification also becomes relevant. Let’s say the patient is a slender white or Asian woman with a low body mass index , or she has a parent who had a hip fracture. Continuing low-dose systemic hormone therapy in this case, particularly for osteoporosis prevention when vasomotor symptoms are no longer present, might make sense. However, if the patient is obese, and, therefore has a lower risk for osteoporosis, it may be that ongoing use of systemic hormone therapy would not be indicated, and that patient should be encouraged to discontinue at that point.
Also, if a uterus is not present – and we’re talking only about estrogen therapy, given its greater safety profile with long-term use with respect to breast cancer – clinicians and women can be more comfortable with continued use of low-dose systemic hormone therapy for osteoporosis prevention. If a uterus is present, then women making decisions about long-term use of hormone therapy need to be aware of the small, but I believe real, elevated risk of breast cancer. With each office visit and when decisions about refilling prescriptions or continuing hormone therapy are made, this is an important issue to discuss, particularly if there’s an intact uterus. These discussions also need to be documented in the record.
What about the route of estrogen? Age, BMI, and oral estrogen therapy each represent independent risk factors for venous thromboembolism. For older, as well as obese menopausal women, who are candidates for systemic hormone therapy, I prefer transdermal over oral estrogen therapy.
Finally, I counsel women that although vasomotor symptoms/hot flashes improve as women age, the same is not true for genitourinary syndrome of menopause (GSM, also known as genital atrophy). If vaginal dryness, pain with sex, or other manifestations of GSM occur in women tapering their dose of systemic hormone therapy or in women who have discontinued systemic hormone therapy, initiation and long-term use of low-dose vaginal estrogen should be considered.
References
1. Menopause. 2014 Jun;21(6):679-81.
Dr. Kaunitz is a professor and associate chair of the department of obstetrics and gynecology, University of Florida in Jacksonville. He is on the board of trustees of the North American Menopause Society. He reports being a consultant or on the advisory board or review panel of several pharmaceutical companies, and receiving grant support from several pharmaceutical companies. He receives royalties from UpToDate.
Extended use of systemic hormone therapy represents one area that clinicians commonly encounter. However, because randomized trial data are not available, helping women make decisions regarding long-term use of hormone therapy is controversial. When it is finalized, the 2016 hormone therapy position statement from the North American Menopause Society will address this topic.
Here I’m referring to the patient who likely started systemic hormone therapy when she was a younger, or more recently menopausal, woman (perhaps in her early 50s), but now she’s in her 60s. In my practice, a patient in this age range would likely be on a lower-than-standard dose of hormone therapy than what she began with originally.
And now the question is, Should she continue, or should she stop, hormone therapy? The median duration of bothersome symptoms is about 10 or 11 years, from the best available data – far longer than what many physicians assume.
And risk stratification also becomes relevant. Let’s say the patient is a slender white or Asian woman with a low body mass index , or she has a parent who had a hip fracture. Continuing low-dose systemic hormone therapy in this case, particularly for osteoporosis prevention when vasomotor symptoms are no longer present, might make sense. However, if the patient is obese, and, therefore has a lower risk for osteoporosis, it may be that ongoing use of systemic hormone therapy would not be indicated, and that patient should be encouraged to discontinue at that point.
Also, if a uterus is not present – and we’re talking only about estrogen therapy, given its greater safety profile with long-term use with respect to breast cancer – clinicians and women can be more comfortable with continued use of low-dose systemic hormone therapy for osteoporosis prevention. If a uterus is present, then women making decisions about long-term use of hormone therapy need to be aware of the small, but I believe real, elevated risk of breast cancer. With each office visit and when decisions about refilling prescriptions or continuing hormone therapy are made, this is an important issue to discuss, particularly if there’s an intact uterus. These discussions also need to be documented in the record.
What about the route of estrogen? Age, BMI, and oral estrogen therapy each represent independent risk factors for venous thromboembolism. For older, as well as obese menopausal women, who are candidates for systemic hormone therapy, I prefer transdermal over oral estrogen therapy.
Finally, I counsel women that although vasomotor symptoms/hot flashes improve as women age, the same is not true for genitourinary syndrome of menopause (GSM, also known as genital atrophy). If vaginal dryness, pain with sex, or other manifestations of GSM occur in women tapering their dose of systemic hormone therapy or in women who have discontinued systemic hormone therapy, initiation and long-term use of low-dose vaginal estrogen should be considered.
References
1. Menopause. 2014 Jun;21(6):679-81.
Dr. Kaunitz is a professor and associate chair of the department of obstetrics and gynecology, University of Florida in Jacksonville. He is on the board of trustees of the North American Menopause Society. He reports being a consultant or on the advisory board or review panel of several pharmaceutical companies, and receiving grant support from several pharmaceutical companies. He receives royalties from UpToDate.
