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The Role of Procalcitonin in the Management of Infectious Diseases
Procalcitonin (PCT) is a precursor to the hormone calcitonin and is a serum biomarker of interest in infectious diseases. Many studies have analyzed its utility and role in assisting clinical decision making, especially in conditions that result in inflammation due to a bacterial infection. A systemic inflammatory response from a bacterial infection begins with the release of endotoxins/exotoxins and a response from immune system mediators that release cytokines, such as interleukin-1β and tumor necrosis factor-α. These cytokines contribute to the development of a fever, the release of stress hormones, such as cortisone and epinephrine, and interleukin-6, which stimulates acute phase reactants, such as C-reactive protein (CRP) and PCT.1,2
C-reactive protein and white blood cell count (WBC) are commonly used clinically as biomarkers that assist in the recognition of the infectious process and may be indicators of disease prognosis, but both lack specificity for bacterial infections. Consequentially, using CRP and WBC as clinical decision aids may result in unnecessary antibiotic therapy, which may result in an increase in drug-related adverse events and antibiotic resistance. A major distinction of PCT is that it has greater specificity than does CRP, because it tends to be elevated primarily as a result of inflammation due to bacterial infections. Procalcitonin can be used to distinguish bacterial from viral infections because its up-regulation is attenuated by interferon-gamma, a cytokine released in response to viral infections.2 Thus, PCT may be a more effective clinical marker for optimizing the diagnosis, monitoring, and treatment in patients with systemic bacterial infections.
Procalcitonin as a Marker
A study evaluating infectious markers compared the use of PCT, lactate, and CRP as diagnostic tools in patients with septic shock. The results of this study indicated that PCT was the only marker significantly elevated in patients with septic shock that was also normal in patients not in septic shock (14 µg/mL vs 1 µg/mL, P = .0003).3 This and other studies led the FDA to approve PCT use in 2005 as an aid to clinical decision making in the assessment of critically ill patients with sepsis.4 Overall, the literature supports the use of PCT as a diagnostic tool in infections requiring antimicrobial therapy within appropriate clinical settings.
Strong evidence exists confirming PCT’s role as an aid to clinical decision making in bronchitis, chronic obstructive pulmonary disease exacerbations, pneumonia, and severe sepsis/shock management.2 Procalcitonin’s kinetic profile makes it a good monitoring tool, because its levels promptly increase within 3 to 6 hours of infection, peak at 12 to 48 hours, and rapidly decline during recovery. Additionally, its levels closely parallel the extent and severity of present inflammation, making it a useful prognostic marker of disease progression and response to antibiotic therapy.2,4,5
Related: Mass Transit for Viruses
Christ-Crain and colleagues studied the outcome of PCT-guided antibiotic algorithms for patients with lower respiratory tract infections (RTIs) presenting to the emergency department. A serum PCT level of 0.25 to 0.5 µg/L suggested a likely bacterial infection, and physicians were advised to initiate antimicrobial therapy. Serum levels above 0.5 µg/L were suggestive of a bacterial infection, and initiation of antimicrobial therapy was strongly recommended. The results showed that PCT-guided algorithms significantly reduced the number of antibiotic-treated patients (n = 99 [83%] vs n = 55 [44%]; P < .0001), reduced the duration of antibiotic treatment (12.8 days vs 10.9 days; P = .03), and decreased the antibiotic cost per patient ($202.5 vs $96.3; P < .0001) compared with the standard group (n = 119) without a significant difference in mortality.6
Sepsis/septic shock is another area in which PCT has been studied. Use of a PCT-guided algorithm in critically ill patients with suspected or documented severe sepsis or septic shock to guide discontinuation of antimicrobial therapy resulted in reduced duration of antibiotic therapy (10 days vs 6 days; P = .003) in the PCT group (n = 31) compared with the standard of care group (n = 37) while maintaining similar mortality and infection recurrence rates between the 2 groups. The PCT algorithm in this study recommended discontinuing antimicrobial therapy when PCT levels had decreased by > 90% from identification of sepsis/septic shock but not prior to 3 or 5 days of therapy, depending on the baseline PCT level.7
Systematic reviews of multiple trials have confirmed these representative results. Using a PCT algorithm to withhold or de-escalate antibiotics in patients with suspected bacterial infection leads to a significant reduction in antimicrobial utilization without adversely affecting patient outcome.8
Related: Health Care Use Among Iraq and Afghanistan Veterans With Infectious Diseases
Procalcitonin levels should be rechecked 48 to 72 hours after beginning antimicrobial therapy in clinically stable patients with RTIs in order to reevaluate patient need for continued therapy. In patients whose antibiotics are withheld due to low PCT levels, it is recommended to obtain a repeat level 12 to 48 hours after the decision if clinical improvement is not seen.6,9-12 Literature suggests that it is reasonable to check PCT levels every 48 to 72 hours in patients with sepsis for considering discontinuation of antibiotic therapy as well as in patients who are not clinically improving and may need to broaden antibiotic therapy.7,12
Limitations of the use of PCT as a clinical biomarker include its inability to be used in immunocompromised patients. In addition, PCT levels are increased in severe, noninfectious inflammatory conditions, such as inhalation injury, pulmonary aspiration, severe burns, pancreatitis, heat stroke, mesenteric infarction, trauma, surgery, and pneumonitis.12 The presence of low-grade inflammation from a bacterial infection can lead to slightly elevated PCT levels that are difficult to quantify due to the low sensitivity of current PCT assays.13
The level of PCT up-regulation may depend on the infecting pathogen. One study showed that PCT was highly elevated in patients with pneumococcal community-acquired pneumonia (CAP), and another study demonstrated that PCT levels did not increase in CAP due to atypical organisms.14,15 Thus, atypical antimicrobial coverage should be continued per current guidelines in patients in whom there is high suspicion of atypical organism-involvement in CAP.
Related: The Importance of an Antimicrobial Stewardship Program
Conclusion
Many studies have analyzed the use of PCT as a biomarker for infectious disease diagnosis, monitoring, and treatment. Current evidence supports its use in RTIs and sepsis, although it may be useful in other conditions as well, such as bacteremia and postoperative infections.2 Due to its limitations and controversy, PCT should not be used as a sole marker but as an adjunct to a patient’s clinical presentation, overall clinical picture, and other biomarkers.
Additional Note
An earlier version of this article appeared in the Pharmacy Related Newsletter: The Capsule, of the William S. Middleton Memorial Veterans Hospital.
Author disclosures
The authors report no actual or potential conflicts of interest with regard to this article.
Disclaimer
The opinions expressed herein are those of the authors and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the U.S. Government, or any of its agencies. This article may discuss unlabeled or investigational use of certain drugs. Please review the complete prescribing information for specific drugs or drug combinations—including indications, contraindications, warnings, and adverse effects—before administering pharmacologic therapy to patients.
Procalcitonin (PCT) is a precursor to the hormone calcitonin and is a serum biomarker of interest in infectious diseases. Many studies have analyzed its utility and role in assisting clinical decision making, especially in conditions that result in inflammation due to a bacterial infection. A systemic inflammatory response from a bacterial infection begins with the release of endotoxins/exotoxins and a response from immune system mediators that release cytokines, such as interleukin-1β and tumor necrosis factor-α. These cytokines contribute to the development of a fever, the release of stress hormones, such as cortisone and epinephrine, and interleukin-6, which stimulates acute phase reactants, such as C-reactive protein (CRP) and PCT.1,2
C-reactive protein and white blood cell count (WBC) are commonly used clinically as biomarkers that assist in the recognition of the infectious process and may be indicators of disease prognosis, but both lack specificity for bacterial infections. Consequentially, using CRP and WBC as clinical decision aids may result in unnecessary antibiotic therapy, which may result in an increase in drug-related adverse events and antibiotic resistance. A major distinction of PCT is that it has greater specificity than does CRP, because it tends to be elevated primarily as a result of inflammation due to bacterial infections. Procalcitonin can be used to distinguish bacterial from viral infections because its up-regulation is attenuated by interferon-gamma, a cytokine released in response to viral infections.2 Thus, PCT may be a more effective clinical marker for optimizing the diagnosis, monitoring, and treatment in patients with systemic bacterial infections.
Procalcitonin as a Marker
A study evaluating infectious markers compared the use of PCT, lactate, and CRP as diagnostic tools in patients with septic shock. The results of this study indicated that PCT was the only marker significantly elevated in patients with septic shock that was also normal in patients not in septic shock (14 µg/mL vs 1 µg/mL, P = .0003).3 This and other studies led the FDA to approve PCT use in 2005 as an aid to clinical decision making in the assessment of critically ill patients with sepsis.4 Overall, the literature supports the use of PCT as a diagnostic tool in infections requiring antimicrobial therapy within appropriate clinical settings.
Strong evidence exists confirming PCT’s role as an aid to clinical decision making in bronchitis, chronic obstructive pulmonary disease exacerbations, pneumonia, and severe sepsis/shock management.2 Procalcitonin’s kinetic profile makes it a good monitoring tool, because its levels promptly increase within 3 to 6 hours of infection, peak at 12 to 48 hours, and rapidly decline during recovery. Additionally, its levels closely parallel the extent and severity of present inflammation, making it a useful prognostic marker of disease progression and response to antibiotic therapy.2,4,5
Related: Mass Transit for Viruses
Christ-Crain and colleagues studied the outcome of PCT-guided antibiotic algorithms for patients with lower respiratory tract infections (RTIs) presenting to the emergency department. A serum PCT level of 0.25 to 0.5 µg/L suggested a likely bacterial infection, and physicians were advised to initiate antimicrobial therapy. Serum levels above 0.5 µg/L were suggestive of a bacterial infection, and initiation of antimicrobial therapy was strongly recommended. The results showed that PCT-guided algorithms significantly reduced the number of antibiotic-treated patients (n = 99 [83%] vs n = 55 [44%]; P < .0001), reduced the duration of antibiotic treatment (12.8 days vs 10.9 days; P = .03), and decreased the antibiotic cost per patient ($202.5 vs $96.3; P < .0001) compared with the standard group (n = 119) without a significant difference in mortality.6
Sepsis/septic shock is another area in which PCT has been studied. Use of a PCT-guided algorithm in critically ill patients with suspected or documented severe sepsis or septic shock to guide discontinuation of antimicrobial therapy resulted in reduced duration of antibiotic therapy (10 days vs 6 days; P = .003) in the PCT group (n = 31) compared with the standard of care group (n = 37) while maintaining similar mortality and infection recurrence rates between the 2 groups. The PCT algorithm in this study recommended discontinuing antimicrobial therapy when PCT levels had decreased by > 90% from identification of sepsis/septic shock but not prior to 3 or 5 days of therapy, depending on the baseline PCT level.7
Systematic reviews of multiple trials have confirmed these representative results. Using a PCT algorithm to withhold or de-escalate antibiotics in patients with suspected bacterial infection leads to a significant reduction in antimicrobial utilization without adversely affecting patient outcome.8
Related: Health Care Use Among Iraq and Afghanistan Veterans With Infectious Diseases
Procalcitonin levels should be rechecked 48 to 72 hours after beginning antimicrobial therapy in clinically stable patients with RTIs in order to reevaluate patient need for continued therapy. In patients whose antibiotics are withheld due to low PCT levels, it is recommended to obtain a repeat level 12 to 48 hours after the decision if clinical improvement is not seen.6,9-12 Literature suggests that it is reasonable to check PCT levels every 48 to 72 hours in patients with sepsis for considering discontinuation of antibiotic therapy as well as in patients who are not clinically improving and may need to broaden antibiotic therapy.7,12
Limitations of the use of PCT as a clinical biomarker include its inability to be used in immunocompromised patients. In addition, PCT levels are increased in severe, noninfectious inflammatory conditions, such as inhalation injury, pulmonary aspiration, severe burns, pancreatitis, heat stroke, mesenteric infarction, trauma, surgery, and pneumonitis.12 The presence of low-grade inflammation from a bacterial infection can lead to slightly elevated PCT levels that are difficult to quantify due to the low sensitivity of current PCT assays.13
The level of PCT up-regulation may depend on the infecting pathogen. One study showed that PCT was highly elevated in patients with pneumococcal community-acquired pneumonia (CAP), and another study demonstrated that PCT levels did not increase in CAP due to atypical organisms.14,15 Thus, atypical antimicrobial coverage should be continued per current guidelines in patients in whom there is high suspicion of atypical organism-involvement in CAP.
Related: The Importance of an Antimicrobial Stewardship Program
Conclusion
Many studies have analyzed the use of PCT as a biomarker for infectious disease diagnosis, monitoring, and treatment. Current evidence supports its use in RTIs and sepsis, although it may be useful in other conditions as well, such as bacteremia and postoperative infections.2 Due to its limitations and controversy, PCT should not be used as a sole marker but as an adjunct to a patient’s clinical presentation, overall clinical picture, and other biomarkers.
Additional Note
An earlier version of this article appeared in the Pharmacy Related Newsletter: The Capsule, of the William S. Middleton Memorial Veterans Hospital.
Author disclosures
The authors report no actual or potential conflicts of interest with regard to this article.
Disclaimer
The opinions expressed herein are those of the authors and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the U.S. Government, or any of its agencies. This article may discuss unlabeled or investigational use of certain drugs. Please review the complete prescribing information for specific drugs or drug combinations—including indications, contraindications, warnings, and adverse effects—before administering pharmacologic therapy to patients.
Procalcitonin (PCT) is a precursor to the hormone calcitonin and is a serum biomarker of interest in infectious diseases. Many studies have analyzed its utility and role in assisting clinical decision making, especially in conditions that result in inflammation due to a bacterial infection. A systemic inflammatory response from a bacterial infection begins with the release of endotoxins/exotoxins and a response from immune system mediators that release cytokines, such as interleukin-1β and tumor necrosis factor-α. These cytokines contribute to the development of a fever, the release of stress hormones, such as cortisone and epinephrine, and interleukin-6, which stimulates acute phase reactants, such as C-reactive protein (CRP) and PCT.1,2
C-reactive protein and white blood cell count (WBC) are commonly used clinically as biomarkers that assist in the recognition of the infectious process and may be indicators of disease prognosis, but both lack specificity for bacterial infections. Consequentially, using CRP and WBC as clinical decision aids may result in unnecessary antibiotic therapy, which may result in an increase in drug-related adverse events and antibiotic resistance. A major distinction of PCT is that it has greater specificity than does CRP, because it tends to be elevated primarily as a result of inflammation due to bacterial infections. Procalcitonin can be used to distinguish bacterial from viral infections because its up-regulation is attenuated by interferon-gamma, a cytokine released in response to viral infections.2 Thus, PCT may be a more effective clinical marker for optimizing the diagnosis, monitoring, and treatment in patients with systemic bacterial infections.
Procalcitonin as a Marker
A study evaluating infectious markers compared the use of PCT, lactate, and CRP as diagnostic tools in patients with septic shock. The results of this study indicated that PCT was the only marker significantly elevated in patients with septic shock that was also normal in patients not in septic shock (14 µg/mL vs 1 µg/mL, P = .0003).3 This and other studies led the FDA to approve PCT use in 2005 as an aid to clinical decision making in the assessment of critically ill patients with sepsis.4 Overall, the literature supports the use of PCT as a diagnostic tool in infections requiring antimicrobial therapy within appropriate clinical settings.
Strong evidence exists confirming PCT’s role as an aid to clinical decision making in bronchitis, chronic obstructive pulmonary disease exacerbations, pneumonia, and severe sepsis/shock management.2 Procalcitonin’s kinetic profile makes it a good monitoring tool, because its levels promptly increase within 3 to 6 hours of infection, peak at 12 to 48 hours, and rapidly decline during recovery. Additionally, its levels closely parallel the extent and severity of present inflammation, making it a useful prognostic marker of disease progression and response to antibiotic therapy.2,4,5
Related: Mass Transit for Viruses
Christ-Crain and colleagues studied the outcome of PCT-guided antibiotic algorithms for patients with lower respiratory tract infections (RTIs) presenting to the emergency department. A serum PCT level of 0.25 to 0.5 µg/L suggested a likely bacterial infection, and physicians were advised to initiate antimicrobial therapy. Serum levels above 0.5 µg/L were suggestive of a bacterial infection, and initiation of antimicrobial therapy was strongly recommended. The results showed that PCT-guided algorithms significantly reduced the number of antibiotic-treated patients (n = 99 [83%] vs n = 55 [44%]; P < .0001), reduced the duration of antibiotic treatment (12.8 days vs 10.9 days; P = .03), and decreased the antibiotic cost per patient ($202.5 vs $96.3; P < .0001) compared with the standard group (n = 119) without a significant difference in mortality.6
Sepsis/septic shock is another area in which PCT has been studied. Use of a PCT-guided algorithm in critically ill patients with suspected or documented severe sepsis or septic shock to guide discontinuation of antimicrobial therapy resulted in reduced duration of antibiotic therapy (10 days vs 6 days; P = .003) in the PCT group (n = 31) compared with the standard of care group (n = 37) while maintaining similar mortality and infection recurrence rates between the 2 groups. The PCT algorithm in this study recommended discontinuing antimicrobial therapy when PCT levels had decreased by > 90% from identification of sepsis/septic shock but not prior to 3 or 5 days of therapy, depending on the baseline PCT level.7
Systematic reviews of multiple trials have confirmed these representative results. Using a PCT algorithm to withhold or de-escalate antibiotics in patients with suspected bacterial infection leads to a significant reduction in antimicrobial utilization without adversely affecting patient outcome.8
Related: Health Care Use Among Iraq and Afghanistan Veterans With Infectious Diseases
Procalcitonin levels should be rechecked 48 to 72 hours after beginning antimicrobial therapy in clinically stable patients with RTIs in order to reevaluate patient need for continued therapy. In patients whose antibiotics are withheld due to low PCT levels, it is recommended to obtain a repeat level 12 to 48 hours after the decision if clinical improvement is not seen.6,9-12 Literature suggests that it is reasonable to check PCT levels every 48 to 72 hours in patients with sepsis for considering discontinuation of antibiotic therapy as well as in patients who are not clinically improving and may need to broaden antibiotic therapy.7,12
Limitations of the use of PCT as a clinical biomarker include its inability to be used in immunocompromised patients. In addition, PCT levels are increased in severe, noninfectious inflammatory conditions, such as inhalation injury, pulmonary aspiration, severe burns, pancreatitis, heat stroke, mesenteric infarction, trauma, surgery, and pneumonitis.12 The presence of low-grade inflammation from a bacterial infection can lead to slightly elevated PCT levels that are difficult to quantify due to the low sensitivity of current PCT assays.13
The level of PCT up-regulation may depend on the infecting pathogen. One study showed that PCT was highly elevated in patients with pneumococcal community-acquired pneumonia (CAP), and another study demonstrated that PCT levels did not increase in CAP due to atypical organisms.14,15 Thus, atypical antimicrobial coverage should be continued per current guidelines in patients in whom there is high suspicion of atypical organism-involvement in CAP.
Related: The Importance of an Antimicrobial Stewardship Program
Conclusion
Many studies have analyzed the use of PCT as a biomarker for infectious disease diagnosis, monitoring, and treatment. Current evidence supports its use in RTIs and sepsis, although it may be useful in other conditions as well, such as bacteremia and postoperative infections.2 Due to its limitations and controversy, PCT should not be used as a sole marker but as an adjunct to a patient’s clinical presentation, overall clinical picture, and other biomarkers.
Additional Note
An earlier version of this article appeared in the Pharmacy Related Newsletter: The Capsule, of the William S. Middleton Memorial Veterans Hospital.
Author disclosures
The authors report no actual or potential conflicts of interest with regard to this article.
Disclaimer
The opinions expressed herein are those of the authors and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the U.S. Government, or any of its agencies. This article may discuss unlabeled or investigational use of certain drugs. Please review the complete prescribing information for specific drugs or drug combinations—including indications, contraindications, warnings, and adverse effects—before administering pharmacologic therapy to patients.
The Changing Face of Pediatric Orthopedics
In my 16 years of practice, there has been tremendous change in the field of pediatric orthopedics in both demographics and scope of practice. Because of scientific and technological advances, efforts of the Pediatric Orthopaedic Society of North America (POSNA), and a changing workforce, the nature of pediatric orthopedics is changing dramatically and will continue to do so.
In the late 1990s, a “typical” pediatric orthopedic surgeon was treating fractures, developmental dysplasia of the hip, clubfeet, and other congenital deformities. Surgery for adolescent idiopathic scoliosis was moving toward anterior instrumentation and correction of the spine. The concepts of early-onset scoliosis and thoracic insufficiency syndrome were in their infancy. Children with anterior cruciate ligament tears were treated with braces until skeletal maturity, often leading to life-altering meniscal pathology. Essential medical treatments for genetic conditions, including bisphosphonates for osteogenesis imperfecta and corticosteroids for Duchenne muscular dystrophy, were considered experimental.
The field itself also was at a crossroads. In 1993, there were 410 active members in POSNA (vs 653 in 2014), and the vast majority were male.1 In the late 1990s, there were approximately 30 pediatric fellowship spots and 10 fellows being trained per year. Simultaneously, approximately 20 to 30 active POSNA members were retiring annually, leading to a projected shortage of pediatric orthopedic surgeons.1 A 2007 American Orthopaedic Association survey found that 59% of members believed that pediatric orthopedics was the most underserved specialty for a variety of reasons, including perceived lower reimbursement, higher volume of nonoperative treatment, and lifestyle issues (such as on-call burden).2
Owing in part to efforts of POSNA in resident/fellow education and mentorship, the practice of pediatric orthopedics in 2016 is dramatically different from a decade ago. The number of fellowship programs has increased to 44 programs, offering a total of 71 fellowship spots, of which 60 were filled by US applicants in 2014. Interestingly, the current active membership of POSNA is 19% female, and the 2014 fellowship class was 34% female. This is in contrast to the 4.4% of all AAOS members who are female. If current trends continue, POSNA could be 40% female by 2025 as senior, predominantly male members retire.1
Pediatric orthopedic practice in 2016 is also dramatically different owing to the development of subspecialization in areas of pediatric sports medicine, hand surgery, trauma, and the treatment of adolescent hip pathology. In fact, a recent survey of fellowship graduates showed that 30% of graduating fellows were going to do a second fellowship.3
While technological advances have driven the care of many pediatric orthopedic conditions such as spinal deformity and sports injuries, there also has been a resurgence of interest in the nonoperative treatment of clubfeet using the Ponseti method and of early-onset scoliosis using Mehta casting. Children with clubfeet even a decade ago were being treated with wide comprehensive releases and capsulotomies, leading to stiff painful feet as young adults. Now comprehensive releases are rarely used. Owing to advances in posterior spinal instrumentation as well as studies showing some decline in pulmonary function after thoracotomy and anterior spinal fusion, the treatment of adolescent scoliosis is predominantly done through the posterior approach. Advances in screening have led to a dramatic decrease in the surgical treatment of hip dysplasia. Medical treatment, such as corticosteroids for Duchenne muscular dystrophy, has prolonged length of life and improved quality of life as well as decreased the number of spinal fusions performed. Recombinant factor replacement for hemophilia has almost eliminated the horrible morbidity associated with hemophilic arthropathy and the need for synovectomy, arthrodesis, and arthroplasty, as well as the infectious issues, such as human immunodeficiency virus (HIV) and hepatitis, associated with the use of pooled blood products. The use of growth-friendly spinal implants, such as the Vertical Expandable Prosthetic Titanium Rib (VEPTR; DePuy Synthes), magnetically driven growing rods (MAGEC; Ellipse), and spinal tethers have improved pulmonary outcomes and presumably life expectancy in young patients with early-onset scoliosis who a decade ago may have had an in situ spinal fusion. These are just a few examples, and there are many more.
The articles in this issue highlight some of these changes. Tibial osteotomy and deformity correction, as described in the article by Burton and Hennrikus (pages 16-18), are classic techniques used by pediatric orthopedists over the past decades and will continue to be useful. The article by Hosseinzadeh and Talwalkar (pages 19-22) reviews unique aspects of pediatric compartment syndrome. While the basic concepts of compartment syndrome have not changed, the signs of compartment syndrome, the 5 Ps we all learned a decade ago (pain, paresthesia, paralysis, pallor, and pulselessness) have now been replaced in children with the 3 As (increasing analgesia, anxiety, and agitation). Finally, the article by Sferopoulos (pages 38-41) describing a case of a giant bone island in a child reminds us that we have a lot more to learn as pediatric orthopedists regarding the molecular nature and cause of disease.
The next few years will continue to be an exciting and dynamic time in the field of pediatric orthopedics. Not only is the workforce itself changing and growing, but so are the definitions of what a pediatric orthopedic surgeon is and does. While subspecialization is the trend in most aspects of medicine, it will be important to continue to monitor<hl name="1"/> this trend to ensure that pediatric orthopedics does not become too highly specialized. With the tremendous inflow of new talent, ideas, and technology, the future for pediatric orthopedics has never looked brighter.
References
1. Sawyer JR, Jones KC, Copley LA, Chambers S; POSNA Practice Management Committee. Pediatric orthopaedic workforce in 2014: current workforce and projections for the future [published online ahead of print October 30, 2015]. J Pediatr Orthop.
2. Salsberg ES, Grover A, Simon MA, Frick SL, Kuremsky MA, Goodman DC. An AOA critical issue. Future physician workforce requirements: implications for orthopaedic surgery education. J Bone Joint Surg Am. 2008;90(5):1143-1159.
3. Glotzbecker MP, Shore BJ, Fletcher ND, Larson AN, Hydorn CR, Sawyer JR; Practice Management Committee of the Pediatric Orthopaedic Society of North America. Early career experience of pediatric orthopaedic fellows: what to expect and need for their services [published online ahead of print March 3, 2015]. J Pediatr Orthop.
In my 16 years of practice, there has been tremendous change in the field of pediatric orthopedics in both demographics and scope of practice. Because of scientific and technological advances, efforts of the Pediatric Orthopaedic Society of North America (POSNA), and a changing workforce, the nature of pediatric orthopedics is changing dramatically and will continue to do so.
In the late 1990s, a “typical” pediatric orthopedic surgeon was treating fractures, developmental dysplasia of the hip, clubfeet, and other congenital deformities. Surgery for adolescent idiopathic scoliosis was moving toward anterior instrumentation and correction of the spine. The concepts of early-onset scoliosis and thoracic insufficiency syndrome were in their infancy. Children with anterior cruciate ligament tears were treated with braces until skeletal maturity, often leading to life-altering meniscal pathology. Essential medical treatments for genetic conditions, including bisphosphonates for osteogenesis imperfecta and corticosteroids for Duchenne muscular dystrophy, were considered experimental.
The field itself also was at a crossroads. In 1993, there were 410 active members in POSNA (vs 653 in 2014), and the vast majority were male.1 In the late 1990s, there were approximately 30 pediatric fellowship spots and 10 fellows being trained per year. Simultaneously, approximately 20 to 30 active POSNA members were retiring annually, leading to a projected shortage of pediatric orthopedic surgeons.1 A 2007 American Orthopaedic Association survey found that 59% of members believed that pediatric orthopedics was the most underserved specialty for a variety of reasons, including perceived lower reimbursement, higher volume of nonoperative treatment, and lifestyle issues (such as on-call burden).2
Owing in part to efforts of POSNA in resident/fellow education and mentorship, the practice of pediatric orthopedics in 2016 is dramatically different from a decade ago. The number of fellowship programs has increased to 44 programs, offering a total of 71 fellowship spots, of which 60 were filled by US applicants in 2014. Interestingly, the current active membership of POSNA is 19% female, and the 2014 fellowship class was 34% female. This is in contrast to the 4.4% of all AAOS members who are female. If current trends continue, POSNA could be 40% female by 2025 as senior, predominantly male members retire.1
Pediatric orthopedic practice in 2016 is also dramatically different owing to the development of subspecialization in areas of pediatric sports medicine, hand surgery, trauma, and the treatment of adolescent hip pathology. In fact, a recent survey of fellowship graduates showed that 30% of graduating fellows were going to do a second fellowship.3
While technological advances have driven the care of many pediatric orthopedic conditions such as spinal deformity and sports injuries, there also has been a resurgence of interest in the nonoperative treatment of clubfeet using the Ponseti method and of early-onset scoliosis using Mehta casting. Children with clubfeet even a decade ago were being treated with wide comprehensive releases and capsulotomies, leading to stiff painful feet as young adults. Now comprehensive releases are rarely used. Owing to advances in posterior spinal instrumentation as well as studies showing some decline in pulmonary function after thoracotomy and anterior spinal fusion, the treatment of adolescent scoliosis is predominantly done through the posterior approach. Advances in screening have led to a dramatic decrease in the surgical treatment of hip dysplasia. Medical treatment, such as corticosteroids for Duchenne muscular dystrophy, has prolonged length of life and improved quality of life as well as decreased the number of spinal fusions performed. Recombinant factor replacement for hemophilia has almost eliminated the horrible morbidity associated with hemophilic arthropathy and the need for synovectomy, arthrodesis, and arthroplasty, as well as the infectious issues, such as human immunodeficiency virus (HIV) and hepatitis, associated with the use of pooled blood products. The use of growth-friendly spinal implants, such as the Vertical Expandable Prosthetic Titanium Rib (VEPTR; DePuy Synthes), magnetically driven growing rods (MAGEC; Ellipse), and spinal tethers have improved pulmonary outcomes and presumably life expectancy in young patients with early-onset scoliosis who a decade ago may have had an in situ spinal fusion. These are just a few examples, and there are many more.
The articles in this issue highlight some of these changes. Tibial osteotomy and deformity correction, as described in the article by Burton and Hennrikus (pages 16-18), are classic techniques used by pediatric orthopedists over the past decades and will continue to be useful. The article by Hosseinzadeh and Talwalkar (pages 19-22) reviews unique aspects of pediatric compartment syndrome. While the basic concepts of compartment syndrome have not changed, the signs of compartment syndrome, the 5 Ps we all learned a decade ago (pain, paresthesia, paralysis, pallor, and pulselessness) have now been replaced in children with the 3 As (increasing analgesia, anxiety, and agitation). Finally, the article by Sferopoulos (pages 38-41) describing a case of a giant bone island in a child reminds us that we have a lot more to learn as pediatric orthopedists regarding the molecular nature and cause of disease.
The next few years will continue to be an exciting and dynamic time in the field of pediatric orthopedics. Not only is the workforce itself changing and growing, but so are the definitions of what a pediatric orthopedic surgeon is and does. While subspecialization is the trend in most aspects of medicine, it will be important to continue to monitor<hl name="1"/> this trend to ensure that pediatric orthopedics does not become too highly specialized. With the tremendous inflow of new talent, ideas, and technology, the future for pediatric orthopedics has never looked brighter.
References
In my 16 years of practice, there has been tremendous change in the field of pediatric orthopedics in both demographics and scope of practice. Because of scientific and technological advances, efforts of the Pediatric Orthopaedic Society of North America (POSNA), and a changing workforce, the nature of pediatric orthopedics is changing dramatically and will continue to do so.
In the late 1990s, a “typical” pediatric orthopedic surgeon was treating fractures, developmental dysplasia of the hip, clubfeet, and other congenital deformities. Surgery for adolescent idiopathic scoliosis was moving toward anterior instrumentation and correction of the spine. The concepts of early-onset scoliosis and thoracic insufficiency syndrome were in their infancy. Children with anterior cruciate ligament tears were treated with braces until skeletal maturity, often leading to life-altering meniscal pathology. Essential medical treatments for genetic conditions, including bisphosphonates for osteogenesis imperfecta and corticosteroids for Duchenne muscular dystrophy, were considered experimental.
The field itself also was at a crossroads. In 1993, there were 410 active members in POSNA (vs 653 in 2014), and the vast majority were male.1 In the late 1990s, there were approximately 30 pediatric fellowship spots and 10 fellows being trained per year. Simultaneously, approximately 20 to 30 active POSNA members were retiring annually, leading to a projected shortage of pediatric orthopedic surgeons.1 A 2007 American Orthopaedic Association survey found that 59% of members believed that pediatric orthopedics was the most underserved specialty for a variety of reasons, including perceived lower reimbursement, higher volume of nonoperative treatment, and lifestyle issues (such as on-call burden).2
Owing in part to efforts of POSNA in resident/fellow education and mentorship, the practice of pediatric orthopedics in 2016 is dramatically different from a decade ago. The number of fellowship programs has increased to 44 programs, offering a total of 71 fellowship spots, of which 60 were filled by US applicants in 2014. Interestingly, the current active membership of POSNA is 19% female, and the 2014 fellowship class was 34% female. This is in contrast to the 4.4% of all AAOS members who are female. If current trends continue, POSNA could be 40% female by 2025 as senior, predominantly male members retire.1
Pediatric orthopedic practice in 2016 is also dramatically different owing to the development of subspecialization in areas of pediatric sports medicine, hand surgery, trauma, and the treatment of adolescent hip pathology. In fact, a recent survey of fellowship graduates showed that 30% of graduating fellows were going to do a second fellowship.3
While technological advances have driven the care of many pediatric orthopedic conditions such as spinal deformity and sports injuries, there also has been a resurgence of interest in the nonoperative treatment of clubfeet using the Ponseti method and of early-onset scoliosis using Mehta casting. Children with clubfeet even a decade ago were being treated with wide comprehensive releases and capsulotomies, leading to stiff painful feet as young adults. Now comprehensive releases are rarely used. Owing to advances in posterior spinal instrumentation as well as studies showing some decline in pulmonary function after thoracotomy and anterior spinal fusion, the treatment of adolescent scoliosis is predominantly done through the posterior approach. Advances in screening have led to a dramatic decrease in the surgical treatment of hip dysplasia. Medical treatment, such as corticosteroids for Duchenne muscular dystrophy, has prolonged length of life and improved quality of life as well as decreased the number of spinal fusions performed. Recombinant factor replacement for hemophilia has almost eliminated the horrible morbidity associated with hemophilic arthropathy and the need for synovectomy, arthrodesis, and arthroplasty, as well as the infectious issues, such as human immunodeficiency virus (HIV) and hepatitis, associated with the use of pooled blood products. The use of growth-friendly spinal implants, such as the Vertical Expandable Prosthetic Titanium Rib (VEPTR; DePuy Synthes), magnetically driven growing rods (MAGEC; Ellipse), and spinal tethers have improved pulmonary outcomes and presumably life expectancy in young patients with early-onset scoliosis who a decade ago may have had an in situ spinal fusion. These are just a few examples, and there are many more.
The articles in this issue highlight some of these changes. Tibial osteotomy and deformity correction, as described in the article by Burton and Hennrikus (pages 16-18), are classic techniques used by pediatric orthopedists over the past decades and will continue to be useful. The article by Hosseinzadeh and Talwalkar (pages 19-22) reviews unique aspects of pediatric compartment syndrome. While the basic concepts of compartment syndrome have not changed, the signs of compartment syndrome, the 5 Ps we all learned a decade ago (pain, paresthesia, paralysis, pallor, and pulselessness) have now been replaced in children with the 3 As (increasing analgesia, anxiety, and agitation). Finally, the article by Sferopoulos (pages 38-41) describing a case of a giant bone island in a child reminds us that we have a lot more to learn as pediatric orthopedists regarding the molecular nature and cause of disease.
The next few years will continue to be an exciting and dynamic time in the field of pediatric orthopedics. Not only is the workforce itself changing and growing, but so are the definitions of what a pediatric orthopedic surgeon is and does. While subspecialization is the trend in most aspects of medicine, it will be important to continue to monitor<hl name="1"/> this trend to ensure that pediatric orthopedics does not become too highly specialized. With the tremendous inflow of new talent, ideas, and technology, the future for pediatric orthopedics has never looked brighter.
References
1. Sawyer JR, Jones KC, Copley LA, Chambers S; POSNA Practice Management Committee. Pediatric orthopaedic workforce in 2014: current workforce and projections for the future [published online ahead of print October 30, 2015]. J Pediatr Orthop.
2. Salsberg ES, Grover A, Simon MA, Frick SL, Kuremsky MA, Goodman DC. An AOA critical issue. Future physician workforce requirements: implications for orthopaedic surgery education. J Bone Joint Surg Am. 2008;90(5):1143-1159.
3. Glotzbecker MP, Shore BJ, Fletcher ND, Larson AN, Hydorn CR, Sawyer JR; Practice Management Committee of the Pediatric Orthopaedic Society of North America. Early career experience of pediatric orthopaedic fellows: what to expect and need for their services [published online ahead of print March 3, 2015]. J Pediatr Orthop.
1. Sawyer JR, Jones KC, Copley LA, Chambers S; POSNA Practice Management Committee. Pediatric orthopaedic workforce in 2014: current workforce and projections for the future [published online ahead of print October 30, 2015]. J Pediatr Orthop.
2. Salsberg ES, Grover A, Simon MA, Frick SL, Kuremsky MA, Goodman DC. An AOA critical issue. Future physician workforce requirements: implications for orthopaedic surgery education. J Bone Joint Surg Am. 2008;90(5):1143-1159.
3. Glotzbecker MP, Shore BJ, Fletcher ND, Larson AN, Hydorn CR, Sawyer JR; Practice Management Committee of the Pediatric Orthopaedic Society of North America. Early career experience of pediatric orthopaedic fellows: what to expect and need for their services [published online ahead of print March 3, 2015]. J Pediatr Orthop.
Good luck convincing patients that generics equal brand-name drugs
Generic drugs have long carried a stigma for at least some people. Patients sometimes feel scared and shortchanged when prescribed them, and some physicians have been wary of their safety and efficacy, compared with brand-name counterparts.
This fall, results appeared from a trio of prospective, randomized studies that compared several generic forms of the antiepileptic drug lamotrigine against the brand-name compound, Lamictal, in patients with epilepsy. As reported earlier this month in a special session at the annual meeting of the American Epilepsy Society, and as I wrote up in a news article, the findings from all three studies consistently and clearly showed that the generic lamotrigine products tested in these three studies all performed identically to Lamictal by both their pharmacokinetic profiles and in their clinical safety and efficacy.
A critic could quibble that the three studies involved relatively small numbers of patients (they included 34-48 subjects), that the treatment times were relatively brief (a matter of a few weeks), and the investigations were limited to just lamotrigine. But the neurologists who reported these findings, a pair of Food and Drug Administration staffers who deal with generics and spoke at the session, and two pharmacy researchers who also participated in the panel all agreed that these groundbreaking studies establish an unprecedented level of confidence in not just the generic products tested but for generic drugs in general.
As Dr. Michael Privitera, director of the Epilepsy Center at the University of Cincinnati and a lead investigator for two of the three studies, told me, controlling seizures in epilepsy patients is a stringent test of drug efficacy and similarity. If generic forms of lamotrigine behave indistinguishably from Lamictal, then it’s very reasonable to expect that virtually any generic form of any brand-name drug used in medicine is also a good mimic if it recently passed FDA muster. His only caveat was selected drugs with very unusual pharmacokinetic properties, such as phenytoin – another antiepileptic drug, which has saturation kinetics making it a special case that requires additional, customized testing to prove equivalence between the generic and brand-name form.
But as he and others at the session highlighted, equivalent pharmacologic properties of generic and brand-name forms of a drug tell just part of the story. They may act the same once inside patients’ bodies, but what’s also important is how patients regard these drugs from the neck up. Psychological factors play a role in how patients perceive and use different forms of chemically identical products. Differences in pill size, shape, and color can confuse patients, and just knowing that a drug is a generic could possibly trigger anxiety in a patient that might perhaps produce a seizure or disrupt their pill-taking behavior. Several clinicians at the session spoke of certain patients who have begged them to specify the brand-name drug on their prescriptions. On the other hand, a generic’s lower price often encourages more conscientious use, a phenomenon documented in a database review reported at the session by pharmacoepidemiologist Joshua J. Gagne, Pharm.D.
Madison Avenue has known for years that function and utility tell just part of the story when it comes to consumer goods. A Kia may be just as durable and effective for transporting someone as a Mercedes or BMW, but cheap isn’t always what a consumer wants or feels comfortable with. Generics that work indistinguishably from brand drugs are certainly attractive for the U.S. health care system and the majority of the American public, but the concept that generic is best will be tough to sell to everyone.
On Twitter @mitchelzoler
Generic drugs have long carried a stigma for at least some people. Patients sometimes feel scared and shortchanged when prescribed them, and some physicians have been wary of their safety and efficacy, compared with brand-name counterparts.
This fall, results appeared from a trio of prospective, randomized studies that compared several generic forms of the antiepileptic drug lamotrigine against the brand-name compound, Lamictal, in patients with epilepsy. As reported earlier this month in a special session at the annual meeting of the American Epilepsy Society, and as I wrote up in a news article, the findings from all three studies consistently and clearly showed that the generic lamotrigine products tested in these three studies all performed identically to Lamictal by both their pharmacokinetic profiles and in their clinical safety and efficacy.
A critic could quibble that the three studies involved relatively small numbers of patients (they included 34-48 subjects), that the treatment times were relatively brief (a matter of a few weeks), and the investigations were limited to just lamotrigine. But the neurologists who reported these findings, a pair of Food and Drug Administration staffers who deal with generics and spoke at the session, and two pharmacy researchers who also participated in the panel all agreed that these groundbreaking studies establish an unprecedented level of confidence in not just the generic products tested but for generic drugs in general.
As Dr. Michael Privitera, director of the Epilepsy Center at the University of Cincinnati and a lead investigator for two of the three studies, told me, controlling seizures in epilepsy patients is a stringent test of drug efficacy and similarity. If generic forms of lamotrigine behave indistinguishably from Lamictal, then it’s very reasonable to expect that virtually any generic form of any brand-name drug used in medicine is also a good mimic if it recently passed FDA muster. His only caveat was selected drugs with very unusual pharmacokinetic properties, such as phenytoin – another antiepileptic drug, which has saturation kinetics making it a special case that requires additional, customized testing to prove equivalence between the generic and brand-name form.
But as he and others at the session highlighted, equivalent pharmacologic properties of generic and brand-name forms of a drug tell just part of the story. They may act the same once inside patients’ bodies, but what’s also important is how patients regard these drugs from the neck up. Psychological factors play a role in how patients perceive and use different forms of chemically identical products. Differences in pill size, shape, and color can confuse patients, and just knowing that a drug is a generic could possibly trigger anxiety in a patient that might perhaps produce a seizure or disrupt their pill-taking behavior. Several clinicians at the session spoke of certain patients who have begged them to specify the brand-name drug on their prescriptions. On the other hand, a generic’s lower price often encourages more conscientious use, a phenomenon documented in a database review reported at the session by pharmacoepidemiologist Joshua J. Gagne, Pharm.D.
Madison Avenue has known for years that function and utility tell just part of the story when it comes to consumer goods. A Kia may be just as durable and effective for transporting someone as a Mercedes or BMW, but cheap isn’t always what a consumer wants or feels comfortable with. Generics that work indistinguishably from brand drugs are certainly attractive for the U.S. health care system and the majority of the American public, but the concept that generic is best will be tough to sell to everyone.
On Twitter @mitchelzoler
Generic drugs have long carried a stigma for at least some people. Patients sometimes feel scared and shortchanged when prescribed them, and some physicians have been wary of their safety and efficacy, compared with brand-name counterparts.
This fall, results appeared from a trio of prospective, randomized studies that compared several generic forms of the antiepileptic drug lamotrigine against the brand-name compound, Lamictal, in patients with epilepsy. As reported earlier this month in a special session at the annual meeting of the American Epilepsy Society, and as I wrote up in a news article, the findings from all three studies consistently and clearly showed that the generic lamotrigine products tested in these three studies all performed identically to Lamictal by both their pharmacokinetic profiles and in their clinical safety and efficacy.
A critic could quibble that the three studies involved relatively small numbers of patients (they included 34-48 subjects), that the treatment times were relatively brief (a matter of a few weeks), and the investigations were limited to just lamotrigine. But the neurologists who reported these findings, a pair of Food and Drug Administration staffers who deal with generics and spoke at the session, and two pharmacy researchers who also participated in the panel all agreed that these groundbreaking studies establish an unprecedented level of confidence in not just the generic products tested but for generic drugs in general.
As Dr. Michael Privitera, director of the Epilepsy Center at the University of Cincinnati and a lead investigator for two of the three studies, told me, controlling seizures in epilepsy patients is a stringent test of drug efficacy and similarity. If generic forms of lamotrigine behave indistinguishably from Lamictal, then it’s very reasonable to expect that virtually any generic form of any brand-name drug used in medicine is also a good mimic if it recently passed FDA muster. His only caveat was selected drugs with very unusual pharmacokinetic properties, such as phenytoin – another antiepileptic drug, which has saturation kinetics making it a special case that requires additional, customized testing to prove equivalence between the generic and brand-name form.
But as he and others at the session highlighted, equivalent pharmacologic properties of generic and brand-name forms of a drug tell just part of the story. They may act the same once inside patients’ bodies, but what’s also important is how patients regard these drugs from the neck up. Psychological factors play a role in how patients perceive and use different forms of chemically identical products. Differences in pill size, shape, and color can confuse patients, and just knowing that a drug is a generic could possibly trigger anxiety in a patient that might perhaps produce a seizure or disrupt their pill-taking behavior. Several clinicians at the session spoke of certain patients who have begged them to specify the brand-name drug on their prescriptions. On the other hand, a generic’s lower price often encourages more conscientious use, a phenomenon documented in a database review reported at the session by pharmacoepidemiologist Joshua J. Gagne, Pharm.D.
Madison Avenue has known for years that function and utility tell just part of the story when it comes to consumer goods. A Kia may be just as durable and effective for transporting someone as a Mercedes or BMW, but cheap isn’t always what a consumer wants or feels comfortable with. Generics that work indistinguishably from brand drugs are certainly attractive for the U.S. health care system and the majority of the American public, but the concept that generic is best will be tough to sell to everyone.
On Twitter @mitchelzoler
Resolutions
For many, the making and breaking of New Year’s resolutions has become a humorless cliché. Still, the beginning of a new year is as good a time as any for reflection and inspiration; and if you restrict your fix-it list to a few realistic promises that can actually be kept, resolution time does not have to be such an exercise in futility.
I can’t presume to know what needs improving in your practice, much less your life; but I do know the office issues I get the most questions about. Perhaps the following examples will provide inspiration for assembling a realistic list of your own:
1. Review your October, November, and December claim payments. That is, all payments since ICD-10 launched. Overall, the transition has been surprisingly smooth; the Centers for Medicare & Medicaid Services says the claim denial rate has not increased significantly, and very few rejections are due to incorrect diagnosis coding. But each private payer has its own procedure, so make sure that none of your payers has dropped the ball. The most common problem so far seems to be inconsistent handling of “Z” codes, such as skin cancer screening (Z12.83), so pay particular attention to those.
2. Do a HIPAA risk assessment. The new HIPAA rules have been in effect for more than a year. Is your office up to speed? Review every procedure that involves confidential information; make sure there are no violations. Penalties for carelessness are a lot stiffer now.
3. Encrypt your mobile devices. This is really a subset of No. 2. The biggest HIPAA vulnerability in many practices is laptops and tablets carrying confidential patient information; losing one could be a disaster. Encryption software is cheap and readily available, and a lost or stolen mobile device will probably not be treated as a HIPAA breach if it is properly encrypted.
4. Reduce your accounts receivable by keeping a credit card number on file for each patient, and charging patient-owed balances as they come in. A series of my past columns in the archive at www.edermatologynews.com explains exactly how to do this. Every hotel in the world does it; you should too.
5. Clear your “horizontal file cabinet.” That’s the mess on your desk, all the paperwork you never seem to get to (probably because you’re tweeting or answering e-mail). Set aside an hour or two and get it all done. You’ll find some interesting stuff in there. Then, for every piece of paper that arrives on your desk from now on, follow the DDD Rule: Do it, Delegate it, or Destroy it. Don’t start a new mess.
6. Keep a closer eye on your office finances. Most physicians delegate the bookkeeping, and that’s fine. But ignoring the financial side creates an atmosphere that facilitates embezzlement. Set aside a couple of hours each month to review the books personally. And make sure your employees know you’re doing it.
7. Make sure your long range financial planning is on track. This is another task physicians tend to “set and forget,” but the Great Recession was an eye opener for many of us. Once a year, sit down with your accountant and planner and make sure your investments are well diversified and all other aspects of your finances – budgets, credit ratings, insurance coverage, tax situations, college savings, estate plans, retirement accounts – are in the best shape possible. January is a good time.
8. Back up your data. Now is also an excellent time to verify that the information on your office and personal computers is being backed up – locally and online – on a regular schedule. Don’t wait until something crashes.
9. Take more vacations. Remember Eastern’s First Law: Your last words will NOT be, “I wish I had spent more time in the office.” This is the year to start spending more time enjoying your life, your friends and family, and the world. As John Lennon said, “Life is what happens to you while you’re busy making other plans.”
10. Look at yourself. A private practice lives or dies on the personalities of its physicians, and your staff copies your personality and style. Take a hard, honest look at yourself. Identify your negative personality traits and work to eliminate them. If you have any difficulty finding habits that need changing … ask your spouse. He or she will be happy to explain them in excruciating detail.
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].
For many, the making and breaking of New Year’s resolutions has become a humorless cliché. Still, the beginning of a new year is as good a time as any for reflection and inspiration; and if you restrict your fix-it list to a few realistic promises that can actually be kept, resolution time does not have to be such an exercise in futility.
I can’t presume to know what needs improving in your practice, much less your life; but I do know the office issues I get the most questions about. Perhaps the following examples will provide inspiration for assembling a realistic list of your own:
1. Review your October, November, and December claim payments. That is, all payments since ICD-10 launched. Overall, the transition has been surprisingly smooth; the Centers for Medicare & Medicaid Services says the claim denial rate has not increased significantly, and very few rejections are due to incorrect diagnosis coding. But each private payer has its own procedure, so make sure that none of your payers has dropped the ball. The most common problem so far seems to be inconsistent handling of “Z” codes, such as skin cancer screening (Z12.83), so pay particular attention to those.
2. Do a HIPAA risk assessment. The new HIPAA rules have been in effect for more than a year. Is your office up to speed? Review every procedure that involves confidential information; make sure there are no violations. Penalties for carelessness are a lot stiffer now.
3. Encrypt your mobile devices. This is really a subset of No. 2. The biggest HIPAA vulnerability in many practices is laptops and tablets carrying confidential patient information; losing one could be a disaster. Encryption software is cheap and readily available, and a lost or stolen mobile device will probably not be treated as a HIPAA breach if it is properly encrypted.
4. Reduce your accounts receivable by keeping a credit card number on file for each patient, and charging patient-owed balances as they come in. A series of my past columns in the archive at www.edermatologynews.com explains exactly how to do this. Every hotel in the world does it; you should too.
5. Clear your “horizontal file cabinet.” That’s the mess on your desk, all the paperwork you never seem to get to (probably because you’re tweeting or answering e-mail). Set aside an hour or two and get it all done. You’ll find some interesting stuff in there. Then, for every piece of paper that arrives on your desk from now on, follow the DDD Rule: Do it, Delegate it, or Destroy it. Don’t start a new mess.
6. Keep a closer eye on your office finances. Most physicians delegate the bookkeeping, and that’s fine. But ignoring the financial side creates an atmosphere that facilitates embezzlement. Set aside a couple of hours each month to review the books personally. And make sure your employees know you’re doing it.
7. Make sure your long range financial planning is on track. This is another task physicians tend to “set and forget,” but the Great Recession was an eye opener for many of us. Once a year, sit down with your accountant and planner and make sure your investments are well diversified and all other aspects of your finances – budgets, credit ratings, insurance coverage, tax situations, college savings, estate plans, retirement accounts – are in the best shape possible. January is a good time.
8. Back up your data. Now is also an excellent time to verify that the information on your office and personal computers is being backed up – locally and online – on a regular schedule. Don’t wait until something crashes.
9. Take more vacations. Remember Eastern’s First Law: Your last words will NOT be, “I wish I had spent more time in the office.” This is the year to start spending more time enjoying your life, your friends and family, and the world. As John Lennon said, “Life is what happens to you while you’re busy making other plans.”
10. Look at yourself. A private practice lives or dies on the personalities of its physicians, and your staff copies your personality and style. Take a hard, honest look at yourself. Identify your negative personality traits and work to eliminate them. If you have any difficulty finding habits that need changing … ask your spouse. He or she will be happy to explain them in excruciating detail.
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].
For many, the making and breaking of New Year’s resolutions has become a humorless cliché. Still, the beginning of a new year is as good a time as any for reflection and inspiration; and if you restrict your fix-it list to a few realistic promises that can actually be kept, resolution time does not have to be such an exercise in futility.
I can’t presume to know what needs improving in your practice, much less your life; but I do know the office issues I get the most questions about. Perhaps the following examples will provide inspiration for assembling a realistic list of your own:
1. Review your October, November, and December claim payments. That is, all payments since ICD-10 launched. Overall, the transition has been surprisingly smooth; the Centers for Medicare & Medicaid Services says the claim denial rate has not increased significantly, and very few rejections are due to incorrect diagnosis coding. But each private payer has its own procedure, so make sure that none of your payers has dropped the ball. The most common problem so far seems to be inconsistent handling of “Z” codes, such as skin cancer screening (Z12.83), so pay particular attention to those.
2. Do a HIPAA risk assessment. The new HIPAA rules have been in effect for more than a year. Is your office up to speed? Review every procedure that involves confidential information; make sure there are no violations. Penalties for carelessness are a lot stiffer now.
3. Encrypt your mobile devices. This is really a subset of No. 2. The biggest HIPAA vulnerability in many practices is laptops and tablets carrying confidential patient information; losing one could be a disaster. Encryption software is cheap and readily available, and a lost or stolen mobile device will probably not be treated as a HIPAA breach if it is properly encrypted.
4. Reduce your accounts receivable by keeping a credit card number on file for each patient, and charging patient-owed balances as they come in. A series of my past columns in the archive at www.edermatologynews.com explains exactly how to do this. Every hotel in the world does it; you should too.
5. Clear your “horizontal file cabinet.” That’s the mess on your desk, all the paperwork you never seem to get to (probably because you’re tweeting or answering e-mail). Set aside an hour or two and get it all done. You’ll find some interesting stuff in there. Then, for every piece of paper that arrives on your desk from now on, follow the DDD Rule: Do it, Delegate it, or Destroy it. Don’t start a new mess.
6. Keep a closer eye on your office finances. Most physicians delegate the bookkeeping, and that’s fine. But ignoring the financial side creates an atmosphere that facilitates embezzlement. Set aside a couple of hours each month to review the books personally. And make sure your employees know you’re doing it.
7. Make sure your long range financial planning is on track. This is another task physicians tend to “set and forget,” but the Great Recession was an eye opener for many of us. Once a year, sit down with your accountant and planner and make sure your investments are well diversified and all other aspects of your finances – budgets, credit ratings, insurance coverage, tax situations, college savings, estate plans, retirement accounts – are in the best shape possible. January is a good time.
8. Back up your data. Now is also an excellent time to verify that the information on your office and personal computers is being backed up – locally and online – on a regular schedule. Don’t wait until something crashes.
9. Take more vacations. Remember Eastern’s First Law: Your last words will NOT be, “I wish I had spent more time in the office.” This is the year to start spending more time enjoying your life, your friends and family, and the world. As John Lennon said, “Life is what happens to you while you’re busy making other plans.”
10. Look at yourself. A private practice lives or dies on the personalities of its physicians, and your staff copies your personality and style. Take a hard, honest look at yourself. Identify your negative personality traits and work to eliminate them. If you have any difficulty finding habits that need changing … ask your spouse. He or she will be happy to explain them in excruciating detail.
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].
Mischief Maker
There is a woman whose mischief is causing me a whole lot of problems. Now, I don’t want you to think that I’m a misogynist or some type of closet chauvinist, but Miss Information is really troublesome. Besides me, this wayward troublemaker has managed to entwine herself in multiple aspects of the daily lives of practicing physicians. The widespread introduction of electronic medical record keeping has opened Pandora’s Box for Miss Information to flit about, inserting a word or two here, and fiddling with macros there. Yet it is not only her delight in altering medical records, although that is where I first noticed her trickery.
There could be no other way to explain that a local cardiologist’s history and physical described his patient as having “3 plus ankle pulses” despite the patient’s being a double amputee. Further, another’s records claimed that a patient was “neurologically intact” although he had suffered a dense left hemiplegia following carotid stenting. When I questioned the patient I got the distinct impression that perhaps Miss Information had disguised herself as his cardiologist. She told him that he needed a carotid stent because he had a 60% stenosis which if not treated would result in a stroke … and now he actually had one. I asked him why he had not consulted with me; after all, I am relatively well respected in my town, or so I thought! He said my web reviews were not stellar. Impossible, I believed! But when I checked, I found that impudent rascal Miss Information had inserted derogatory reviews about the cleanliness and friendliness of my office staff. I knew it was her doing because she had actually made a mistake in my favor. She had erroneously claimed that the wait time in my office was better than average and I know for a fact I am tardy in that respect.
Coincidentally, I had just Googled “indications for carotid surgery and stenting” since I had to give a talk on asymptomatic carotid stenosis at the VEITH symposium. To my consternation, I discovered evidence that Miss Information had also infiltrated the Internet. The mischievous imp has jumbled the data, causing researchers to write contrary articles demonstrating stents to be less dangerous than endarterectomy, but equally that they are more hazardous. She also has inserted articles suggesting that patients with greater than 70% blockages need invasive treatment whereas other references adamantly proclaim that no one should have CEA or CAS unless they are symptomatic.
I don’t want to insinuate that Miss Information is necessarily unethical, but I am concerned by how she has altered the credentials of some of the doctors in my area. For example, I read an ad in the newspaper that a general surgeon who does vein therapy claimed to be a “Board Certified Vascular Surgeon,” whereas he had never taken a fellowship, nor ever passed the boards in vascular surgery. Surely, such a mistaken advertisement could only have resulted from that playful wordsmith, Miss Information. The same doctor’s records had also been manipulated by this little devil. She altered the note of one of his patients to falsely claim that the patient had severe pain despite having complied with insurance regulations that required exercising and wearing stockings for 3 months. The patient had no pain and had not worn stockings at all. Further, the duplex scan described an incompetent saphenous vein that had previously been removed for his cardiac bypass.
And, lo and behold, even our patients can succumb to her advances. A 30-year-old fitness instructor informed me that he suffered from such severe pain from an ugly calf varicose vein that he was reduced to consuming large quantities of analgesics. He did not want phlebectomy even though scars would be minimal. Rather, he requested that I prescribe oxycodone!
Miss Information even seems to be able to get herself on TV. I saw her in an ad masquerading as a vein doctor claiming that varicose veins can lead to life-threatening complications. Like the sorcerer that she is, she charms viewers by assuring them that most insurers will pay for treatment. Another of her tricks is to show spider veins vanishing in an instant with sclerotherapy, when we all know they may look even worse for a while. And, every morning and throughout the day, I see TV ads touting that a large legal firm specializing in malpractice asserts that it is “For the people”… Really?
Even a hospital with all its ability to keep out dangerous pathogens can be infected by this ill-behaved sprite. A hospital in a neighboring county claims to be a full service hospital, but has no vascular surgeon to cover the emergency department. Two other local hospitals claim to be in the “Top 100” of American hospitals. Yet one was cited by the state department of health services for unsanitary conditions. The other just paid $2 million to the U.S. Department of Justice to settle allegations of improperly implanted cardiac devices. Miss Information, acting as the spokesperson for the latter hospital, claimed that payment was made to avoid “costly and distracting litigation.”
Industry also is not immune to her conniving ways. I have already devoted an editorial to target lesion revascularization (TLR), a term she frequently uses to mislead us into believing one device is better than another.
With all the potential for Miss Information to negatively affect our professional judgment and outcomes, I question the government’s insistence that we all use electronic medical records. The premise for widespread use of an EMR is that if a surgeon has easy access to patient records from another state, he or she will not have to repeat costly tests or procedures. However, how do we know if Miss Information has rendered these tests unreliable? I was recently placed in a clinical quandary when an insurance company insisted that it would not pay for a confirmatory duplex scan on its client. I was aware that the patient had the scan performed at another lab where Miss Information would notoriously exaggerate the degree of stenosis to support unnecessary endarterectomies.
I have tried to make myself immune to Miss Information’s depravity since I know how insidious her efforts can be. However, it is possible that even some of my writings may be contaminated. Accordingly, I must sadly acknowledge that some of the “stories” I relayed above might not be completely factual. You will have to decide which, if any, Miss Information got hold of. Good luck!
Dr. Samson is clinical professor of surgery (vascular) at Florida State University Medical School, is president of Mote Vascular Foundation, and an attending vascular surgeon, Sarasota (Fla.) Vascular Specialists. Dr. Samson also considers himself a member of his proposed American College of Vascular Surgery.
There is a woman whose mischief is causing me a whole lot of problems. Now, I don’t want you to think that I’m a misogynist or some type of closet chauvinist, but Miss Information is really troublesome. Besides me, this wayward troublemaker has managed to entwine herself in multiple aspects of the daily lives of practicing physicians. The widespread introduction of electronic medical record keeping has opened Pandora’s Box for Miss Information to flit about, inserting a word or two here, and fiddling with macros there. Yet it is not only her delight in altering medical records, although that is where I first noticed her trickery.
There could be no other way to explain that a local cardiologist’s history and physical described his patient as having “3 plus ankle pulses” despite the patient’s being a double amputee. Further, another’s records claimed that a patient was “neurologically intact” although he had suffered a dense left hemiplegia following carotid stenting. When I questioned the patient I got the distinct impression that perhaps Miss Information had disguised herself as his cardiologist. She told him that he needed a carotid stent because he had a 60% stenosis which if not treated would result in a stroke … and now he actually had one. I asked him why he had not consulted with me; after all, I am relatively well respected in my town, or so I thought! He said my web reviews were not stellar. Impossible, I believed! But when I checked, I found that impudent rascal Miss Information had inserted derogatory reviews about the cleanliness and friendliness of my office staff. I knew it was her doing because she had actually made a mistake in my favor. She had erroneously claimed that the wait time in my office was better than average and I know for a fact I am tardy in that respect.
Coincidentally, I had just Googled “indications for carotid surgery and stenting” since I had to give a talk on asymptomatic carotid stenosis at the VEITH symposium. To my consternation, I discovered evidence that Miss Information had also infiltrated the Internet. The mischievous imp has jumbled the data, causing researchers to write contrary articles demonstrating stents to be less dangerous than endarterectomy, but equally that they are more hazardous. She also has inserted articles suggesting that patients with greater than 70% blockages need invasive treatment whereas other references adamantly proclaim that no one should have CEA or CAS unless they are symptomatic.
I don’t want to insinuate that Miss Information is necessarily unethical, but I am concerned by how she has altered the credentials of some of the doctors in my area. For example, I read an ad in the newspaper that a general surgeon who does vein therapy claimed to be a “Board Certified Vascular Surgeon,” whereas he had never taken a fellowship, nor ever passed the boards in vascular surgery. Surely, such a mistaken advertisement could only have resulted from that playful wordsmith, Miss Information. The same doctor’s records had also been manipulated by this little devil. She altered the note of one of his patients to falsely claim that the patient had severe pain despite having complied with insurance regulations that required exercising and wearing stockings for 3 months. The patient had no pain and had not worn stockings at all. Further, the duplex scan described an incompetent saphenous vein that had previously been removed for his cardiac bypass.
And, lo and behold, even our patients can succumb to her advances. A 30-year-old fitness instructor informed me that he suffered from such severe pain from an ugly calf varicose vein that he was reduced to consuming large quantities of analgesics. He did not want phlebectomy even though scars would be minimal. Rather, he requested that I prescribe oxycodone!
Miss Information even seems to be able to get herself on TV. I saw her in an ad masquerading as a vein doctor claiming that varicose veins can lead to life-threatening complications. Like the sorcerer that she is, she charms viewers by assuring them that most insurers will pay for treatment. Another of her tricks is to show spider veins vanishing in an instant with sclerotherapy, when we all know they may look even worse for a while. And, every morning and throughout the day, I see TV ads touting that a large legal firm specializing in malpractice asserts that it is “For the people”… Really?
Even a hospital with all its ability to keep out dangerous pathogens can be infected by this ill-behaved sprite. A hospital in a neighboring county claims to be a full service hospital, but has no vascular surgeon to cover the emergency department. Two other local hospitals claim to be in the “Top 100” of American hospitals. Yet one was cited by the state department of health services for unsanitary conditions. The other just paid $2 million to the U.S. Department of Justice to settle allegations of improperly implanted cardiac devices. Miss Information, acting as the spokesperson for the latter hospital, claimed that payment was made to avoid “costly and distracting litigation.”
Industry also is not immune to her conniving ways. I have already devoted an editorial to target lesion revascularization (TLR), a term she frequently uses to mislead us into believing one device is better than another.
With all the potential for Miss Information to negatively affect our professional judgment and outcomes, I question the government’s insistence that we all use electronic medical records. The premise for widespread use of an EMR is that if a surgeon has easy access to patient records from another state, he or she will not have to repeat costly tests or procedures. However, how do we know if Miss Information has rendered these tests unreliable? I was recently placed in a clinical quandary when an insurance company insisted that it would not pay for a confirmatory duplex scan on its client. I was aware that the patient had the scan performed at another lab where Miss Information would notoriously exaggerate the degree of stenosis to support unnecessary endarterectomies.
I have tried to make myself immune to Miss Information’s depravity since I know how insidious her efforts can be. However, it is possible that even some of my writings may be contaminated. Accordingly, I must sadly acknowledge that some of the “stories” I relayed above might not be completely factual. You will have to decide which, if any, Miss Information got hold of. Good luck!
Dr. Samson is clinical professor of surgery (vascular) at Florida State University Medical School, is president of Mote Vascular Foundation, and an attending vascular surgeon, Sarasota (Fla.) Vascular Specialists. Dr. Samson also considers himself a member of his proposed American College of Vascular Surgery.
There is a woman whose mischief is causing me a whole lot of problems. Now, I don’t want you to think that I’m a misogynist or some type of closet chauvinist, but Miss Information is really troublesome. Besides me, this wayward troublemaker has managed to entwine herself in multiple aspects of the daily lives of practicing physicians. The widespread introduction of electronic medical record keeping has opened Pandora’s Box for Miss Information to flit about, inserting a word or two here, and fiddling with macros there. Yet it is not only her delight in altering medical records, although that is where I first noticed her trickery.
There could be no other way to explain that a local cardiologist’s history and physical described his patient as having “3 plus ankle pulses” despite the patient’s being a double amputee. Further, another’s records claimed that a patient was “neurologically intact” although he had suffered a dense left hemiplegia following carotid stenting. When I questioned the patient I got the distinct impression that perhaps Miss Information had disguised herself as his cardiologist. She told him that he needed a carotid stent because he had a 60% stenosis which if not treated would result in a stroke … and now he actually had one. I asked him why he had not consulted with me; after all, I am relatively well respected in my town, or so I thought! He said my web reviews were not stellar. Impossible, I believed! But when I checked, I found that impudent rascal Miss Information had inserted derogatory reviews about the cleanliness and friendliness of my office staff. I knew it was her doing because she had actually made a mistake in my favor. She had erroneously claimed that the wait time in my office was better than average and I know for a fact I am tardy in that respect.
Coincidentally, I had just Googled “indications for carotid surgery and stenting” since I had to give a talk on asymptomatic carotid stenosis at the VEITH symposium. To my consternation, I discovered evidence that Miss Information had also infiltrated the Internet. The mischievous imp has jumbled the data, causing researchers to write contrary articles demonstrating stents to be less dangerous than endarterectomy, but equally that they are more hazardous. She also has inserted articles suggesting that patients with greater than 70% blockages need invasive treatment whereas other references adamantly proclaim that no one should have CEA or CAS unless they are symptomatic.
I don’t want to insinuate that Miss Information is necessarily unethical, but I am concerned by how she has altered the credentials of some of the doctors in my area. For example, I read an ad in the newspaper that a general surgeon who does vein therapy claimed to be a “Board Certified Vascular Surgeon,” whereas he had never taken a fellowship, nor ever passed the boards in vascular surgery. Surely, such a mistaken advertisement could only have resulted from that playful wordsmith, Miss Information. The same doctor’s records had also been manipulated by this little devil. She altered the note of one of his patients to falsely claim that the patient had severe pain despite having complied with insurance regulations that required exercising and wearing stockings for 3 months. The patient had no pain and had not worn stockings at all. Further, the duplex scan described an incompetent saphenous vein that had previously been removed for his cardiac bypass.
And, lo and behold, even our patients can succumb to her advances. A 30-year-old fitness instructor informed me that he suffered from such severe pain from an ugly calf varicose vein that he was reduced to consuming large quantities of analgesics. He did not want phlebectomy even though scars would be minimal. Rather, he requested that I prescribe oxycodone!
Miss Information even seems to be able to get herself on TV. I saw her in an ad masquerading as a vein doctor claiming that varicose veins can lead to life-threatening complications. Like the sorcerer that she is, she charms viewers by assuring them that most insurers will pay for treatment. Another of her tricks is to show spider veins vanishing in an instant with sclerotherapy, when we all know they may look even worse for a while. And, every morning and throughout the day, I see TV ads touting that a large legal firm specializing in malpractice asserts that it is “For the people”… Really?
Even a hospital with all its ability to keep out dangerous pathogens can be infected by this ill-behaved sprite. A hospital in a neighboring county claims to be a full service hospital, but has no vascular surgeon to cover the emergency department. Two other local hospitals claim to be in the “Top 100” of American hospitals. Yet one was cited by the state department of health services for unsanitary conditions. The other just paid $2 million to the U.S. Department of Justice to settle allegations of improperly implanted cardiac devices. Miss Information, acting as the spokesperson for the latter hospital, claimed that payment was made to avoid “costly and distracting litigation.”
Industry also is not immune to her conniving ways. I have already devoted an editorial to target lesion revascularization (TLR), a term she frequently uses to mislead us into believing one device is better than another.
With all the potential for Miss Information to negatively affect our professional judgment and outcomes, I question the government’s insistence that we all use electronic medical records. The premise for widespread use of an EMR is that if a surgeon has easy access to patient records from another state, he or she will not have to repeat costly tests or procedures. However, how do we know if Miss Information has rendered these tests unreliable? I was recently placed in a clinical quandary when an insurance company insisted that it would not pay for a confirmatory duplex scan on its client. I was aware that the patient had the scan performed at another lab where Miss Information would notoriously exaggerate the degree of stenosis to support unnecessary endarterectomies.
I have tried to make myself immune to Miss Information’s depravity since I know how insidious her efforts can be. However, it is possible that even some of my writings may be contaminated. Accordingly, I must sadly acknowledge that some of the “stories” I relayed above might not be completely factual. You will have to decide which, if any, Miss Information got hold of. Good luck!
Dr. Samson is clinical professor of surgery (vascular) at Florida State University Medical School, is president of Mote Vascular Foundation, and an attending vascular surgeon, Sarasota (Fla.) Vascular Specialists. Dr. Samson also considers himself a member of his proposed American College of Vascular Surgery.
Special unit shows encouraging results for ELBW babies
Decades ago, a baby born at just 28 weeks’ gestation and weighing less than 1,000 grams would not likely survive. Today, thanks to the latest advances in neonatal intensive care, the survival rates for these infants have significantly improved.
Survival is just the first hurdle on these patients’ journey. Despite numerous medical advancements, many of these “micro-preemies” still may be discharged with significant challenges, including neurodevelopmental delays and/or chronic medical problems.
Our goal at Children’s Hospital of Orange County (CHOC Children’s) is to ensure that extremely-low-birth-weight (ELBW) babies not only survive, but that they do so with fewer long-term complications.
Outcomes from our small baby unit (SBU) show we’re doing just that.
Unique environment, bonds
Established in 2010, the SBU consists of four individual patient rooms, two of which are surgical suites, and three four-bed pods. Different from a traditional neonatal intensive care unit (NICU), this smaller unit allows a darker, quieter environment that encourages developmentally supportive care.
In the SBU, patients lie inside covered incubators that keep light away from their underdeveloped eyes. Families and staff members speak in “library voices,” because even a whisper is too harsh for these babies’ ears in the early stages of care. The goal is to create an environment that respects and supports the physiologic needs of the baby to grow and develop after being born so prematurely. Grouping this population also provides parents an opportunity to form strong bonds with other families sharing similar experiences. Only another parent of an ELBW baby can truly understand the fear felt when delivering an infant 12-16 weeks early; the trial of a months-long hospital stay; and the elation on discharge day. Anecdotally, these bonds have sometimes lasted years after discharge.
Dedicated, coordinated care
An objective of the initiative was to cohort ELBW infants in a single location physically separated from the main NICU, and to recognize that progressive changes in unit culture were essential for successfully shifting the practice model.
Experienced multidisciplinary NICU staff with interest and expertise in caring for ELBW patients became the initiative’s core tore team members. They received education – both independent study as well as an 8-hour class – prior to opening the SBU, and continuing education and team building remain key components of program development.
Improved outcomes
By utilizing a dedicated team with expertise in the care of these patients, CHOC Children’s clinicians have determined that establishing a unit dedicated to the care of ELBW patients has led to improved quality and outcomes.
Reducing chronic lung disease was a top motivation for the creation of the unit, and rates of chronic lung disease dropped from 48% of babies 2 years prior to the unit’s 2010 opening to 36% after the first 4 years of the program. The percentage of babies discharged on oxygen decreased from 23% to 18%. Continued improvement over time showed as well in both areas.
Infants being discharged with growth restriction (combined weight and head circumference less than the 10th percentile) decreased from 62% to 37%, and continued improvement showed over time.
Rates of hospital-acquired infections decreased from 39% to 19%, which led to fewer days of antibiotic administration.
Coordinated care from a dedicated multidisciplinary team also led to the reduction of ordering unnecessary tests. For example, the mean number per patient of routine laboratory tests decreased from 224 to 82 and radiographs decreased from 45 to 22 during the infants’ hospitalization.
Eliminating practice variation
Because practice variation often complicates care, the SBU cares for patients through a standardized, evidence-based practice that incorporates guidelines and checklists.
Evidence and unit culture informed the development of guidelines, and input was sought from the whole team: nursing staff, neonatal nurse practitioners, neonatologists, respiratory therapists, developmental specialists, dietitians, lactation support, pharmacists, social services, transport services, and high-risk infant follow-up clinic staff.
Checklists helped standardize practices, reduce variation, and improve safety.
Culture, consistency are key
Our clinicians found that improved outcomes in ELBW infants can be achieved by changing the culture of the practice. The successful outcomes likely reflect the benefits of consistency in practice by a dedicated team that gained expertise in the care of this population in a separate developmentally appropriate location.
In addition, there was a reduction in complications among infants prior to leaving the SBU. Engaging the team on an ongoing basis can sustain improved outcomes, including improved staff satisfaction.
Mindy Morris is a neonatal nurse practitioner and coordinator of the extremely-low-birth-weight program at Children’s Hospital of Orange County in Southern California.
Decades ago, a baby born at just 28 weeks’ gestation and weighing less than 1,000 grams would not likely survive. Today, thanks to the latest advances in neonatal intensive care, the survival rates for these infants have significantly improved.
Survival is just the first hurdle on these patients’ journey. Despite numerous medical advancements, many of these “micro-preemies” still may be discharged with significant challenges, including neurodevelopmental delays and/or chronic medical problems.
Our goal at Children’s Hospital of Orange County (CHOC Children’s) is to ensure that extremely-low-birth-weight (ELBW) babies not only survive, but that they do so with fewer long-term complications.
Outcomes from our small baby unit (SBU) show we’re doing just that.
Unique environment, bonds
Established in 2010, the SBU consists of four individual patient rooms, two of which are surgical suites, and three four-bed pods. Different from a traditional neonatal intensive care unit (NICU), this smaller unit allows a darker, quieter environment that encourages developmentally supportive care.
In the SBU, patients lie inside covered incubators that keep light away from their underdeveloped eyes. Families and staff members speak in “library voices,” because even a whisper is too harsh for these babies’ ears in the early stages of care. The goal is to create an environment that respects and supports the physiologic needs of the baby to grow and develop after being born so prematurely. Grouping this population also provides parents an opportunity to form strong bonds with other families sharing similar experiences. Only another parent of an ELBW baby can truly understand the fear felt when delivering an infant 12-16 weeks early; the trial of a months-long hospital stay; and the elation on discharge day. Anecdotally, these bonds have sometimes lasted years after discharge.
Dedicated, coordinated care
An objective of the initiative was to cohort ELBW infants in a single location physically separated from the main NICU, and to recognize that progressive changes in unit culture were essential for successfully shifting the practice model.
Experienced multidisciplinary NICU staff with interest and expertise in caring for ELBW patients became the initiative’s core tore team members. They received education – both independent study as well as an 8-hour class – prior to opening the SBU, and continuing education and team building remain key components of program development.
Improved outcomes
By utilizing a dedicated team with expertise in the care of these patients, CHOC Children’s clinicians have determined that establishing a unit dedicated to the care of ELBW patients has led to improved quality and outcomes.
Reducing chronic lung disease was a top motivation for the creation of the unit, and rates of chronic lung disease dropped from 48% of babies 2 years prior to the unit’s 2010 opening to 36% after the first 4 years of the program. The percentage of babies discharged on oxygen decreased from 23% to 18%. Continued improvement over time showed as well in both areas.
Infants being discharged with growth restriction (combined weight and head circumference less than the 10th percentile) decreased from 62% to 37%, and continued improvement showed over time.
Rates of hospital-acquired infections decreased from 39% to 19%, which led to fewer days of antibiotic administration.
Coordinated care from a dedicated multidisciplinary team also led to the reduction of ordering unnecessary tests. For example, the mean number per patient of routine laboratory tests decreased from 224 to 82 and radiographs decreased from 45 to 22 during the infants’ hospitalization.
Eliminating practice variation
Because practice variation often complicates care, the SBU cares for patients through a standardized, evidence-based practice that incorporates guidelines and checklists.
Evidence and unit culture informed the development of guidelines, and input was sought from the whole team: nursing staff, neonatal nurse practitioners, neonatologists, respiratory therapists, developmental specialists, dietitians, lactation support, pharmacists, social services, transport services, and high-risk infant follow-up clinic staff.
Checklists helped standardize practices, reduce variation, and improve safety.
Culture, consistency are key
Our clinicians found that improved outcomes in ELBW infants can be achieved by changing the culture of the practice. The successful outcomes likely reflect the benefits of consistency in practice by a dedicated team that gained expertise in the care of this population in a separate developmentally appropriate location.
In addition, there was a reduction in complications among infants prior to leaving the SBU. Engaging the team on an ongoing basis can sustain improved outcomes, including improved staff satisfaction.
Mindy Morris is a neonatal nurse practitioner and coordinator of the extremely-low-birth-weight program at Children’s Hospital of Orange County in Southern California.
Decades ago, a baby born at just 28 weeks’ gestation and weighing less than 1,000 grams would not likely survive. Today, thanks to the latest advances in neonatal intensive care, the survival rates for these infants have significantly improved.
Survival is just the first hurdle on these patients’ journey. Despite numerous medical advancements, many of these “micro-preemies” still may be discharged with significant challenges, including neurodevelopmental delays and/or chronic medical problems.
Our goal at Children’s Hospital of Orange County (CHOC Children’s) is to ensure that extremely-low-birth-weight (ELBW) babies not only survive, but that they do so with fewer long-term complications.
Outcomes from our small baby unit (SBU) show we’re doing just that.
Unique environment, bonds
Established in 2010, the SBU consists of four individual patient rooms, two of which are surgical suites, and three four-bed pods. Different from a traditional neonatal intensive care unit (NICU), this smaller unit allows a darker, quieter environment that encourages developmentally supportive care.
In the SBU, patients lie inside covered incubators that keep light away from their underdeveloped eyes. Families and staff members speak in “library voices,” because even a whisper is too harsh for these babies’ ears in the early stages of care. The goal is to create an environment that respects and supports the physiologic needs of the baby to grow and develop after being born so prematurely. Grouping this population also provides parents an opportunity to form strong bonds with other families sharing similar experiences. Only another parent of an ELBW baby can truly understand the fear felt when delivering an infant 12-16 weeks early; the trial of a months-long hospital stay; and the elation on discharge day. Anecdotally, these bonds have sometimes lasted years after discharge.
Dedicated, coordinated care
An objective of the initiative was to cohort ELBW infants in a single location physically separated from the main NICU, and to recognize that progressive changes in unit culture were essential for successfully shifting the practice model.
Experienced multidisciplinary NICU staff with interest and expertise in caring for ELBW patients became the initiative’s core tore team members. They received education – both independent study as well as an 8-hour class – prior to opening the SBU, and continuing education and team building remain key components of program development.
Improved outcomes
By utilizing a dedicated team with expertise in the care of these patients, CHOC Children’s clinicians have determined that establishing a unit dedicated to the care of ELBW patients has led to improved quality and outcomes.
Reducing chronic lung disease was a top motivation for the creation of the unit, and rates of chronic lung disease dropped from 48% of babies 2 years prior to the unit’s 2010 opening to 36% after the first 4 years of the program. The percentage of babies discharged on oxygen decreased from 23% to 18%. Continued improvement over time showed as well in both areas.
Infants being discharged with growth restriction (combined weight and head circumference less than the 10th percentile) decreased from 62% to 37%, and continued improvement showed over time.
Rates of hospital-acquired infections decreased from 39% to 19%, which led to fewer days of antibiotic administration.
Coordinated care from a dedicated multidisciplinary team also led to the reduction of ordering unnecessary tests. For example, the mean number per patient of routine laboratory tests decreased from 224 to 82 and radiographs decreased from 45 to 22 during the infants’ hospitalization.
Eliminating practice variation
Because practice variation often complicates care, the SBU cares for patients through a standardized, evidence-based practice that incorporates guidelines and checklists.
Evidence and unit culture informed the development of guidelines, and input was sought from the whole team: nursing staff, neonatal nurse practitioners, neonatologists, respiratory therapists, developmental specialists, dietitians, lactation support, pharmacists, social services, transport services, and high-risk infant follow-up clinic staff.
Checklists helped standardize practices, reduce variation, and improve safety.
Culture, consistency are key
Our clinicians found that improved outcomes in ELBW infants can be achieved by changing the culture of the practice. The successful outcomes likely reflect the benefits of consistency in practice by a dedicated team that gained expertise in the care of this population in a separate developmentally appropriate location.
In addition, there was a reduction in complications among infants prior to leaving the SBU. Engaging the team on an ongoing basis can sustain improved outcomes, including improved staff satisfaction.
Mindy Morris is a neonatal nurse practitioner and coordinator of the extremely-low-birth-weight program at Children’s Hospital of Orange County in Southern California.
Does cannabis cause psychosis? A brief review of the evidence
As more and more states consider legalizing marijuana for recreational use, the widely held belief that cannabis is associated with few serious health consequences has been challenged by many medical and substance use professionals. One potential risk that has been discussed is the possibility that cannabis use increases the risk for psychotic symptoms that may be long lasting and develop into schizophrenia. The data, however, have not been completely consistent and often are methodologically flawed, leading proponents of legalization to downplay this possible risk. This debate has even made its way to prominent science journals such as Nature where scholars have presented opposing views (Nature. 2015 Sep 24;525[7570]:S14and Nature. 2015 Nov 19;527[7578]:305).
These divergent opinions can lead to some confusion and hesitancy on the part of pediatricians who may be asked to offer an opinion about the dangers of cannabis use to individual patients and families during this time of public debate. Thus, this column will attempt to offer a brief overview and synthesis of the evidence that cannabis plays a causal role in the progression of psychotic disorders.
A recent review of the subject examined 10 epidemiological studies that have now been performed on the association between cannabis and psychotic disorders. Overall, a nearly 50% increased risk of psychosis was found among cannabis users, compared to nonusers (Biol Psychiatry. 2015 Aug 12. pii: S0006-3223[15]00647-2). This association rises among heavier cannabis users (Lancet. 2007 Jul 28;370[9584]:319-28). Because all of these longitudinal studies were observational in nature, however, proving causation in the face of association has remained challenging. Many of these studies have attempted to control for baseline psychotic symptoms to address the “reverse causation hypothesis,” which posits that early psychotic symptoms leads to cannabis use rather than the other way around. It is also worth pointing out that the inevitable limitations and potential biases of these studies could potentially lead to both overestimation and underestimation of the actual risk.
Putting all of this together, the authors concluded that “there is a strong body of epidemiologic evidence to support the view that regular or heavy cannabis use increases the risk of developing psychotic disorders that persist beyond the direct effects of exogenous cannabinoids.” In making this conclusion, despite the inherent uncertainties of interpreting observational studies, the authors describe a number of lines of evidence that support the likelihood of a causal connection. These include the following:
• The well-known fact that acute intoxication of cannabis can produce transient psychotic symptoms.
• The replicated finding that there is a dose-dependent response between amount of cannabis use and psychosis.
• An increased risk of psychosis among cannabis users who carry specific risk genes (Biol Psychiatry. 2012 Nov 15;72[10]:811-6).
• Increasing evidence that the more potent marijuana that is available now may be associated with additional risk.
• The finding that the link between cannabis and psychosis is not equal for all age groups, but may be stronger for adolescents.
One line of argument against a causal role of cannabis in the development of psychotic disorders is that the rate of schizophrenia has remained relatively flat over the years that cannabis use has increased. Countering that assertion, however, Large and colleagues pointed out that some studies do show increasing rates of schizophrenia (Nature. 2015 Nov 19;527[7578]:305). Further, it is somewhat precarious to conclude that a possible risk factor is not consequential when it moves in a different direction than a multifactorial disorder such as schizophrenia. Lead toxicity, for example, is an accepted risk factor for attention-deficit/hyperactivity disorder (ADHD), yet exposure has been decreasing while rates of ADHD climb.
Overall, the data appear to be strengthening that cannabis does play a causal role in the development of psychosis and psychotic disorders. This risk is combined with data showing links between cannabis use and decreased IQ, academic underachievement, car accidents, and use of other types of drugs (Addiction. 2015 Jan;110[1]:19-35). These dangers need to be articulated in discussions about the wisdom of legalizing cannabis at the state and federal level.
Dr. Rettew is associate professor of psychiatry and pediatrics at the University of Vermont, Burlington. He said he has no relevant financial disclosures. Follow him on Twitter @pedipsych. E-mail him at [email protected].
As more and more states consider legalizing marijuana for recreational use, the widely held belief that cannabis is associated with few serious health consequences has been challenged by many medical and substance use professionals. One potential risk that has been discussed is the possibility that cannabis use increases the risk for psychotic symptoms that may be long lasting and develop into schizophrenia. The data, however, have not been completely consistent and often are methodologically flawed, leading proponents of legalization to downplay this possible risk. This debate has even made its way to prominent science journals such as Nature where scholars have presented opposing views (Nature. 2015 Sep 24;525[7570]:S14and Nature. 2015 Nov 19;527[7578]:305).
These divergent opinions can lead to some confusion and hesitancy on the part of pediatricians who may be asked to offer an opinion about the dangers of cannabis use to individual patients and families during this time of public debate. Thus, this column will attempt to offer a brief overview and synthesis of the evidence that cannabis plays a causal role in the progression of psychotic disorders.
A recent review of the subject examined 10 epidemiological studies that have now been performed on the association between cannabis and psychotic disorders. Overall, a nearly 50% increased risk of psychosis was found among cannabis users, compared to nonusers (Biol Psychiatry. 2015 Aug 12. pii: S0006-3223[15]00647-2). This association rises among heavier cannabis users (Lancet. 2007 Jul 28;370[9584]:319-28). Because all of these longitudinal studies were observational in nature, however, proving causation in the face of association has remained challenging. Many of these studies have attempted to control for baseline psychotic symptoms to address the “reverse causation hypothesis,” which posits that early psychotic symptoms leads to cannabis use rather than the other way around. It is also worth pointing out that the inevitable limitations and potential biases of these studies could potentially lead to both overestimation and underestimation of the actual risk.
Putting all of this together, the authors concluded that “there is a strong body of epidemiologic evidence to support the view that regular or heavy cannabis use increases the risk of developing psychotic disorders that persist beyond the direct effects of exogenous cannabinoids.” In making this conclusion, despite the inherent uncertainties of interpreting observational studies, the authors describe a number of lines of evidence that support the likelihood of a causal connection. These include the following:
• The well-known fact that acute intoxication of cannabis can produce transient psychotic symptoms.
• The replicated finding that there is a dose-dependent response between amount of cannabis use and psychosis.
• An increased risk of psychosis among cannabis users who carry specific risk genes (Biol Psychiatry. 2012 Nov 15;72[10]:811-6).
• Increasing evidence that the more potent marijuana that is available now may be associated with additional risk.
• The finding that the link between cannabis and psychosis is not equal for all age groups, but may be stronger for adolescents.
One line of argument against a causal role of cannabis in the development of psychotic disorders is that the rate of schizophrenia has remained relatively flat over the years that cannabis use has increased. Countering that assertion, however, Large and colleagues pointed out that some studies do show increasing rates of schizophrenia (Nature. 2015 Nov 19;527[7578]:305). Further, it is somewhat precarious to conclude that a possible risk factor is not consequential when it moves in a different direction than a multifactorial disorder such as schizophrenia. Lead toxicity, for example, is an accepted risk factor for attention-deficit/hyperactivity disorder (ADHD), yet exposure has been decreasing while rates of ADHD climb.
Overall, the data appear to be strengthening that cannabis does play a causal role in the development of psychosis and psychotic disorders. This risk is combined with data showing links between cannabis use and decreased IQ, academic underachievement, car accidents, and use of other types of drugs (Addiction. 2015 Jan;110[1]:19-35). These dangers need to be articulated in discussions about the wisdom of legalizing cannabis at the state and federal level.
Dr. Rettew is associate professor of psychiatry and pediatrics at the University of Vermont, Burlington. He said he has no relevant financial disclosures. Follow him on Twitter @pedipsych. E-mail him at [email protected].
As more and more states consider legalizing marijuana for recreational use, the widely held belief that cannabis is associated with few serious health consequences has been challenged by many medical and substance use professionals. One potential risk that has been discussed is the possibility that cannabis use increases the risk for psychotic symptoms that may be long lasting and develop into schizophrenia. The data, however, have not been completely consistent and often are methodologically flawed, leading proponents of legalization to downplay this possible risk. This debate has even made its way to prominent science journals such as Nature where scholars have presented opposing views (Nature. 2015 Sep 24;525[7570]:S14and Nature. 2015 Nov 19;527[7578]:305).
These divergent opinions can lead to some confusion and hesitancy on the part of pediatricians who may be asked to offer an opinion about the dangers of cannabis use to individual patients and families during this time of public debate. Thus, this column will attempt to offer a brief overview and synthesis of the evidence that cannabis plays a causal role in the progression of psychotic disorders.
A recent review of the subject examined 10 epidemiological studies that have now been performed on the association between cannabis and psychotic disorders. Overall, a nearly 50% increased risk of psychosis was found among cannabis users, compared to nonusers (Biol Psychiatry. 2015 Aug 12. pii: S0006-3223[15]00647-2). This association rises among heavier cannabis users (Lancet. 2007 Jul 28;370[9584]:319-28). Because all of these longitudinal studies were observational in nature, however, proving causation in the face of association has remained challenging. Many of these studies have attempted to control for baseline psychotic symptoms to address the “reverse causation hypothesis,” which posits that early psychotic symptoms leads to cannabis use rather than the other way around. It is also worth pointing out that the inevitable limitations and potential biases of these studies could potentially lead to both overestimation and underestimation of the actual risk.
Putting all of this together, the authors concluded that “there is a strong body of epidemiologic evidence to support the view that regular or heavy cannabis use increases the risk of developing psychotic disorders that persist beyond the direct effects of exogenous cannabinoids.” In making this conclusion, despite the inherent uncertainties of interpreting observational studies, the authors describe a number of lines of evidence that support the likelihood of a causal connection. These include the following:
• The well-known fact that acute intoxication of cannabis can produce transient psychotic symptoms.
• The replicated finding that there is a dose-dependent response between amount of cannabis use and psychosis.
• An increased risk of psychosis among cannabis users who carry specific risk genes (Biol Psychiatry. 2012 Nov 15;72[10]:811-6).
• Increasing evidence that the more potent marijuana that is available now may be associated with additional risk.
• The finding that the link between cannabis and psychosis is not equal for all age groups, but may be stronger for adolescents.
One line of argument against a causal role of cannabis in the development of psychotic disorders is that the rate of schizophrenia has remained relatively flat over the years that cannabis use has increased. Countering that assertion, however, Large and colleagues pointed out that some studies do show increasing rates of schizophrenia (Nature. 2015 Nov 19;527[7578]:305). Further, it is somewhat precarious to conclude that a possible risk factor is not consequential when it moves in a different direction than a multifactorial disorder such as schizophrenia. Lead toxicity, for example, is an accepted risk factor for attention-deficit/hyperactivity disorder (ADHD), yet exposure has been decreasing while rates of ADHD climb.
Overall, the data appear to be strengthening that cannabis does play a causal role in the development of psychosis and psychotic disorders. This risk is combined with data showing links between cannabis use and decreased IQ, academic underachievement, car accidents, and use of other types of drugs (Addiction. 2015 Jan;110[1]:19-35). These dangers need to be articulated in discussions about the wisdom of legalizing cannabis at the state and federal level.
Dr. Rettew is associate professor of psychiatry and pediatrics at the University of Vermont, Burlington. He said he has no relevant financial disclosures. Follow him on Twitter @pedipsych. E-mail him at [email protected].
Poor stewardship
To those of us who live and practice in the northeast, it comes as no surprise that the mortality rate for middle class whites is climbing. Obituaries in our local papers often include men and women in their forties “dying at home,” with no mention of cancer or chronic disease. Rarely, the family can bring itself to announce that their loved one has died of a drug overdose.
Deaths attributable to prescription opioid overdoses quadrupled in the decade from 1999 to 2010, and the trend shows little sign of abating as the number of prescriptions for opioids has risen tenfold over the last 20 years (“How Doctors Helped Drive the Addiction Crisis,” by Dr. Richard Friedman, New York Times, Nov. 7, 2015). Could physician behavior have contributed to outbreak of this deadly plague of addiction? That is like asking if something the zookeeper did or didn’t do could have been responsible for the escape of the man-eating tiger that is devouring the neighborhood children. Regardless of what other factors might be responsible for the epidemic of fatal prescription opioid overdoses, physicians must admit some culpability.
Until recently, I assumed that the problem of prescription opioids finding their way to addicts was unique to physicians treating adults. However, a study reported at the annual meeting of the American Society of Anesthesiologists reveals pediatricians and other clinicians prescribing for children must share in the blame.
Dr. Myron Yaster at Johns Hopkins University Hospital, Baltimore, has found that in a group of nearly 300 pediatric patients (average age, 11 years and average weight of 44 kg), overall the patients used only 42% of the prescribed amount of opioids. Almost half of the patients had a teenage sibling, a group that Dr. Yaster describes as the “target population of drug abuse.”
What’s going on here? Some of the problem dates back to the 1990s when physicians were urged to shift their focus toward the problem of inadequately treated pain. With the help of nurses armed with pain-rating schemes and smiley/grumpy face charts, the mantra became “no pain shall go unmedicated,” when the better response should have been “no pain shall go unmanaged.” But good pain management takes time. It requires that the physician and staff consider each patient as a unique individual. In many cases, reassurance and education can make a non–opioid medication or even no medication a better choice.
However, according to Dr. Yaster, “leftover medicine is the most important element in drug addiction.” Why did physicians prescribe 10 days of medication when his study revealed that most patients took the medication for only 5? It could just be a bad habit. Or it could be ignorance or inexperience. How many physicians ask at follow-up appointments “How long did you take your medication? Tell me the history of your pain.”
Or could it be that physicians are simply trying to prevent those annoying calls from patients who have run out of their medication? Dr. Yaster’s findings suggest that those calls would be few and far between. More careful thought into how much medication we prescribe also would mean that when a patient called for more medication that there was a problem. Either the patient’s recuperation has hit a worrisome bump in the road or possibly her medication is being diverted.
History tells us that physicians, even pediatricians, have been poor stewards of the powerful medications with which we have been entrusted. First, it was antibiotics and now opioids have joined the list.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics including “How to Say No to Your Toddler.” Email him at [email protected].
To those of us who live and practice in the northeast, it comes as no surprise that the mortality rate for middle class whites is climbing. Obituaries in our local papers often include men and women in their forties “dying at home,” with no mention of cancer or chronic disease. Rarely, the family can bring itself to announce that their loved one has died of a drug overdose.
Deaths attributable to prescription opioid overdoses quadrupled in the decade from 1999 to 2010, and the trend shows little sign of abating as the number of prescriptions for opioids has risen tenfold over the last 20 years (“How Doctors Helped Drive the Addiction Crisis,” by Dr. Richard Friedman, New York Times, Nov. 7, 2015). Could physician behavior have contributed to outbreak of this deadly plague of addiction? That is like asking if something the zookeeper did or didn’t do could have been responsible for the escape of the man-eating tiger that is devouring the neighborhood children. Regardless of what other factors might be responsible for the epidemic of fatal prescription opioid overdoses, physicians must admit some culpability.
Until recently, I assumed that the problem of prescription opioids finding their way to addicts was unique to physicians treating adults. However, a study reported at the annual meeting of the American Society of Anesthesiologists reveals pediatricians and other clinicians prescribing for children must share in the blame.
Dr. Myron Yaster at Johns Hopkins University Hospital, Baltimore, has found that in a group of nearly 300 pediatric patients (average age, 11 years and average weight of 44 kg), overall the patients used only 42% of the prescribed amount of opioids. Almost half of the patients had a teenage sibling, a group that Dr. Yaster describes as the “target population of drug abuse.”
What’s going on here? Some of the problem dates back to the 1990s when physicians were urged to shift their focus toward the problem of inadequately treated pain. With the help of nurses armed with pain-rating schemes and smiley/grumpy face charts, the mantra became “no pain shall go unmedicated,” when the better response should have been “no pain shall go unmanaged.” But good pain management takes time. It requires that the physician and staff consider each patient as a unique individual. In many cases, reassurance and education can make a non–opioid medication or even no medication a better choice.
However, according to Dr. Yaster, “leftover medicine is the most important element in drug addiction.” Why did physicians prescribe 10 days of medication when his study revealed that most patients took the medication for only 5? It could just be a bad habit. Or it could be ignorance or inexperience. How many physicians ask at follow-up appointments “How long did you take your medication? Tell me the history of your pain.”
Or could it be that physicians are simply trying to prevent those annoying calls from patients who have run out of their medication? Dr. Yaster’s findings suggest that those calls would be few and far between. More careful thought into how much medication we prescribe also would mean that when a patient called for more medication that there was a problem. Either the patient’s recuperation has hit a worrisome bump in the road or possibly her medication is being diverted.
History tells us that physicians, even pediatricians, have been poor stewards of the powerful medications with which we have been entrusted. First, it was antibiotics and now opioids have joined the list.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics including “How to Say No to Your Toddler.” Email him at [email protected].
To those of us who live and practice in the northeast, it comes as no surprise that the mortality rate for middle class whites is climbing. Obituaries in our local papers often include men and women in their forties “dying at home,” with no mention of cancer or chronic disease. Rarely, the family can bring itself to announce that their loved one has died of a drug overdose.
Deaths attributable to prescription opioid overdoses quadrupled in the decade from 1999 to 2010, and the trend shows little sign of abating as the number of prescriptions for opioids has risen tenfold over the last 20 years (“How Doctors Helped Drive the Addiction Crisis,” by Dr. Richard Friedman, New York Times, Nov. 7, 2015). Could physician behavior have contributed to outbreak of this deadly plague of addiction? That is like asking if something the zookeeper did or didn’t do could have been responsible for the escape of the man-eating tiger that is devouring the neighborhood children. Regardless of what other factors might be responsible for the epidemic of fatal prescription opioid overdoses, physicians must admit some culpability.
Until recently, I assumed that the problem of prescription opioids finding their way to addicts was unique to physicians treating adults. However, a study reported at the annual meeting of the American Society of Anesthesiologists reveals pediatricians and other clinicians prescribing for children must share in the blame.
Dr. Myron Yaster at Johns Hopkins University Hospital, Baltimore, has found that in a group of nearly 300 pediatric patients (average age, 11 years and average weight of 44 kg), overall the patients used only 42% of the prescribed amount of opioids. Almost half of the patients had a teenage sibling, a group that Dr. Yaster describes as the “target population of drug abuse.”
What’s going on here? Some of the problem dates back to the 1990s when physicians were urged to shift their focus toward the problem of inadequately treated pain. With the help of nurses armed with pain-rating schemes and smiley/grumpy face charts, the mantra became “no pain shall go unmedicated,” when the better response should have been “no pain shall go unmanaged.” But good pain management takes time. It requires that the physician and staff consider each patient as a unique individual. In many cases, reassurance and education can make a non–opioid medication or even no medication a better choice.
However, according to Dr. Yaster, “leftover medicine is the most important element in drug addiction.” Why did physicians prescribe 10 days of medication when his study revealed that most patients took the medication for only 5? It could just be a bad habit. Or it could be ignorance or inexperience. How many physicians ask at follow-up appointments “How long did you take your medication? Tell me the history of your pain.”
Or could it be that physicians are simply trying to prevent those annoying calls from patients who have run out of their medication? Dr. Yaster’s findings suggest that those calls would be few and far between. More careful thought into how much medication we prescribe also would mean that when a patient called for more medication that there was a problem. Either the patient’s recuperation has hit a worrisome bump in the road or possibly her medication is being diverted.
History tells us that physicians, even pediatricians, have been poor stewards of the powerful medications with which we have been entrusted. First, it was antibiotics and now opioids have joined the list.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics including “How to Say No to Your Toddler.” Email him at [email protected].
Prior authorization sausage factory turns approvals into denials
“We are just statistics, born to consume resources.” –Horace
You know the winter is coming when rheumatologists spend their weekends writing appeal letters for sildenafil.
I inherited a scleroderma patient from a retired colleague. She has had severe Raynaud’s for which she’d been on sildenafil since 2013. On Nov. 23, 2015, I received a letter stating that the medication would no longer be covered because the patient did not meet criteria (in this case, pulmonary arterial hypertension).
I had to submit a letter of appeal, in which I explained how, despite maximum tolerated doses of nifedipine and pentoxifylline, she continued to have digital ischemia, and how, when she finally started the sildenafil, which they had approved prior, the problem went away. I continued to say:
“In the medical literature on this problem, the PDE-5 inhibitors, of which sildenafil is one, is typically recommended, after vasodilation, on the basis of Level I evidence (that is, evidence from high quality randomized controlled trials). Sildenafil has been shown to promote complete healing of digital ulcers and prevents the formation of new ulcers. Thought leaders in the field uniformly recommend this drug as an important part of therapy particularly in patients who have already had digital ulcers. I am happy to provide you with the literature upon request.
“I urge you to reconsider your decision. If you withhold this drug there is a chance that the patient will end up with ulcers again and this could potentially cost you even more. Not only would it impair the patient’s ability to work, which leads to loss of income for her, it would also cost you more in terms of paying for her health care.”
On Nov. 28, I received a second denial, no different than the first letter: “Your request was reviewed by a Medical Doctor specialized in Internal Medicine/Rheumatology. Upon review of the available information, it was determined that the previous decision should be upheld because the Prior Authorization criteria is not met. This determination was made based upon our review of your health condition in relation to the prior authorization criteria and/or guidelines listed below. You have CREST ... with Raynaud’s phenomenon which is not a covered diagnosis. You do not have Pulmonary Arterial Hypertension. Therefore the requested drug sildenafil citrate is not medically necessary according to plan criteria. The denial is therefore appropriate and consistent with your benefits.
“Sildenafil will be approved based on one of the following criteria:
(1) All of the following:
(A) Pulmonary arterial hypertension is symptomatic; AND
(B) Submission of medical records documenting diagnosis of pulmonary arterial hypertension that is confirmed by right heart catheterization; OR
(2) Patient is currently on any therapy for the diagnosis of pulmonary arterial hypertension.”
On Dec. 4, I fired off the following response:
“I received your decision letter dated 11/28/2015 in which you reiterate that your criteria for approval requires a diagnosis of pulmonary hypertension, as if you had not read my first letter at all. This request is not for pulmonary hypertension, it is to prevent limb-threatening gangrene and ischemia from Raynaud’s phenomenon. Please reconsider your decision. We do not want this young patient to lose any digits.”
It’s quite ironic that on the same weekend that I wrote my first letter, a mentor and friend of mine who is a rheumatologist also wrote a letter of appeal to get a prescription for sildenafil approved for a scleroderma patient with Raynaud’s who failed previous medications. She got sildenafil approved. At her suggestion, I attached a copy of the 2005 study published in Circulation demonstrating the efficacy of sildenafil for Raynaud’s to support my letter after the second denial (Circulation. 2005 Nov 8;112[19]:2980-5). As of this writing, I still have not heard back.
Dr. Chan practices rheumatology in Pawtucket, R.I.
“We are just statistics, born to consume resources.” –Horace
You know the winter is coming when rheumatologists spend their weekends writing appeal letters for sildenafil.
I inherited a scleroderma patient from a retired colleague. She has had severe Raynaud’s for which she’d been on sildenafil since 2013. On Nov. 23, 2015, I received a letter stating that the medication would no longer be covered because the patient did not meet criteria (in this case, pulmonary arterial hypertension).
I had to submit a letter of appeal, in which I explained how, despite maximum tolerated doses of nifedipine and pentoxifylline, she continued to have digital ischemia, and how, when she finally started the sildenafil, which they had approved prior, the problem went away. I continued to say:
“In the medical literature on this problem, the PDE-5 inhibitors, of which sildenafil is one, is typically recommended, after vasodilation, on the basis of Level I evidence (that is, evidence from high quality randomized controlled trials). Sildenafil has been shown to promote complete healing of digital ulcers and prevents the formation of new ulcers. Thought leaders in the field uniformly recommend this drug as an important part of therapy particularly in patients who have already had digital ulcers. I am happy to provide you with the literature upon request.
“I urge you to reconsider your decision. If you withhold this drug there is a chance that the patient will end up with ulcers again and this could potentially cost you even more. Not only would it impair the patient’s ability to work, which leads to loss of income for her, it would also cost you more in terms of paying for her health care.”
On Nov. 28, I received a second denial, no different than the first letter: “Your request was reviewed by a Medical Doctor specialized in Internal Medicine/Rheumatology. Upon review of the available information, it was determined that the previous decision should be upheld because the Prior Authorization criteria is not met. This determination was made based upon our review of your health condition in relation to the prior authorization criteria and/or guidelines listed below. You have CREST ... with Raynaud’s phenomenon which is not a covered diagnosis. You do not have Pulmonary Arterial Hypertension. Therefore the requested drug sildenafil citrate is not medically necessary according to plan criteria. The denial is therefore appropriate and consistent with your benefits.
“Sildenafil will be approved based on one of the following criteria:
(1) All of the following:
(A) Pulmonary arterial hypertension is symptomatic; AND
(B) Submission of medical records documenting diagnosis of pulmonary arterial hypertension that is confirmed by right heart catheterization; OR
(2) Patient is currently on any therapy for the diagnosis of pulmonary arterial hypertension.”
On Dec. 4, I fired off the following response:
“I received your decision letter dated 11/28/2015 in which you reiterate that your criteria for approval requires a diagnosis of pulmonary hypertension, as if you had not read my first letter at all. This request is not for pulmonary hypertension, it is to prevent limb-threatening gangrene and ischemia from Raynaud’s phenomenon. Please reconsider your decision. We do not want this young patient to lose any digits.”
It’s quite ironic that on the same weekend that I wrote my first letter, a mentor and friend of mine who is a rheumatologist also wrote a letter of appeal to get a prescription for sildenafil approved for a scleroderma patient with Raynaud’s who failed previous medications. She got sildenafil approved. At her suggestion, I attached a copy of the 2005 study published in Circulation demonstrating the efficacy of sildenafil for Raynaud’s to support my letter after the second denial (Circulation. 2005 Nov 8;112[19]:2980-5). As of this writing, I still have not heard back.
Dr. Chan practices rheumatology in Pawtucket, R.I.
“We are just statistics, born to consume resources.” –Horace
You know the winter is coming when rheumatologists spend their weekends writing appeal letters for sildenafil.
I inherited a scleroderma patient from a retired colleague. She has had severe Raynaud’s for which she’d been on sildenafil since 2013. On Nov. 23, 2015, I received a letter stating that the medication would no longer be covered because the patient did not meet criteria (in this case, pulmonary arterial hypertension).
I had to submit a letter of appeal, in which I explained how, despite maximum tolerated doses of nifedipine and pentoxifylline, she continued to have digital ischemia, and how, when she finally started the sildenafil, which they had approved prior, the problem went away. I continued to say:
“In the medical literature on this problem, the PDE-5 inhibitors, of which sildenafil is one, is typically recommended, after vasodilation, on the basis of Level I evidence (that is, evidence from high quality randomized controlled trials). Sildenafil has been shown to promote complete healing of digital ulcers and prevents the formation of new ulcers. Thought leaders in the field uniformly recommend this drug as an important part of therapy particularly in patients who have already had digital ulcers. I am happy to provide you with the literature upon request.
“I urge you to reconsider your decision. If you withhold this drug there is a chance that the patient will end up with ulcers again and this could potentially cost you even more. Not only would it impair the patient’s ability to work, which leads to loss of income for her, it would also cost you more in terms of paying for her health care.”
On Nov. 28, I received a second denial, no different than the first letter: “Your request was reviewed by a Medical Doctor specialized in Internal Medicine/Rheumatology. Upon review of the available information, it was determined that the previous decision should be upheld because the Prior Authorization criteria is not met. This determination was made based upon our review of your health condition in relation to the prior authorization criteria and/or guidelines listed below. You have CREST ... with Raynaud’s phenomenon which is not a covered diagnosis. You do not have Pulmonary Arterial Hypertension. Therefore the requested drug sildenafil citrate is not medically necessary according to plan criteria. The denial is therefore appropriate and consistent with your benefits.
“Sildenafil will be approved based on one of the following criteria:
(1) All of the following:
(A) Pulmonary arterial hypertension is symptomatic; AND
(B) Submission of medical records documenting diagnosis of pulmonary arterial hypertension that is confirmed by right heart catheterization; OR
(2) Patient is currently on any therapy for the diagnosis of pulmonary arterial hypertension.”
On Dec. 4, I fired off the following response:
“I received your decision letter dated 11/28/2015 in which you reiterate that your criteria for approval requires a diagnosis of pulmonary hypertension, as if you had not read my first letter at all. This request is not for pulmonary hypertension, it is to prevent limb-threatening gangrene and ischemia from Raynaud’s phenomenon. Please reconsider your decision. We do not want this young patient to lose any digits.”
It’s quite ironic that on the same weekend that I wrote my first letter, a mentor and friend of mine who is a rheumatologist also wrote a letter of appeal to get a prescription for sildenafil approved for a scleroderma patient with Raynaud’s who failed previous medications. She got sildenafil approved. At her suggestion, I attached a copy of the 2005 study published in Circulation demonstrating the efficacy of sildenafil for Raynaud’s to support my letter after the second denial (Circulation. 2005 Nov 8;112[19]:2980-5). As of this writing, I still have not heard back.
Dr. Chan practices rheumatology in Pawtucket, R.I.
New education law should improve services for children 0-5 years
One of the perceived failings of the No Child Left Behind Act was that it attempted to address disparities by increasing standardized testing throughout the K-12 period. Ironically, it left children under 5 years … well, behind. To more effectively prevent problems and reduce disparities, our nation should improve its early detection and intervention system.
This means increasing standardized screening for developmental-behavioral problems or at-risk conditions from 0 through 5 years – and then, swiftly connecting at-risk children/families to the most effective and appropriate community services. This strategy is analogous to quickly detecting and putting out small fires before they morph into raging forest fires.
On Dec. 10, The Every Child Achieves Act of 2015 was signed into law by President Obama with bipartisan support. One seemingly minor, but important new change is that federal funds can be allocated for states, school districts, and schools to improve early childhood learning services. However, the extent to which different states invest in early childhood programs remains to be seen.
A month earlier, a Pediatrics article entitled “Systemwide Solutions to Improve Early Intervention for Developmental-Behavioral Concerns” offered expert advice on how to frugally invest those dollars (Pediatrics 2015 Nov. doi: 10.1542/peds.2015-1723). For children aged 0- 5 years, my coauthors and I proposed that every state needs:
• Systemwide screening and care coordination.
• Comprehensive, equitable, and tiered assessments for at-risk or referred children.
• Universal access to high-quality early learning or preschool programs.
• Continuous accountability for the early detection and intervention process.
Systemwide screening
The American Academy of Pediatrics (AAP), along with a federal-level initiative, Birth to 5: Watch Me Thrive! recommends every infant, toddler, and preschooler be periodically screened for developmental-behavioral problems. The new mantra is, “Learn the Signs. Act Early.”
Parents should know that high-quality screening does not prematurely label children with a diagnosis. Instead, regular screenings help raise awareness of their child’s development, making it easier to expect and celebrate developmental milestones. Very importantly, screening has also been proven to substantially improve the percentage of children receiving early intervention (EI).
Connecting the dots, high-quality EI substantially lowers rates of academic remediation or failure, teenage pregnancy, antisocial or criminal behavior, substance abuse, suicidal ideation and attempts, unemployment, and welfare dependency. Just think how preventing all these problems relates to what has been in the news recently.
In reality, many health care clinics, day care centers, and preschools still don’t offer high-quality screening. Even pediatricians can struggle with implementing the AAP’s recommendations . In a busy office, proper implementation requires teamwork. At a statewide level, entire populations need to be accurately screened and tracked.
Systemwide care coordination
Unfortunately, only about 50% of referred children are promptly connected to EI services (Clin Pediatr [Phila]. 2011 Sep;50[9]:853-68). Many overwhelmed or anxious parents don’t follow up. This is problematic because these same “lost to follow-up” children typically perform well below average and have numerous, predictive academic and psychosocial risk factors. Meanwhile, health care providers struggle with tracking at-risk children. And sometimes, pediatric offices don’t share referral information (including screening results) with EI agencies. However, if the child lives in a community with systemwide care coordination, then more than 80% of referred children will be linked to the EI intervention agency or an alternative resource like Early Head Start, a parenting program, or a home visitation program. Connecticut has more than double the EI enrollment rate (3.8%) of Georgia (1.5%), even though they share the exact same eligibility definition. The difference is Connecticut’s Help Me Grow program. Nevertheless, most states lack systemwide care coordination.
Comprehensive, equitable, and tiered assessments
Nonsensically, there are 22 state-specific numerical definitions for EI eligibility, and the majority of states have inappropriately strict criteria (Pediatrics 2013 Jan:131[1]38-46). The proportion of children enrolled in EI ranges from a shameful 1.5% (Georgia) to a meager 7% (Massachusetts). On average, approximately 2.8% of children receive EI even though 25% of moderate- to high-income and 48% of low-income kindergarteners are “not ready to learn.”
Instead of a state-specific EI-eligible versus EI-ineligible process, comprehensive and equitable assessments should lead to a tiered spectrum of high-quality interventions for all at-risk children – most especially, disadvantaged children who are frequently missed. For example, the infant with a poor depressed mother is frequently deemed “ineligible,” but then is significantly behind by kindergarten age. To avoid squandering time-sensitive windows of opportunity, states need a national, research-driven definition of what constitutes a developmental–behavioral delay or at-risk condition. Families need EI or supports that are appropriately intensive, based on their continuum of need.
Universal access
Expanding early learning initiatives would yield benefits to society of roughly $8.60 for every $1 spent, about half of which comes from increased earnings for children when they grow up, according to a White House study by the President’s Council of Economic Advisers. Critics frequently ignore systematic reviews, which demonstrate beneficial outcomes for “high-quality” or “comprehensive” programs – and the younger the intervention, the better the outcomes.
Continuous accountability
This is needed to ensure children are being screened and swiftly linked to high-quality services. Accountability should include a low-cost metric of developmental-behavioral status at 5 years (that is, a school-based kindergarten-readiness intake assessment). If our ultimate goal is to improve outcomes and reduce disparities, then we need to make certain the system is working. That way, states can tweak their processes to optimize child outcomes over time.
Without a doubt, acting early builds better brains. The leadership question remains: Will politicians adequately invest in these systemwide solutions?
Dr. Marks is a general pediatrician at PeaceHealth Medical Group in Eugene, Ore. He disclosed he is a coauthor of “Developmental Screening in Your Community: An Integrated Approach for Connecting Children with Services,” but has no other relevant disclosures. Email him at [email protected].
One of the perceived failings of the No Child Left Behind Act was that it attempted to address disparities by increasing standardized testing throughout the K-12 period. Ironically, it left children under 5 years … well, behind. To more effectively prevent problems and reduce disparities, our nation should improve its early detection and intervention system.
This means increasing standardized screening for developmental-behavioral problems or at-risk conditions from 0 through 5 years – and then, swiftly connecting at-risk children/families to the most effective and appropriate community services. This strategy is analogous to quickly detecting and putting out small fires before they morph into raging forest fires.
On Dec. 10, The Every Child Achieves Act of 2015 was signed into law by President Obama with bipartisan support. One seemingly minor, but important new change is that federal funds can be allocated for states, school districts, and schools to improve early childhood learning services. However, the extent to which different states invest in early childhood programs remains to be seen.
A month earlier, a Pediatrics article entitled “Systemwide Solutions to Improve Early Intervention for Developmental-Behavioral Concerns” offered expert advice on how to frugally invest those dollars (Pediatrics 2015 Nov. doi: 10.1542/peds.2015-1723). For children aged 0- 5 years, my coauthors and I proposed that every state needs:
• Systemwide screening and care coordination.
• Comprehensive, equitable, and tiered assessments for at-risk or referred children.
• Universal access to high-quality early learning or preschool programs.
• Continuous accountability for the early detection and intervention process.
Systemwide screening
The American Academy of Pediatrics (AAP), along with a federal-level initiative, Birth to 5: Watch Me Thrive! recommends every infant, toddler, and preschooler be periodically screened for developmental-behavioral problems. The new mantra is, “Learn the Signs. Act Early.”
Parents should know that high-quality screening does not prematurely label children with a diagnosis. Instead, regular screenings help raise awareness of their child’s development, making it easier to expect and celebrate developmental milestones. Very importantly, screening has also been proven to substantially improve the percentage of children receiving early intervention (EI).
Connecting the dots, high-quality EI substantially lowers rates of academic remediation or failure, teenage pregnancy, antisocial or criminal behavior, substance abuse, suicidal ideation and attempts, unemployment, and welfare dependency. Just think how preventing all these problems relates to what has been in the news recently.
In reality, many health care clinics, day care centers, and preschools still don’t offer high-quality screening. Even pediatricians can struggle with implementing the AAP’s recommendations . In a busy office, proper implementation requires teamwork. At a statewide level, entire populations need to be accurately screened and tracked.
Systemwide care coordination
Unfortunately, only about 50% of referred children are promptly connected to EI services (Clin Pediatr [Phila]. 2011 Sep;50[9]:853-68). Many overwhelmed or anxious parents don’t follow up. This is problematic because these same “lost to follow-up” children typically perform well below average and have numerous, predictive academic and psychosocial risk factors. Meanwhile, health care providers struggle with tracking at-risk children. And sometimes, pediatric offices don’t share referral information (including screening results) with EI agencies. However, if the child lives in a community with systemwide care coordination, then more than 80% of referred children will be linked to the EI intervention agency or an alternative resource like Early Head Start, a parenting program, or a home visitation program. Connecticut has more than double the EI enrollment rate (3.8%) of Georgia (1.5%), even though they share the exact same eligibility definition. The difference is Connecticut’s Help Me Grow program. Nevertheless, most states lack systemwide care coordination.
Comprehensive, equitable, and tiered assessments
Nonsensically, there are 22 state-specific numerical definitions for EI eligibility, and the majority of states have inappropriately strict criteria (Pediatrics 2013 Jan:131[1]38-46). The proportion of children enrolled in EI ranges from a shameful 1.5% (Georgia) to a meager 7% (Massachusetts). On average, approximately 2.8% of children receive EI even though 25% of moderate- to high-income and 48% of low-income kindergarteners are “not ready to learn.”
Instead of a state-specific EI-eligible versus EI-ineligible process, comprehensive and equitable assessments should lead to a tiered spectrum of high-quality interventions for all at-risk children – most especially, disadvantaged children who are frequently missed. For example, the infant with a poor depressed mother is frequently deemed “ineligible,” but then is significantly behind by kindergarten age. To avoid squandering time-sensitive windows of opportunity, states need a national, research-driven definition of what constitutes a developmental–behavioral delay or at-risk condition. Families need EI or supports that are appropriately intensive, based on their continuum of need.
Universal access
Expanding early learning initiatives would yield benefits to society of roughly $8.60 for every $1 spent, about half of which comes from increased earnings for children when they grow up, according to a White House study by the President’s Council of Economic Advisers. Critics frequently ignore systematic reviews, which demonstrate beneficial outcomes for “high-quality” or “comprehensive” programs – and the younger the intervention, the better the outcomes.
Continuous accountability
This is needed to ensure children are being screened and swiftly linked to high-quality services. Accountability should include a low-cost metric of developmental-behavioral status at 5 years (that is, a school-based kindergarten-readiness intake assessment). If our ultimate goal is to improve outcomes and reduce disparities, then we need to make certain the system is working. That way, states can tweak their processes to optimize child outcomes over time.
Without a doubt, acting early builds better brains. The leadership question remains: Will politicians adequately invest in these systemwide solutions?
Dr. Marks is a general pediatrician at PeaceHealth Medical Group in Eugene, Ore. He disclosed he is a coauthor of “Developmental Screening in Your Community: An Integrated Approach for Connecting Children with Services,” but has no other relevant disclosures. Email him at [email protected].
One of the perceived failings of the No Child Left Behind Act was that it attempted to address disparities by increasing standardized testing throughout the K-12 period. Ironically, it left children under 5 years … well, behind. To more effectively prevent problems and reduce disparities, our nation should improve its early detection and intervention system.
This means increasing standardized screening for developmental-behavioral problems or at-risk conditions from 0 through 5 years – and then, swiftly connecting at-risk children/families to the most effective and appropriate community services. This strategy is analogous to quickly detecting and putting out small fires before they morph into raging forest fires.
On Dec. 10, The Every Child Achieves Act of 2015 was signed into law by President Obama with bipartisan support. One seemingly minor, but important new change is that federal funds can be allocated for states, school districts, and schools to improve early childhood learning services. However, the extent to which different states invest in early childhood programs remains to be seen.
A month earlier, a Pediatrics article entitled “Systemwide Solutions to Improve Early Intervention for Developmental-Behavioral Concerns” offered expert advice on how to frugally invest those dollars (Pediatrics 2015 Nov. doi: 10.1542/peds.2015-1723). For children aged 0- 5 years, my coauthors and I proposed that every state needs:
• Systemwide screening and care coordination.
• Comprehensive, equitable, and tiered assessments for at-risk or referred children.
• Universal access to high-quality early learning or preschool programs.
• Continuous accountability for the early detection and intervention process.
Systemwide screening
The American Academy of Pediatrics (AAP), along with a federal-level initiative, Birth to 5: Watch Me Thrive! recommends every infant, toddler, and preschooler be periodically screened for developmental-behavioral problems. The new mantra is, “Learn the Signs. Act Early.”
Parents should know that high-quality screening does not prematurely label children with a diagnosis. Instead, regular screenings help raise awareness of their child’s development, making it easier to expect and celebrate developmental milestones. Very importantly, screening has also been proven to substantially improve the percentage of children receiving early intervention (EI).
Connecting the dots, high-quality EI substantially lowers rates of academic remediation or failure, teenage pregnancy, antisocial or criminal behavior, substance abuse, suicidal ideation and attempts, unemployment, and welfare dependency. Just think how preventing all these problems relates to what has been in the news recently.
In reality, many health care clinics, day care centers, and preschools still don’t offer high-quality screening. Even pediatricians can struggle with implementing the AAP’s recommendations . In a busy office, proper implementation requires teamwork. At a statewide level, entire populations need to be accurately screened and tracked.
Systemwide care coordination
Unfortunately, only about 50% of referred children are promptly connected to EI services (Clin Pediatr [Phila]. 2011 Sep;50[9]:853-68). Many overwhelmed or anxious parents don’t follow up. This is problematic because these same “lost to follow-up” children typically perform well below average and have numerous, predictive academic and psychosocial risk factors. Meanwhile, health care providers struggle with tracking at-risk children. And sometimes, pediatric offices don’t share referral information (including screening results) with EI agencies. However, if the child lives in a community with systemwide care coordination, then more than 80% of referred children will be linked to the EI intervention agency or an alternative resource like Early Head Start, a parenting program, or a home visitation program. Connecticut has more than double the EI enrollment rate (3.8%) of Georgia (1.5%), even though they share the exact same eligibility definition. The difference is Connecticut’s Help Me Grow program. Nevertheless, most states lack systemwide care coordination.
Comprehensive, equitable, and tiered assessments
Nonsensically, there are 22 state-specific numerical definitions for EI eligibility, and the majority of states have inappropriately strict criteria (Pediatrics 2013 Jan:131[1]38-46). The proportion of children enrolled in EI ranges from a shameful 1.5% (Georgia) to a meager 7% (Massachusetts). On average, approximately 2.8% of children receive EI even though 25% of moderate- to high-income and 48% of low-income kindergarteners are “not ready to learn.”
Instead of a state-specific EI-eligible versus EI-ineligible process, comprehensive and equitable assessments should lead to a tiered spectrum of high-quality interventions for all at-risk children – most especially, disadvantaged children who are frequently missed. For example, the infant with a poor depressed mother is frequently deemed “ineligible,” but then is significantly behind by kindergarten age. To avoid squandering time-sensitive windows of opportunity, states need a national, research-driven definition of what constitutes a developmental–behavioral delay or at-risk condition. Families need EI or supports that are appropriately intensive, based on their continuum of need.
Universal access
Expanding early learning initiatives would yield benefits to society of roughly $8.60 for every $1 spent, about half of which comes from increased earnings for children when they grow up, according to a White House study by the President’s Council of Economic Advisers. Critics frequently ignore systematic reviews, which demonstrate beneficial outcomes for “high-quality” or “comprehensive” programs – and the younger the intervention, the better the outcomes.
Continuous accountability
This is needed to ensure children are being screened and swiftly linked to high-quality services. Accountability should include a low-cost metric of developmental-behavioral status at 5 years (that is, a school-based kindergarten-readiness intake assessment). If our ultimate goal is to improve outcomes and reduce disparities, then we need to make certain the system is working. That way, states can tweak their processes to optimize child outcomes over time.
Without a doubt, acting early builds better brains. The leadership question remains: Will politicians adequately invest in these systemwide solutions?
Dr. Marks is a general pediatrician at PeaceHealth Medical Group in Eugene, Ore. He disclosed he is a coauthor of “Developmental Screening in Your Community: An Integrated Approach for Connecting Children with Services,” but has no other relevant disclosures. Email him at [email protected].
