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The Defense Health Agency Stands Up
For the past 2 years, military health has been undergoing one of the largest transformations in its history. In the midst of an active war in Afghanistan, the wind down to another in Iraq, and a humanitarian mission to Liberia, the transformation has been ongoing. “We were building the airplane as we flew it,” Lt Gen Douglas J. Robb, DO, admitted.
The Defense Health Agency (DHA) brings together the previously independent health care operations of the Army, Navy, and Air Force, with unique cultures, procedures, and technologies. The underlying DHA goals have been to improve interoperability, efficiency, and cost reduction by sharing services.
The operation is massive. The DHA cares for a TRICARE-eligible population of 9.5 million, including 1.4 million service members on active duty, with more than 1 million inpatient admissions and 95.6 million outpatient visits in 2014.
That transformation formally ends on October 1, 2015, as the DHA becomes fully operational and the organization moves into its next phase. Building such a large system has been a daunting challenge, but it has been “exhilarating… to watch what our people can do if you give them the opportunity,” Lt Gen Robb explained.
Establishing the Defense Health Agency
Lt Gen Douglas J. Robb, DO. You have to go back to look at where the seeds were planted on the journey that we have been on since June 2011. Back in 2011, then Deputy Secretary of Defense William Lynn established an internal task force to take a look at whether there is a better way to conduct a military health system governance.
How do we ensure the incredible medical support for our current and future military operations in an environment that was becoming fiscally constrained? We needed to look at how we could transform ourselves to make us better, stronger, more relevant, and, ultimately, viable. One of the other things that we had going for us at the time was broad congressional support that also supported a need for change.
We had a task force that assemmbled. I think this is key—it was a very broad based and a very representative task force. We had military departments, the Joint Staff, and the Office of the Secretary of Defense [OSD] who were all part of this task force…. Individuals that had a vested interest in the way we would organize a new entity that would, hopefully, and I would argue will, change the way we practice medicine....
Out of that task force came some recommendations. And one of those recommendations had to do with the overall governance of the military health system. People may be aware there are several models out there. In fact, there were 5 models that we looked at. One was a unified medical command, one was a defense health agency, one was a single-service model, another was a hybrid model, and then the status quo.
And what the task force recommendation that was put forth came down to was the recommendation of a defense health agency. And with that, the DEPSECDEF [Deputy Secretary of Defense] said, “Plan for it.” In November 2012, we had a planning work group report that went to the DEPSECDEF. And then, finally, in March 2013, the DEPSECDEF said, “Go forth and create and stand up the Defense Health Agency,” in what was then known as the Nine Commandments Memo.
The bottom line was no matter what model we chose, whatever organizational construct, the bottom line was we needed to ensure a medically ready force and a ready medical force…. One of the things that I think is key is that through these 10 years of conflict—actually, now going on 13—we have witnessed the ability for our medical services (the Army, Navy, the Air Force, and the Marine Corps) to come together in a joint environment, in the deployed setting, to essentially produce the lowest lethality rate in the history of recorded conflict. And it is amazing what our people have been able to do in saving the lives of our soldiers, sailors, and marines coalition forces and our civilians.
At the same time, we have also come together in avery joint manner to also achieve, what we call, the lowest disease nonbattle injury rate in the history of recorded conflict. That is a tribute to the services ensuring that all our forces are ready and deployable.
Shared Services
Lt Gen Robb. Essentially, we were running, in many cases, 3 parallel health care systems, 3 separate health information and technology systems. Three separate facilities divisions…. There was a lot of duplication, and there was a lot of redundancy. And so if you look at the challenge of the fiscal environment coupled with how to continue to provide high-quality health care in a deployed environment and in garrison, that was really the driving force behind the Defense Health Agency.
How could we find significant cost savings? How do we reduce the duplication? How do we reduce the variation? That’s what our models looked at. How do you create a dispute resolution process with clear decision authority and clear accountability as you move toward joint solutions where they make sense?
One of the other issues that we had was: Is it doable? Is whatever we propose doable in the environments and acceptable not only to the services, but to the Office of the Secretary of Defense? And so all those came into play as we proposed what then became the Defense Health Agency proposal for a new wave of doing governance.
When we built the Defense Health Agency, we looked at the 10 shared services… where we could see savings either in efficiencies or quality or dollars. Those 10 shared services were facilities, medical logistics, health information and technology, TRICARE, pharmacy operations, budget and resource management, contracting, research, development, acquisition, medical education and training, and public health.… We felt that there was opportunity there.
Now, as we moved forward, and people need to remember this, the Defense Health Agency and the future governance model was not created in a vacuum. It was created by the services’ participation—Army, Navy, and Air Force medicine. Each of those shared services had subject matter experts from all 3 services participating in shaping the future joint force solutions, where it makes sense. That is key. It wasn’t a bunch of headquarters officials or OSD or joint staff sitting in a dark room creating this in a vacuum and then bringing it out and saying, “Hey, this is what we’re going to do.” It was transparent, it was open, and then it actually ended up running through what we would then create the new governance system as we moved forward.
Each of those shared services underwent, what I call, a rigorous—and I’m going to repeat that word, rigorous—reproducible and transparent business case analysis. And after that, then you say, “Hey is there opportunity here?” Then part 2 was a rigorous, transparent, and reproducible business process re-engineering. And so we went through each of those shared services. And it just so happened that there was opportunity. In other words, there was opportunity for increased efficiencies, increased effectiveness, dollar savings, or resource savings, some of the above or all the above in all of these 10 shared services.
We put $3.5 billion on the table as potential shared services cost savings for the fiscal years [FY] 2015 to 2019. That’s not an insignificant number. Now folks say, “That’s a lot of money to put on the table. Are you going to deliver?” And the answer is yes, we will deliver. I’m going to be honest with you, they took that right off the topline of our Defense Health budget right off the bat, so we had no choice but to deliver now. But I’m confident that we will because of the very rigorous work and dedication of those who did that.
If you want to look at an early win here: In March of 2013 is when DEPSECDEF said, “Go forth and stand up the Defense Health Agency.” And then we set a target date of 1 October 2013 to be at initial operating capability when we stood up the Defense Health Agency. So that first year in FY14, the Defense Health Agency achieved—and this was not included in the FY15 to FY19 [budget]—achieved cost savings of $350 million….
Standing up 1 October 2013 in the middle of sequestration, I told my staff, “If there is any money you need for initial investment, you’re going to have to either find it yourself or make it.” And they did.… We paid our own way that first year, and I’m not so sure there are a lot of organizations out there that can say they paid their own way the first year. But I was very proud of our staff, especially when you create an organization that is supposed to lean out.
Remember, our staff in the Defense Health Agency is made of the men and women, the subject matter experts, the extreme talent that comes from the Army, Navy, and the Air Force medical services. When I talk about the Defense Health Agency, they’re not Defense Health Agency people. These are people that are in the Defense Health Agency that are providing services back and capability back to Army, Navy, Air Force, and Marine medicine. It is truly a team effort and a collaborative effort.
Standing Up
Lt Gen Robb. When I come to work each day, I think about the progress we’ve made in the journey of this military health system transformation. When you look at it, this is probably the largest military health care transformation that has occurred in decades, if not ever.
Dr. Jonathan Woods is an incredible leader, number one; but number two, he has a strategic vision and a strategic ability to make things happen. And he has a great deputy in Dr. Karen Guice. Both are incredible leaders at the right place, at the right time, coupled with congressional support. And then through the task force and the services, getting the Joint Staff and the services support as we move forward.
On 1 October 2013 we stood up and we created an organizational construct…. Those 10 shared services are embedded in an organizational construct that has 6 directorates. One is health care operations, number 2 is health information technology, number 3 is research and development, number 4 is education and training, number 5 is business support, and then, number 6 through a process that evolved [into] … the Multiservice Market National Capital Region Directorate.
Let’s look at the commitment not only by the OSD, but also from the services. So you’ve got 6 directorates and each of those directorates are led by a general officer, an admiral, or a senior executive service official…. There were no new general offices allotted to the Defense Health Agency. So those general offices came from the services. It [was] with the men and women who were part of the Army, Navy, and Air Force medicine who are now part of the Defense Health Agency.
What we’ve done in these 2 years is we’ve molded and we’ve melded and we’ve grown those teams to support those directorates and then the divisions within those directorates and the staff to support the shared services inside our organizational construct.
Joint Platforms
Lt Gen Robb. We’ve matured and there are in each of those directorates, in each of those shared services, success stories It’s one thing to stand something up. But we often say, “We were building the airplane as we flew it.” And we were producing, again, what I call, at times long overdue, joint products in support of the services.…
I’m excited about standing up again a joint platform that allows the military health system to accelerate business and operational elements to make a more effective and efficient military health system. But probably just as important, if not more important, it allows us to be a lot more agile and responsive to the challenges that come our way.
One of the positive spinoffs that I’ve had the privilege to experience is that when we stood up the Defense Health Agency, it then became a member of a group of organizations that in many ways work together.… The Defense Health Agency, Defense Information Systems Agency (DISA), and Defense Logistics Agency (DLA) exist solely to provide capability and joint capability where it makes sense to the services, and they are enablers.
The Defense Health Agency is also a designated combat support agency, which means not only are we answerable to the service surgeons general and to the service chiefs, but we are also directly responsible to the Chairman of the Joint Chiefs of Staff to provide combat support capability for our commanders.…
We are supporting and we will be responsive to the needs of the services. We will look for opportunity. We will continue to mature. We will continue to progress in our organizational construct. But at the same time… we have set up a senior level group from the services led by a general officer who will look at making sure that we are delivering on our initial 10 shared services and that we are continuing to meet what we said we were going to do. And then also for them to feed back to us where is there opportunity, where are there needs, but also that group is out there to look at where are there future opportunities.
Is there another shared service out there, or is there another shared joint first solution opportunity out there that we need to put into the queue to address to make us better, stronger, more relevant in the 21st century but at the same time, viable and in a very fiscally constrained environment?
Quality, Safety, and Access for Patients
Lt Gen Robb. The world doesn’t stop just because you’re building an organization.... Now that we’ve got this joint platform, we can aggregate the patient safety and the quality data that we have out there and look at where there is opportunity for the military health system to improve. We have bought an enterprise-wide analytic capability that will support the services as we continue to drive toward a high reliability organization, number one, and to continuously improve both quality, safety, and access. Much like DLA is to the logistics world and DISA is to the information systems world, we’re a centralized organizational construct that can bring the services together to create, what I call, an interoperable or joint force solution where it makes sense.
We have stood up the P4I initiative, which is a partnership for improvement of which the core of that will be the Defense Health Agency analytic cell, but the Defense Health Agency Healthcare Operations has become a gathering spot or the platform where the services come together. And for the first time, we have an enterprise dashboard. There [are] about 30 metrics out there where we’re looking at quality, safety, and access…. That’s just one example. And I could go through each of the shared services one by one by one and talk about where we have made a difference.
Consolidating Services
Lt Gen Robb. One of the ones that has been as exciting as anything and challenging at the same time is our health information and technology consolidation, which is being led by Mr. Dave Bowen, our chief information officer [CIO]. We had a single health care record, AHLTA, but we were basically running 3 separate health information and technology systems—Army, Navy, and Air Force. When you talk about being interoperable on the battlefield, sometimes we had some centralization on the battlefield, but as it worked its way back, you started working your way into 3 separate systems.
When you look at any major health care organization that has consolidated,… we absolutely spent time with leaders in the health care industry about how you set up an enterprise-wide health care system that’s effective and efficient. But most important, how do you drive quality and how do you drive safety? Standardization is key not only in what we would call cost and resource things, but standardization also drives—and study after study also drives—increased quality.…
What we’re doing is we’re going basically from the major data warehouse servers all the way down to the desktop, [it] is going to be managed centrally. But when I say “managed,” I’m talking about manned and managed. So the men and women that were running the health care information technology for the Army or the Navy or the Air Force are now part of a large organization called the Health Information and Technology [HIT] Directorate.
And we are standardizing. We’re standardizing the desktop, we are standardizing the infrastructure at the base level, at the service level; and with the help of the DoD CIO across the board. This is exciting. And as you can imagine, there are savings to be had there in the reduction of duplications. In fact, in 2014 just in the infrastructure consolidation, HIT came up with about $5 million [savings] and then another $12 million in savings so far in 2015. We have created a single, joint integrated infrastructure that supports our joint integrated delivered health care so it makes sense.
About 45%, almost 50% of our health care direct care systems, in other words our military treatment facilities, is delivered in 6 markets where 2 or more of the services—Army, Navy, or Air Force—exist side by side. You think of San Antonio with the Army and the Air Force; you think of the National Capital Region Army, Navy, and Air Force medicine; you think about the tidewater area where you have Army, Navy, and Air Force medicine. It makes sense that we have a single, integrated, consolidated health information and technology.
Interoperability and Interdependence
Lt Gen Robb. By nature of what we do, we’ve created an interoperability and interdependence within the Defense Health Agency.
Let’s look at education and training. The 3 services had up to 23 different online knowledge systems. It was either a library of knowledge or there was training going on. The Education and Training Directorate leadership said, “Hey, it makes sense to put all of our different learning portals on 1 portal.” So we’re consolidating from about 23 down to a single learning portal.
And you can just begin to imagine the efficiencies gained there, not to mention the savings. We’re looking at about $500,000 in savings in 2015 and probably another million [dollars] for 2016 just on consolidation of that. So these are all early deliveries by a very young but enthusiastic and aggressive organization called the Defense Health Agency.
We’re looking at a single entity for, what we call, third-party collections across all 3 services. We could never do that before, but now we can. We’re also looking at the way we account for dollars. In other words, when you want to manage your budget, and, as you know, we have different bags of money and each of them is used for certain things, but we weren’t doing that in a standardized manner. So if you want to make a system efficient, you’ve got to call things the same, you’ve got to measure things the same, you’ve got to measure them in the same bucket of money.…
Let’s think about logistic support. Those individuals form a community of practice have always been joint oriented, but it’s always been tough for them to get what was best for the enterprise, because the services wanted to do it but when they went back and they prioritized within the services, it may not have made the cut. And so not that we didn’t want to do it from an enterprise, but the services prioritized different.
But now with the logistics directorate, we prioritize as an enterprise we run it through governance, and we make a decision. So we now have very robust e-commerce. And there were different ways. Folks were using what we call the credit card method before, because it was convenient. But the problem was it’s more expensive to do it that way. So now we’ve made a more robust and more user-friendly and customer-friendly e-commerce. And so now we’re up to about 70% compliance, and we’re saving millions of dollars right there.
When you think about the Defense Logistics Agency, their job is to get the best price and product for the Department of Defense. So can you imagine before they were having to deal with the Army medicine, Navy medicine, and Air Force medicine. Now they’re dealing with the Defense Health Agency Logistics Directorate, so it’s a single point of contact. Now when we go out and do group buys, they can get a better deal for us. So what makes us look good makes them look good.…
DISA used to have to negotiate way ahead with Army, Navy, and Air Force medicine. Now they’re negotiating and looking at a joint force solution where it makes sense for the enterprise. That’s 2 examples right there, and it’s been exhilarating to watch. When you take the blinders off and you take the muzzle off, what our people can do if you give them the opportunity.
Working With the VA
Lt Gen Robb. I’m sure you’re aware that right now the Department of Defense and the VA have about 8.4 million shared records through what we would call a joint legacy viewer and enterprise. But what’s the future look like?
With the consolidation of the Health Information and Technology Directorate and then as we move forward with the acquisition of this new electronic health record, what our consolidated Health Information and Technology Directorate has done is created a single point of contact and a single entity for all things in relation to the new electronic health record.
Before, we had Army, Navy, and Air Force health information and technologies and it would have been… a lot harder to acquire something this large when you were dealing with 3 [systems]. Now we’re dealing with one entity. It is also the backbone and that’s where, what I would call, our academic center of gravity is and also our workhorses.
What is key for the interoperability between the Department of Defense and the VA as we transition the service member across is that the data flow from the Department of Defense to the Department of Veterans Affairs. We were handing over 3 different packages of data to the VA. Now we’re going to bring 1 package of data. So now the Department of Defense will have a single plug to go into the Department of Veterans Affairs.
The Department of Defense and the Department of Veterans Affairs have been working very hard the last couple of years, quietly in the background. But we are working on standardized data elements. In other words, what I call the Department of Defense and the VA will speak the same language and the same dialect when it comes to moving data. You don’t have to have the same electronic health record.… You have to have the ability to move those common data elements through your system.
The standardization of the infrastructure has allowed us to roll out the electronic health record, which will be our backbone and then we’ll move that data to the VA electronic health record of the future…. Our people inside the Defense Health Agency have been working with all the teams with these infrastructure upgrades and the new electronic health records [requirements]. It’s working the data elements, it’s working the joint requirements. All these things are all coming together to support our soldiers, sailors, airmen, and marines as they move forward in the transition from the Department of Defense to the Department of Veterans Affairs.
For the past 2 years, military health has been undergoing one of the largest transformations in its history. In the midst of an active war in Afghanistan, the wind down to another in Iraq, and a humanitarian mission to Liberia, the transformation has been ongoing. “We were building the airplane as we flew it,” Lt Gen Douglas J. Robb, DO, admitted.
The Defense Health Agency (DHA) brings together the previously independent health care operations of the Army, Navy, and Air Force, with unique cultures, procedures, and technologies. The underlying DHA goals have been to improve interoperability, efficiency, and cost reduction by sharing services.
The operation is massive. The DHA cares for a TRICARE-eligible population of 9.5 million, including 1.4 million service members on active duty, with more than 1 million inpatient admissions and 95.6 million outpatient visits in 2014.
That transformation formally ends on October 1, 2015, as the DHA becomes fully operational and the organization moves into its next phase. Building such a large system has been a daunting challenge, but it has been “exhilarating… to watch what our people can do if you give them the opportunity,” Lt Gen Robb explained.
Establishing the Defense Health Agency
Lt Gen Douglas J. Robb, DO. You have to go back to look at where the seeds were planted on the journey that we have been on since June 2011. Back in 2011, then Deputy Secretary of Defense William Lynn established an internal task force to take a look at whether there is a better way to conduct a military health system governance.
How do we ensure the incredible medical support for our current and future military operations in an environment that was becoming fiscally constrained? We needed to look at how we could transform ourselves to make us better, stronger, more relevant, and, ultimately, viable. One of the other things that we had going for us at the time was broad congressional support that also supported a need for change.
We had a task force that assemmbled. I think this is key—it was a very broad based and a very representative task force. We had military departments, the Joint Staff, and the Office of the Secretary of Defense [OSD] who were all part of this task force…. Individuals that had a vested interest in the way we would organize a new entity that would, hopefully, and I would argue will, change the way we practice medicine....
Out of that task force came some recommendations. And one of those recommendations had to do with the overall governance of the military health system. People may be aware there are several models out there. In fact, there were 5 models that we looked at. One was a unified medical command, one was a defense health agency, one was a single-service model, another was a hybrid model, and then the status quo.
And what the task force recommendation that was put forth came down to was the recommendation of a defense health agency. And with that, the DEPSECDEF [Deputy Secretary of Defense] said, “Plan for it.” In November 2012, we had a planning work group report that went to the DEPSECDEF. And then, finally, in March 2013, the DEPSECDEF said, “Go forth and create and stand up the Defense Health Agency,” in what was then known as the Nine Commandments Memo.
The bottom line was no matter what model we chose, whatever organizational construct, the bottom line was we needed to ensure a medically ready force and a ready medical force…. One of the things that I think is key is that through these 10 years of conflict—actually, now going on 13—we have witnessed the ability for our medical services (the Army, Navy, the Air Force, and the Marine Corps) to come together in a joint environment, in the deployed setting, to essentially produce the lowest lethality rate in the history of recorded conflict. And it is amazing what our people have been able to do in saving the lives of our soldiers, sailors, and marines coalition forces and our civilians.
At the same time, we have also come together in avery joint manner to also achieve, what we call, the lowest disease nonbattle injury rate in the history of recorded conflict. That is a tribute to the services ensuring that all our forces are ready and deployable.
Shared Services
Lt Gen Robb. Essentially, we were running, in many cases, 3 parallel health care systems, 3 separate health information and technology systems. Three separate facilities divisions…. There was a lot of duplication, and there was a lot of redundancy. And so if you look at the challenge of the fiscal environment coupled with how to continue to provide high-quality health care in a deployed environment and in garrison, that was really the driving force behind the Defense Health Agency.
How could we find significant cost savings? How do we reduce the duplication? How do we reduce the variation? That’s what our models looked at. How do you create a dispute resolution process with clear decision authority and clear accountability as you move toward joint solutions where they make sense?
One of the other issues that we had was: Is it doable? Is whatever we propose doable in the environments and acceptable not only to the services, but to the Office of the Secretary of Defense? And so all those came into play as we proposed what then became the Defense Health Agency proposal for a new wave of doing governance.
When we built the Defense Health Agency, we looked at the 10 shared services… where we could see savings either in efficiencies or quality or dollars. Those 10 shared services were facilities, medical logistics, health information and technology, TRICARE, pharmacy operations, budget and resource management, contracting, research, development, acquisition, medical education and training, and public health.… We felt that there was opportunity there.
Now, as we moved forward, and people need to remember this, the Defense Health Agency and the future governance model was not created in a vacuum. It was created by the services’ participation—Army, Navy, and Air Force medicine. Each of those shared services had subject matter experts from all 3 services participating in shaping the future joint force solutions, where it makes sense. That is key. It wasn’t a bunch of headquarters officials or OSD or joint staff sitting in a dark room creating this in a vacuum and then bringing it out and saying, “Hey, this is what we’re going to do.” It was transparent, it was open, and then it actually ended up running through what we would then create the new governance system as we moved forward.
Each of those shared services underwent, what I call, a rigorous—and I’m going to repeat that word, rigorous—reproducible and transparent business case analysis. And after that, then you say, “Hey is there opportunity here?” Then part 2 was a rigorous, transparent, and reproducible business process re-engineering. And so we went through each of those shared services. And it just so happened that there was opportunity. In other words, there was opportunity for increased efficiencies, increased effectiveness, dollar savings, or resource savings, some of the above or all the above in all of these 10 shared services.
We put $3.5 billion on the table as potential shared services cost savings for the fiscal years [FY] 2015 to 2019. That’s not an insignificant number. Now folks say, “That’s a lot of money to put on the table. Are you going to deliver?” And the answer is yes, we will deliver. I’m going to be honest with you, they took that right off the topline of our Defense Health budget right off the bat, so we had no choice but to deliver now. But I’m confident that we will because of the very rigorous work and dedication of those who did that.
If you want to look at an early win here: In March of 2013 is when DEPSECDEF said, “Go forth and stand up the Defense Health Agency.” And then we set a target date of 1 October 2013 to be at initial operating capability when we stood up the Defense Health Agency. So that first year in FY14, the Defense Health Agency achieved—and this was not included in the FY15 to FY19 [budget]—achieved cost savings of $350 million….
Standing up 1 October 2013 in the middle of sequestration, I told my staff, “If there is any money you need for initial investment, you’re going to have to either find it yourself or make it.” And they did.… We paid our own way that first year, and I’m not so sure there are a lot of organizations out there that can say they paid their own way the first year. But I was very proud of our staff, especially when you create an organization that is supposed to lean out.
Remember, our staff in the Defense Health Agency is made of the men and women, the subject matter experts, the extreme talent that comes from the Army, Navy, and the Air Force medical services. When I talk about the Defense Health Agency, they’re not Defense Health Agency people. These are people that are in the Defense Health Agency that are providing services back and capability back to Army, Navy, Air Force, and Marine medicine. It is truly a team effort and a collaborative effort.
Standing Up
Lt Gen Robb. When I come to work each day, I think about the progress we’ve made in the journey of this military health system transformation. When you look at it, this is probably the largest military health care transformation that has occurred in decades, if not ever.
Dr. Jonathan Woods is an incredible leader, number one; but number two, he has a strategic vision and a strategic ability to make things happen. And he has a great deputy in Dr. Karen Guice. Both are incredible leaders at the right place, at the right time, coupled with congressional support. And then through the task force and the services, getting the Joint Staff and the services support as we move forward.
On 1 October 2013 we stood up and we created an organizational construct…. Those 10 shared services are embedded in an organizational construct that has 6 directorates. One is health care operations, number 2 is health information technology, number 3 is research and development, number 4 is education and training, number 5 is business support, and then, number 6 through a process that evolved [into] … the Multiservice Market National Capital Region Directorate.
Let’s look at the commitment not only by the OSD, but also from the services. So you’ve got 6 directorates and each of those directorates are led by a general officer, an admiral, or a senior executive service official…. There were no new general offices allotted to the Defense Health Agency. So those general offices came from the services. It [was] with the men and women who were part of the Army, Navy, and Air Force medicine who are now part of the Defense Health Agency.
What we’ve done in these 2 years is we’ve molded and we’ve melded and we’ve grown those teams to support those directorates and then the divisions within those directorates and the staff to support the shared services inside our organizational construct.
Joint Platforms
Lt Gen Robb. We’ve matured and there are in each of those directorates, in each of those shared services, success stories It’s one thing to stand something up. But we often say, “We were building the airplane as we flew it.” And we were producing, again, what I call, at times long overdue, joint products in support of the services.…
I’m excited about standing up again a joint platform that allows the military health system to accelerate business and operational elements to make a more effective and efficient military health system. But probably just as important, if not more important, it allows us to be a lot more agile and responsive to the challenges that come our way.
One of the positive spinoffs that I’ve had the privilege to experience is that when we stood up the Defense Health Agency, it then became a member of a group of organizations that in many ways work together.… The Defense Health Agency, Defense Information Systems Agency (DISA), and Defense Logistics Agency (DLA) exist solely to provide capability and joint capability where it makes sense to the services, and they are enablers.
The Defense Health Agency is also a designated combat support agency, which means not only are we answerable to the service surgeons general and to the service chiefs, but we are also directly responsible to the Chairman of the Joint Chiefs of Staff to provide combat support capability for our commanders.…
We are supporting and we will be responsive to the needs of the services. We will look for opportunity. We will continue to mature. We will continue to progress in our organizational construct. But at the same time… we have set up a senior level group from the services led by a general officer who will look at making sure that we are delivering on our initial 10 shared services and that we are continuing to meet what we said we were going to do. And then also for them to feed back to us where is there opportunity, where are there needs, but also that group is out there to look at where are there future opportunities.
Is there another shared service out there, or is there another shared joint first solution opportunity out there that we need to put into the queue to address to make us better, stronger, more relevant in the 21st century but at the same time, viable and in a very fiscally constrained environment?
Quality, Safety, and Access for Patients
Lt Gen Robb. The world doesn’t stop just because you’re building an organization.... Now that we’ve got this joint platform, we can aggregate the patient safety and the quality data that we have out there and look at where there is opportunity for the military health system to improve. We have bought an enterprise-wide analytic capability that will support the services as we continue to drive toward a high reliability organization, number one, and to continuously improve both quality, safety, and access. Much like DLA is to the logistics world and DISA is to the information systems world, we’re a centralized organizational construct that can bring the services together to create, what I call, an interoperable or joint force solution where it makes sense.
We have stood up the P4I initiative, which is a partnership for improvement of which the core of that will be the Defense Health Agency analytic cell, but the Defense Health Agency Healthcare Operations has become a gathering spot or the platform where the services come together. And for the first time, we have an enterprise dashboard. There [are] about 30 metrics out there where we’re looking at quality, safety, and access…. That’s just one example. And I could go through each of the shared services one by one by one and talk about where we have made a difference.
Consolidating Services
Lt Gen Robb. One of the ones that has been as exciting as anything and challenging at the same time is our health information and technology consolidation, which is being led by Mr. Dave Bowen, our chief information officer [CIO]. We had a single health care record, AHLTA, but we were basically running 3 separate health information and technology systems—Army, Navy, and Air Force. When you talk about being interoperable on the battlefield, sometimes we had some centralization on the battlefield, but as it worked its way back, you started working your way into 3 separate systems.
When you look at any major health care organization that has consolidated,… we absolutely spent time with leaders in the health care industry about how you set up an enterprise-wide health care system that’s effective and efficient. But most important, how do you drive quality and how do you drive safety? Standardization is key not only in what we would call cost and resource things, but standardization also drives—and study after study also drives—increased quality.…
What we’re doing is we’re going basically from the major data warehouse servers all the way down to the desktop, [it] is going to be managed centrally. But when I say “managed,” I’m talking about manned and managed. So the men and women that were running the health care information technology for the Army or the Navy or the Air Force are now part of a large organization called the Health Information and Technology [HIT] Directorate.
And we are standardizing. We’re standardizing the desktop, we are standardizing the infrastructure at the base level, at the service level; and with the help of the DoD CIO across the board. This is exciting. And as you can imagine, there are savings to be had there in the reduction of duplications. In fact, in 2014 just in the infrastructure consolidation, HIT came up with about $5 million [savings] and then another $12 million in savings so far in 2015. We have created a single, joint integrated infrastructure that supports our joint integrated delivered health care so it makes sense.
About 45%, almost 50% of our health care direct care systems, in other words our military treatment facilities, is delivered in 6 markets where 2 or more of the services—Army, Navy, or Air Force—exist side by side. You think of San Antonio with the Army and the Air Force; you think of the National Capital Region Army, Navy, and Air Force medicine; you think about the tidewater area where you have Army, Navy, and Air Force medicine. It makes sense that we have a single, integrated, consolidated health information and technology.
Interoperability and Interdependence
Lt Gen Robb. By nature of what we do, we’ve created an interoperability and interdependence within the Defense Health Agency.
Let’s look at education and training. The 3 services had up to 23 different online knowledge systems. It was either a library of knowledge or there was training going on. The Education and Training Directorate leadership said, “Hey, it makes sense to put all of our different learning portals on 1 portal.” So we’re consolidating from about 23 down to a single learning portal.
And you can just begin to imagine the efficiencies gained there, not to mention the savings. We’re looking at about $500,000 in savings in 2015 and probably another million [dollars] for 2016 just on consolidation of that. So these are all early deliveries by a very young but enthusiastic and aggressive organization called the Defense Health Agency.
We’re looking at a single entity for, what we call, third-party collections across all 3 services. We could never do that before, but now we can. We’re also looking at the way we account for dollars. In other words, when you want to manage your budget, and, as you know, we have different bags of money and each of them is used for certain things, but we weren’t doing that in a standardized manner. So if you want to make a system efficient, you’ve got to call things the same, you’ve got to measure things the same, you’ve got to measure them in the same bucket of money.…
Let’s think about logistic support. Those individuals form a community of practice have always been joint oriented, but it’s always been tough for them to get what was best for the enterprise, because the services wanted to do it but when they went back and they prioritized within the services, it may not have made the cut. And so not that we didn’t want to do it from an enterprise, but the services prioritized different.
But now with the logistics directorate, we prioritize as an enterprise we run it through governance, and we make a decision. So we now have very robust e-commerce. And there were different ways. Folks were using what we call the credit card method before, because it was convenient. But the problem was it’s more expensive to do it that way. So now we’ve made a more robust and more user-friendly and customer-friendly e-commerce. And so now we’re up to about 70% compliance, and we’re saving millions of dollars right there.
When you think about the Defense Logistics Agency, their job is to get the best price and product for the Department of Defense. So can you imagine before they were having to deal with the Army medicine, Navy medicine, and Air Force medicine. Now they’re dealing with the Defense Health Agency Logistics Directorate, so it’s a single point of contact. Now when we go out and do group buys, they can get a better deal for us. So what makes us look good makes them look good.…
DISA used to have to negotiate way ahead with Army, Navy, and Air Force medicine. Now they’re negotiating and looking at a joint force solution where it makes sense for the enterprise. That’s 2 examples right there, and it’s been exhilarating to watch. When you take the blinders off and you take the muzzle off, what our people can do if you give them the opportunity.
Working With the VA
Lt Gen Robb. I’m sure you’re aware that right now the Department of Defense and the VA have about 8.4 million shared records through what we would call a joint legacy viewer and enterprise. But what’s the future look like?
With the consolidation of the Health Information and Technology Directorate and then as we move forward with the acquisition of this new electronic health record, what our consolidated Health Information and Technology Directorate has done is created a single point of contact and a single entity for all things in relation to the new electronic health record.
Before, we had Army, Navy, and Air Force health information and technologies and it would have been… a lot harder to acquire something this large when you were dealing with 3 [systems]. Now we’re dealing with one entity. It is also the backbone and that’s where, what I would call, our academic center of gravity is and also our workhorses.
What is key for the interoperability between the Department of Defense and the VA as we transition the service member across is that the data flow from the Department of Defense to the Department of Veterans Affairs. We were handing over 3 different packages of data to the VA. Now we’re going to bring 1 package of data. So now the Department of Defense will have a single plug to go into the Department of Veterans Affairs.
The Department of Defense and the Department of Veterans Affairs have been working very hard the last couple of years, quietly in the background. But we are working on standardized data elements. In other words, what I call the Department of Defense and the VA will speak the same language and the same dialect when it comes to moving data. You don’t have to have the same electronic health record.… You have to have the ability to move those common data elements through your system.
The standardization of the infrastructure has allowed us to roll out the electronic health record, which will be our backbone and then we’ll move that data to the VA electronic health record of the future…. Our people inside the Defense Health Agency have been working with all the teams with these infrastructure upgrades and the new electronic health records [requirements]. It’s working the data elements, it’s working the joint requirements. All these things are all coming together to support our soldiers, sailors, airmen, and marines as they move forward in the transition from the Department of Defense to the Department of Veterans Affairs.
For the past 2 years, military health has been undergoing one of the largest transformations in its history. In the midst of an active war in Afghanistan, the wind down to another in Iraq, and a humanitarian mission to Liberia, the transformation has been ongoing. “We were building the airplane as we flew it,” Lt Gen Douglas J. Robb, DO, admitted.
The Defense Health Agency (DHA) brings together the previously independent health care operations of the Army, Navy, and Air Force, with unique cultures, procedures, and technologies. The underlying DHA goals have been to improve interoperability, efficiency, and cost reduction by sharing services.
The operation is massive. The DHA cares for a TRICARE-eligible population of 9.5 million, including 1.4 million service members on active duty, with more than 1 million inpatient admissions and 95.6 million outpatient visits in 2014.
That transformation formally ends on October 1, 2015, as the DHA becomes fully operational and the organization moves into its next phase. Building such a large system has been a daunting challenge, but it has been “exhilarating… to watch what our people can do if you give them the opportunity,” Lt Gen Robb explained.
Establishing the Defense Health Agency
Lt Gen Douglas J. Robb, DO. You have to go back to look at where the seeds were planted on the journey that we have been on since June 2011. Back in 2011, then Deputy Secretary of Defense William Lynn established an internal task force to take a look at whether there is a better way to conduct a military health system governance.
How do we ensure the incredible medical support for our current and future military operations in an environment that was becoming fiscally constrained? We needed to look at how we could transform ourselves to make us better, stronger, more relevant, and, ultimately, viable. One of the other things that we had going for us at the time was broad congressional support that also supported a need for change.
We had a task force that assemmbled. I think this is key—it was a very broad based and a very representative task force. We had military departments, the Joint Staff, and the Office of the Secretary of Defense [OSD] who were all part of this task force…. Individuals that had a vested interest in the way we would organize a new entity that would, hopefully, and I would argue will, change the way we practice medicine....
Out of that task force came some recommendations. And one of those recommendations had to do with the overall governance of the military health system. People may be aware there are several models out there. In fact, there were 5 models that we looked at. One was a unified medical command, one was a defense health agency, one was a single-service model, another was a hybrid model, and then the status quo.
And what the task force recommendation that was put forth came down to was the recommendation of a defense health agency. And with that, the DEPSECDEF [Deputy Secretary of Defense] said, “Plan for it.” In November 2012, we had a planning work group report that went to the DEPSECDEF. And then, finally, in March 2013, the DEPSECDEF said, “Go forth and create and stand up the Defense Health Agency,” in what was then known as the Nine Commandments Memo.
The bottom line was no matter what model we chose, whatever organizational construct, the bottom line was we needed to ensure a medically ready force and a ready medical force…. One of the things that I think is key is that through these 10 years of conflict—actually, now going on 13—we have witnessed the ability for our medical services (the Army, Navy, the Air Force, and the Marine Corps) to come together in a joint environment, in the deployed setting, to essentially produce the lowest lethality rate in the history of recorded conflict. And it is amazing what our people have been able to do in saving the lives of our soldiers, sailors, and marines coalition forces and our civilians.
At the same time, we have also come together in avery joint manner to also achieve, what we call, the lowest disease nonbattle injury rate in the history of recorded conflict. That is a tribute to the services ensuring that all our forces are ready and deployable.
Shared Services
Lt Gen Robb. Essentially, we were running, in many cases, 3 parallel health care systems, 3 separate health information and technology systems. Three separate facilities divisions…. There was a lot of duplication, and there was a lot of redundancy. And so if you look at the challenge of the fiscal environment coupled with how to continue to provide high-quality health care in a deployed environment and in garrison, that was really the driving force behind the Defense Health Agency.
How could we find significant cost savings? How do we reduce the duplication? How do we reduce the variation? That’s what our models looked at. How do you create a dispute resolution process with clear decision authority and clear accountability as you move toward joint solutions where they make sense?
One of the other issues that we had was: Is it doable? Is whatever we propose doable in the environments and acceptable not only to the services, but to the Office of the Secretary of Defense? And so all those came into play as we proposed what then became the Defense Health Agency proposal for a new wave of doing governance.
When we built the Defense Health Agency, we looked at the 10 shared services… where we could see savings either in efficiencies or quality or dollars. Those 10 shared services were facilities, medical logistics, health information and technology, TRICARE, pharmacy operations, budget and resource management, contracting, research, development, acquisition, medical education and training, and public health.… We felt that there was opportunity there.
Now, as we moved forward, and people need to remember this, the Defense Health Agency and the future governance model was not created in a vacuum. It was created by the services’ participation—Army, Navy, and Air Force medicine. Each of those shared services had subject matter experts from all 3 services participating in shaping the future joint force solutions, where it makes sense. That is key. It wasn’t a bunch of headquarters officials or OSD or joint staff sitting in a dark room creating this in a vacuum and then bringing it out and saying, “Hey, this is what we’re going to do.” It was transparent, it was open, and then it actually ended up running through what we would then create the new governance system as we moved forward.
Each of those shared services underwent, what I call, a rigorous—and I’m going to repeat that word, rigorous—reproducible and transparent business case analysis. And after that, then you say, “Hey is there opportunity here?” Then part 2 was a rigorous, transparent, and reproducible business process re-engineering. And so we went through each of those shared services. And it just so happened that there was opportunity. In other words, there was opportunity for increased efficiencies, increased effectiveness, dollar savings, or resource savings, some of the above or all the above in all of these 10 shared services.
We put $3.5 billion on the table as potential shared services cost savings for the fiscal years [FY] 2015 to 2019. That’s not an insignificant number. Now folks say, “That’s a lot of money to put on the table. Are you going to deliver?” And the answer is yes, we will deliver. I’m going to be honest with you, they took that right off the topline of our Defense Health budget right off the bat, so we had no choice but to deliver now. But I’m confident that we will because of the very rigorous work and dedication of those who did that.
If you want to look at an early win here: In March of 2013 is when DEPSECDEF said, “Go forth and stand up the Defense Health Agency.” And then we set a target date of 1 October 2013 to be at initial operating capability when we stood up the Defense Health Agency. So that first year in FY14, the Defense Health Agency achieved—and this was not included in the FY15 to FY19 [budget]—achieved cost savings of $350 million….
Standing up 1 October 2013 in the middle of sequestration, I told my staff, “If there is any money you need for initial investment, you’re going to have to either find it yourself or make it.” And they did.… We paid our own way that first year, and I’m not so sure there are a lot of organizations out there that can say they paid their own way the first year. But I was very proud of our staff, especially when you create an organization that is supposed to lean out.
Remember, our staff in the Defense Health Agency is made of the men and women, the subject matter experts, the extreme talent that comes from the Army, Navy, and the Air Force medical services. When I talk about the Defense Health Agency, they’re not Defense Health Agency people. These are people that are in the Defense Health Agency that are providing services back and capability back to Army, Navy, Air Force, and Marine medicine. It is truly a team effort and a collaborative effort.
Standing Up
Lt Gen Robb. When I come to work each day, I think about the progress we’ve made in the journey of this military health system transformation. When you look at it, this is probably the largest military health care transformation that has occurred in decades, if not ever.
Dr. Jonathan Woods is an incredible leader, number one; but number two, he has a strategic vision and a strategic ability to make things happen. And he has a great deputy in Dr. Karen Guice. Both are incredible leaders at the right place, at the right time, coupled with congressional support. And then through the task force and the services, getting the Joint Staff and the services support as we move forward.
On 1 October 2013 we stood up and we created an organizational construct…. Those 10 shared services are embedded in an organizational construct that has 6 directorates. One is health care operations, number 2 is health information technology, number 3 is research and development, number 4 is education and training, number 5 is business support, and then, number 6 through a process that evolved [into] … the Multiservice Market National Capital Region Directorate.
Let’s look at the commitment not only by the OSD, but also from the services. So you’ve got 6 directorates and each of those directorates are led by a general officer, an admiral, or a senior executive service official…. There were no new general offices allotted to the Defense Health Agency. So those general offices came from the services. It [was] with the men and women who were part of the Army, Navy, and Air Force medicine who are now part of the Defense Health Agency.
What we’ve done in these 2 years is we’ve molded and we’ve melded and we’ve grown those teams to support those directorates and then the divisions within those directorates and the staff to support the shared services inside our organizational construct.
Joint Platforms
Lt Gen Robb. We’ve matured and there are in each of those directorates, in each of those shared services, success stories It’s one thing to stand something up. But we often say, “We were building the airplane as we flew it.” And we were producing, again, what I call, at times long overdue, joint products in support of the services.…
I’m excited about standing up again a joint platform that allows the military health system to accelerate business and operational elements to make a more effective and efficient military health system. But probably just as important, if not more important, it allows us to be a lot more agile and responsive to the challenges that come our way.
One of the positive spinoffs that I’ve had the privilege to experience is that when we stood up the Defense Health Agency, it then became a member of a group of organizations that in many ways work together.… The Defense Health Agency, Defense Information Systems Agency (DISA), and Defense Logistics Agency (DLA) exist solely to provide capability and joint capability where it makes sense to the services, and they are enablers.
The Defense Health Agency is also a designated combat support agency, which means not only are we answerable to the service surgeons general and to the service chiefs, but we are also directly responsible to the Chairman of the Joint Chiefs of Staff to provide combat support capability for our commanders.…
We are supporting and we will be responsive to the needs of the services. We will look for opportunity. We will continue to mature. We will continue to progress in our organizational construct. But at the same time… we have set up a senior level group from the services led by a general officer who will look at making sure that we are delivering on our initial 10 shared services and that we are continuing to meet what we said we were going to do. And then also for them to feed back to us where is there opportunity, where are there needs, but also that group is out there to look at where are there future opportunities.
Is there another shared service out there, or is there another shared joint first solution opportunity out there that we need to put into the queue to address to make us better, stronger, more relevant in the 21st century but at the same time, viable and in a very fiscally constrained environment?
Quality, Safety, and Access for Patients
Lt Gen Robb. The world doesn’t stop just because you’re building an organization.... Now that we’ve got this joint platform, we can aggregate the patient safety and the quality data that we have out there and look at where there is opportunity for the military health system to improve. We have bought an enterprise-wide analytic capability that will support the services as we continue to drive toward a high reliability organization, number one, and to continuously improve both quality, safety, and access. Much like DLA is to the logistics world and DISA is to the information systems world, we’re a centralized organizational construct that can bring the services together to create, what I call, an interoperable or joint force solution where it makes sense.
We have stood up the P4I initiative, which is a partnership for improvement of which the core of that will be the Defense Health Agency analytic cell, but the Defense Health Agency Healthcare Operations has become a gathering spot or the platform where the services come together. And for the first time, we have an enterprise dashboard. There [are] about 30 metrics out there where we’re looking at quality, safety, and access…. That’s just one example. And I could go through each of the shared services one by one by one and talk about where we have made a difference.
Consolidating Services
Lt Gen Robb. One of the ones that has been as exciting as anything and challenging at the same time is our health information and technology consolidation, which is being led by Mr. Dave Bowen, our chief information officer [CIO]. We had a single health care record, AHLTA, but we were basically running 3 separate health information and technology systems—Army, Navy, and Air Force. When you talk about being interoperable on the battlefield, sometimes we had some centralization on the battlefield, but as it worked its way back, you started working your way into 3 separate systems.
When you look at any major health care organization that has consolidated,… we absolutely spent time with leaders in the health care industry about how you set up an enterprise-wide health care system that’s effective and efficient. But most important, how do you drive quality and how do you drive safety? Standardization is key not only in what we would call cost and resource things, but standardization also drives—and study after study also drives—increased quality.…
What we’re doing is we’re going basically from the major data warehouse servers all the way down to the desktop, [it] is going to be managed centrally. But when I say “managed,” I’m talking about manned and managed. So the men and women that were running the health care information technology for the Army or the Navy or the Air Force are now part of a large organization called the Health Information and Technology [HIT] Directorate.
And we are standardizing. We’re standardizing the desktop, we are standardizing the infrastructure at the base level, at the service level; and with the help of the DoD CIO across the board. This is exciting. And as you can imagine, there are savings to be had there in the reduction of duplications. In fact, in 2014 just in the infrastructure consolidation, HIT came up with about $5 million [savings] and then another $12 million in savings so far in 2015. We have created a single, joint integrated infrastructure that supports our joint integrated delivered health care so it makes sense.
About 45%, almost 50% of our health care direct care systems, in other words our military treatment facilities, is delivered in 6 markets where 2 or more of the services—Army, Navy, or Air Force—exist side by side. You think of San Antonio with the Army and the Air Force; you think of the National Capital Region Army, Navy, and Air Force medicine; you think about the tidewater area where you have Army, Navy, and Air Force medicine. It makes sense that we have a single, integrated, consolidated health information and technology.
Interoperability and Interdependence
Lt Gen Robb. By nature of what we do, we’ve created an interoperability and interdependence within the Defense Health Agency.
Let’s look at education and training. The 3 services had up to 23 different online knowledge systems. It was either a library of knowledge or there was training going on. The Education and Training Directorate leadership said, “Hey, it makes sense to put all of our different learning portals on 1 portal.” So we’re consolidating from about 23 down to a single learning portal.
And you can just begin to imagine the efficiencies gained there, not to mention the savings. We’re looking at about $500,000 in savings in 2015 and probably another million [dollars] for 2016 just on consolidation of that. So these are all early deliveries by a very young but enthusiastic and aggressive organization called the Defense Health Agency.
We’re looking at a single entity for, what we call, third-party collections across all 3 services. We could never do that before, but now we can. We’re also looking at the way we account for dollars. In other words, when you want to manage your budget, and, as you know, we have different bags of money and each of them is used for certain things, but we weren’t doing that in a standardized manner. So if you want to make a system efficient, you’ve got to call things the same, you’ve got to measure things the same, you’ve got to measure them in the same bucket of money.…
Let’s think about logistic support. Those individuals form a community of practice have always been joint oriented, but it’s always been tough for them to get what was best for the enterprise, because the services wanted to do it but when they went back and they prioritized within the services, it may not have made the cut. And so not that we didn’t want to do it from an enterprise, but the services prioritized different.
But now with the logistics directorate, we prioritize as an enterprise we run it through governance, and we make a decision. So we now have very robust e-commerce. And there were different ways. Folks were using what we call the credit card method before, because it was convenient. But the problem was it’s more expensive to do it that way. So now we’ve made a more robust and more user-friendly and customer-friendly e-commerce. And so now we’re up to about 70% compliance, and we’re saving millions of dollars right there.
When you think about the Defense Logistics Agency, their job is to get the best price and product for the Department of Defense. So can you imagine before they were having to deal with the Army medicine, Navy medicine, and Air Force medicine. Now they’re dealing with the Defense Health Agency Logistics Directorate, so it’s a single point of contact. Now when we go out and do group buys, they can get a better deal for us. So what makes us look good makes them look good.…
DISA used to have to negotiate way ahead with Army, Navy, and Air Force medicine. Now they’re negotiating and looking at a joint force solution where it makes sense for the enterprise. That’s 2 examples right there, and it’s been exhilarating to watch. When you take the blinders off and you take the muzzle off, what our people can do if you give them the opportunity.
Working With the VA
Lt Gen Robb. I’m sure you’re aware that right now the Department of Defense and the VA have about 8.4 million shared records through what we would call a joint legacy viewer and enterprise. But what’s the future look like?
With the consolidation of the Health Information and Technology Directorate and then as we move forward with the acquisition of this new electronic health record, what our consolidated Health Information and Technology Directorate has done is created a single point of contact and a single entity for all things in relation to the new electronic health record.
Before, we had Army, Navy, and Air Force health information and technologies and it would have been… a lot harder to acquire something this large when you were dealing with 3 [systems]. Now we’re dealing with one entity. It is also the backbone and that’s where, what I would call, our academic center of gravity is and also our workhorses.
What is key for the interoperability between the Department of Defense and the VA as we transition the service member across is that the data flow from the Department of Defense to the Department of Veterans Affairs. We were handing over 3 different packages of data to the VA. Now we’re going to bring 1 package of data. So now the Department of Defense will have a single plug to go into the Department of Veterans Affairs.
The Department of Defense and the Department of Veterans Affairs have been working very hard the last couple of years, quietly in the background. But we are working on standardized data elements. In other words, what I call the Department of Defense and the VA will speak the same language and the same dialect when it comes to moving data. You don’t have to have the same electronic health record.… You have to have the ability to move those common data elements through your system.
The standardization of the infrastructure has allowed us to roll out the electronic health record, which will be our backbone and then we’ll move that data to the VA electronic health record of the future…. Our people inside the Defense Health Agency have been working with all the teams with these infrastructure upgrades and the new electronic health records [requirements]. It’s working the data elements, it’s working the joint requirements. All these things are all coming together to support our soldiers, sailors, airmen, and marines as they move forward in the transition from the Department of Defense to the Department of Veterans Affairs.
Metronidazole and alcohol
A 32-year-old man develops diarrhea after receiving amoxicillin/clavulanate to treat an infection following a dog bite. He is diagnosed with Clostridium difficile and prescribed a 10-day course of metronidazole. He has no other medical problems. He will be the best man at his brother’s wedding tomorrow. What advice should you give him about alcohol use at the reception?
A. Do not take metronidazole the day of the wedding if you will be drinking alcohol.
B. Take metronidazole, do not drink alcohol.
C. It’s okay to drink alcohol.
For years, we have advised patients to not use alcohol if they are taking metronidazole because of concern for a disulfiram-like reaction between alcohol and metronidazole. This has been a standard warning given by physicians and appears as a contraindication in the prescribing information. It has been well accepted as a true, proven reaction.
Is it true?
As early as the 1960s, case reports and an uncontrolled study suggested that combining metronidazole with alcohol produced a disulfiram-like reaction, with case reports of severe reactions, including death.1, 2, 3 This was initially considered an area that might be therapeutic in the treatment of alcoholism, but several studies showed no benefit.4, 5
Caroline S. Williams and Dr. Kevin R. Woodcock reviewed the case reports for evidence of proof of a true interaction between metronidazole and ethanol.6 The case reports referenced textbooks to substantiate the interaction, but they did not present clear evidence of an interaction as the cause of elevated acetaldehyde levels.
Researchers have shown in a rat model that metronidazole can increase intracolonic, but not blood, acetaldehyde levels in rats that have received a combination of ethanol and metronidazole.7 Metronidazole did not have any inhibitory effect on hepatic or colonic alcohol dehydrogenase or aldehyde dehydrogenase. What was found was that rats treated with metronidazole had increased growth of Enterobacteriaceae, an alcohol dehydrogenase–containing aerobe, which could be the cause of the higher intracolonic acetaldehyde levels.
Jukka-Pekka Visapää and his colleagues studied the effect of coadministration of metronidazole and ethanol in young, healthy male volunteers.8 The study was a placebo-controlled, randomized trial. The study was small, with 12 participants. One-half of the study participants received metronidazole three times a day for 5 days; the other half received placebo. All participants then received ethanol 0.4g/kg, with blood testing being done every 20 minutes for the next 4 hours. Blood was tested for ethanol concentrations and for acetaldehyde levels. The study participants also had blood pressure, pulse, skin temperature, and symptoms monitored during the study.
There was no difference in blood acetaldehyde levels, vital signs, or symptoms between patients who received metronidazole or placebo. None of the subjects in the study had any measurable symptoms.
Metronidazole has many side effects, including nausea, vomiting, headache, dizziness, and seizures. These symptoms have a great deal of overlap with the symptoms of alcohol-disulfiram interaction. It has been assumed in early case reports that metronidazole caused a similar interaction with alcohol and raised acetaldehyde levels by interfering with aldehyde dehydrogenase.
Animal models and the human study do not show this to be the case. It is possible that metronidazole side effects alone were the cause of the symptoms in case reports. The one human study done was on healthy male volunteers, so projecting the results to a population with liver disease or other serious illness is a bit of a stretch. I think that if a problem exists with alcohol and metronidazole, it is uncommon and unlikely to occur in healthy individuals.
So, what would I advise the patient in the case about whether he can drink alcohol? I think that the risk would be minimal and that it would be safe for him to drink alcohol.
References
1. Br J Clin Pract. 1985 Jul;39(7):292-3.
2. Psychiatr Neurol. 1966;152:395-401.
3. Am J Forensic Med Pathol. 1996 Dec;17(4):343-6.
4. Q J Stud Alcohol. 1972 Sep;33: 734-40.
5. Q J Stud Ethanol. 1969 Mar;30: 140-51.
6. Ann Pharmacother. 2000 Feb;34(2):255-7.
7. Alcohol Clin Exp Res. 2000 Apr;24(4):570-5.
8. Ann Pharmacother. 2002 Jun;36(6):971-4.
Dr. Paauw is professor of medicine in the division of general internal medicine at the University of Washington, Seattle, and he serves as third-year medical student clerkship director at the University of Washington. Contact Dr. Paauw at [email protected].
A 32-year-old man develops diarrhea after receiving amoxicillin/clavulanate to treat an infection following a dog bite. He is diagnosed with Clostridium difficile and prescribed a 10-day course of metronidazole. He has no other medical problems. He will be the best man at his brother’s wedding tomorrow. What advice should you give him about alcohol use at the reception?
A. Do not take metronidazole the day of the wedding if you will be drinking alcohol.
B. Take metronidazole, do not drink alcohol.
C. It’s okay to drink alcohol.
For years, we have advised patients to not use alcohol if they are taking metronidazole because of concern for a disulfiram-like reaction between alcohol and metronidazole. This has been a standard warning given by physicians and appears as a contraindication in the prescribing information. It has been well accepted as a true, proven reaction.
Is it true?
As early as the 1960s, case reports and an uncontrolled study suggested that combining metronidazole with alcohol produced a disulfiram-like reaction, with case reports of severe reactions, including death.1, 2, 3 This was initially considered an area that might be therapeutic in the treatment of alcoholism, but several studies showed no benefit.4, 5
Caroline S. Williams and Dr. Kevin R. Woodcock reviewed the case reports for evidence of proof of a true interaction between metronidazole and ethanol.6 The case reports referenced textbooks to substantiate the interaction, but they did not present clear evidence of an interaction as the cause of elevated acetaldehyde levels.
Researchers have shown in a rat model that metronidazole can increase intracolonic, but not blood, acetaldehyde levels in rats that have received a combination of ethanol and metronidazole.7 Metronidazole did not have any inhibitory effect on hepatic or colonic alcohol dehydrogenase or aldehyde dehydrogenase. What was found was that rats treated with metronidazole had increased growth of Enterobacteriaceae, an alcohol dehydrogenase–containing aerobe, which could be the cause of the higher intracolonic acetaldehyde levels.
Jukka-Pekka Visapää and his colleagues studied the effect of coadministration of metronidazole and ethanol in young, healthy male volunteers.8 The study was a placebo-controlled, randomized trial. The study was small, with 12 participants. One-half of the study participants received metronidazole three times a day for 5 days; the other half received placebo. All participants then received ethanol 0.4g/kg, with blood testing being done every 20 minutes for the next 4 hours. Blood was tested for ethanol concentrations and for acetaldehyde levels. The study participants also had blood pressure, pulse, skin temperature, and symptoms monitored during the study.
There was no difference in blood acetaldehyde levels, vital signs, or symptoms between patients who received metronidazole or placebo. None of the subjects in the study had any measurable symptoms.
Metronidazole has many side effects, including nausea, vomiting, headache, dizziness, and seizures. These symptoms have a great deal of overlap with the symptoms of alcohol-disulfiram interaction. It has been assumed in early case reports that metronidazole caused a similar interaction with alcohol and raised acetaldehyde levels by interfering with aldehyde dehydrogenase.
Animal models and the human study do not show this to be the case. It is possible that metronidazole side effects alone were the cause of the symptoms in case reports. The one human study done was on healthy male volunteers, so projecting the results to a population with liver disease or other serious illness is a bit of a stretch. I think that if a problem exists with alcohol and metronidazole, it is uncommon and unlikely to occur in healthy individuals.
So, what would I advise the patient in the case about whether he can drink alcohol? I think that the risk would be minimal and that it would be safe for him to drink alcohol.
References
1. Br J Clin Pract. 1985 Jul;39(7):292-3.
2. Psychiatr Neurol. 1966;152:395-401.
3. Am J Forensic Med Pathol. 1996 Dec;17(4):343-6.
4. Q J Stud Alcohol. 1972 Sep;33: 734-40.
5. Q J Stud Ethanol. 1969 Mar;30: 140-51.
6. Ann Pharmacother. 2000 Feb;34(2):255-7.
7. Alcohol Clin Exp Res. 2000 Apr;24(4):570-5.
8. Ann Pharmacother. 2002 Jun;36(6):971-4.
Dr. Paauw is professor of medicine in the division of general internal medicine at the University of Washington, Seattle, and he serves as third-year medical student clerkship director at the University of Washington. Contact Dr. Paauw at [email protected].
A 32-year-old man develops diarrhea after receiving amoxicillin/clavulanate to treat an infection following a dog bite. He is diagnosed with Clostridium difficile and prescribed a 10-day course of metronidazole. He has no other medical problems. He will be the best man at his brother’s wedding tomorrow. What advice should you give him about alcohol use at the reception?
A. Do not take metronidazole the day of the wedding if you will be drinking alcohol.
B. Take metronidazole, do not drink alcohol.
C. It’s okay to drink alcohol.
For years, we have advised patients to not use alcohol if they are taking metronidazole because of concern for a disulfiram-like reaction between alcohol and metronidazole. This has been a standard warning given by physicians and appears as a contraindication in the prescribing information. It has been well accepted as a true, proven reaction.
Is it true?
As early as the 1960s, case reports and an uncontrolled study suggested that combining metronidazole with alcohol produced a disulfiram-like reaction, with case reports of severe reactions, including death.1, 2, 3 This was initially considered an area that might be therapeutic in the treatment of alcoholism, but several studies showed no benefit.4, 5
Caroline S. Williams and Dr. Kevin R. Woodcock reviewed the case reports for evidence of proof of a true interaction between metronidazole and ethanol.6 The case reports referenced textbooks to substantiate the interaction, but they did not present clear evidence of an interaction as the cause of elevated acetaldehyde levels.
Researchers have shown in a rat model that metronidazole can increase intracolonic, but not blood, acetaldehyde levels in rats that have received a combination of ethanol and metronidazole.7 Metronidazole did not have any inhibitory effect on hepatic or colonic alcohol dehydrogenase or aldehyde dehydrogenase. What was found was that rats treated with metronidazole had increased growth of Enterobacteriaceae, an alcohol dehydrogenase–containing aerobe, which could be the cause of the higher intracolonic acetaldehyde levels.
Jukka-Pekka Visapää and his colleagues studied the effect of coadministration of metronidazole and ethanol in young, healthy male volunteers.8 The study was a placebo-controlled, randomized trial. The study was small, with 12 participants. One-half of the study participants received metronidazole three times a day for 5 days; the other half received placebo. All participants then received ethanol 0.4g/kg, with blood testing being done every 20 minutes for the next 4 hours. Blood was tested for ethanol concentrations and for acetaldehyde levels. The study participants also had blood pressure, pulse, skin temperature, and symptoms monitored during the study.
There was no difference in blood acetaldehyde levels, vital signs, or symptoms between patients who received metronidazole or placebo. None of the subjects in the study had any measurable symptoms.
Metronidazole has many side effects, including nausea, vomiting, headache, dizziness, and seizures. These symptoms have a great deal of overlap with the symptoms of alcohol-disulfiram interaction. It has been assumed in early case reports that metronidazole caused a similar interaction with alcohol and raised acetaldehyde levels by interfering with aldehyde dehydrogenase.
Animal models and the human study do not show this to be the case. It is possible that metronidazole side effects alone were the cause of the symptoms in case reports. The one human study done was on healthy male volunteers, so projecting the results to a population with liver disease or other serious illness is a bit of a stretch. I think that if a problem exists with alcohol and metronidazole, it is uncommon and unlikely to occur in healthy individuals.
So, what would I advise the patient in the case about whether he can drink alcohol? I think that the risk would be minimal and that it would be safe for him to drink alcohol.
References
1. Br J Clin Pract. 1985 Jul;39(7):292-3.
2. Psychiatr Neurol. 1966;152:395-401.
3. Am J Forensic Med Pathol. 1996 Dec;17(4):343-6.
4. Q J Stud Alcohol. 1972 Sep;33: 734-40.
5. Q J Stud Ethanol. 1969 Mar;30: 140-51.
6. Ann Pharmacother. 2000 Feb;34(2):255-7.
7. Alcohol Clin Exp Res. 2000 Apr;24(4):570-5.
8. Ann Pharmacother. 2002 Jun;36(6):971-4.
Dr. Paauw is professor of medicine in the division of general internal medicine at the University of Washington, Seattle, and he serves as third-year medical student clerkship director at the University of Washington. Contact Dr. Paauw at [email protected].
Electronic Brachytherapy: Overused and Overpriced?
The introduction of high-density radiation electronic brachytherapy (eBX) for the treatment of nonmelanoma skin cancers has induced great angst within the dermatology community.1 The Current Procedural Terminology (CPT) code 0182T (high dose rate eBX) reimburses at an extraordinarily high rate, which has drawn a substantial amount of attention. Some critics see it as another case of overutilization, of sucking more money out of a bleeding Medicare system. The financial opportunity afforded by eBX has even led some entrepreneurs to purchase dermatology clinics so that skin cancer patients can be treated via this modality instead of more traditional and less costly techniques (personal communication, 2014).
Among radiation oncologists, high-density radiation eBX is considered to be an important treatment option for select patients who have skin cancers staged as T1 or T2 tumors that are 4 cm or smaller in diameter and 5 mm or less in depth.2 Additionally, ideal candidates for nonsurgical treatment options such as eBX include patients with lesions in cosmetically challenging areas (eg, ears, nose), those who may experience problematic wound healing due to tumor location (eg, lower extremities) or medical conditions (eg, diabetes mellitus, peripheral vascular disease), those with medical comorbidities that may preclude them from surgery, those currently taking anticoagulants, and those who are not interested in undergoing surgery.
A common criticism of eBX is that there is little data on long-term treatment outcomes, which will soon be addressed by a 5-year multicenter, prospective, randomized study of 720 patients with basal cell carcinoma and squamous cell carcinoma led by the University of California, Irvine, and the University of California, San Diego (study protocol currently with institutional review board). Another criticism is that some manufacturers of eBX devices gained the less rigorous US Food and Drug Administration Premarket Notification 510(k) certification; however, this certification is quite commonplace in the United States, and an examination of the data actually shows a lower recall rate with this method when compared to the longer premarket approval application process.3 A more important criticism of eBX might be that radiation therapy is associated with a substantial increase in skin cancers that may occur decades later in irradiated areas; however, there remains a paucity of studies examining the safety data on eBX during the posttreatment period when such effects would be expected.
In practice, the forces for good and evil are not only limited to those who utilize eBX. It is widely known that CPT codes for Mohs micrographic surgery also have been abused—that is, the procedure has been used in circumstances where it was not absolutely necessary4—which led to an effort by dermatologic surgery organizations to agree on appropriate use criteria for Mohs surgery.5 These criteria are not perfect but should help curb the misuse of a valuable technique, which is one that is recognized as being optimal for the treatment of complex skin cancers. One might suggest forming similar appropriate use criteria for eBX and limiting this treatment to patients who either are older than 65 years, have serious medical issues, are currently taking anticoagulants, are immobile, or simply cannot handle further dermatologic surgeries.
The American Medical Association has developed new Category III CPT codes for treatment of the skin with eBX that will become effective January 2016.6 These codes take into consideration the need for a radiation oncologist and a physicist to be present for planning, dosimetry, simulation, and selection of parameters for the appropriate depth. Although I do not know the reimbursement rates for these new codes yet, they will likely be substantially less than the current payment for treatment with eBX. That said, the gravy train has left the station, and those who have invested in the devices for eBX will either see the benefit of continued treatment for their patients or divest themselves of eBX now that the reimbursement will be more modest.
Some of my dermatology colleagues, who also are some of my very good friends, have a visceral and absolute objection to the use of any form of radiation therapy, and I respect their opinions. However, eBX does play a role in treating cutaneous malignancies, and our radiation oncology colleagues—many who treat patients with extensive, aggressive, and recurrent skin cancers—also have a place at the table.
Speaking as a fellowship-trained dermatologic surgeon and a department chair, I am very aware that the teaching we provide today for our dermatology residents and fellows is likely to be their modus operandi for the future, a future in which the Patient Protection and Affordable Care Act will force physicians to carefully choose quality of care over personal gain and where financial rewards will be based on appropriate utilization and measurable outcomes. Electronic brachytherapy is one tool amongst many. I have a plethora of patients in their 70s and 80s who have given up on surgery for skin cancer and who would prefer painless treatment with eBX, which allows for the appropriate use of such a controversial therapy.
Acknowledgments—I would like to thank Janellen Smith, MD (Irvine, California), Joshua Spanogle, MD (Saint Augustine, Florida), and Jordan V. Wang, MBE (Philadelphia, Pennsylvania), for their constructive comments.
1. Linos E, VanBeek M, Resneck JS Jr. A sudden and concerning increase in the use of electronic brachytherapy for skin cancer. JAMA Dermatol. 2015;151:699-700.
2. Bhatnagar A. Nonmelanoma skin cancer treated with electronic brachytherapy: results at 1 year [published online ahead of print January 9, 2013]. Brachytherapy. 2013;12:134-140.
3. Connor JT, Lewis RJ, Berry DA, et al. FDA recalls not as alarming as they seem. Arch Intern Med. 2011;171:1044-1046.
4. Goldman G. Mohs surgery comes under the microscope. Member to Member American Academy of Dermatology E-newsletter. https://www.aad.org/members/publications /member-to-member/2013-archive/november-8-2013 /mohs-surgery-comes-under-the-microscope. Published November 8, 2013. Accessed August 10, 2015.
5. Ad Hoc Task Force, Connolly SM, Baker DR, et al. AAD/ACMS/ASDSA/ASMS 2012 appropriate use criteria for Mohs micrographic surgery: a report of the American Academy of Dermatology, American College of Mohs Surgery, American Society for Dermatologic Surgery Association, and the American Society for Mohs Surgery [published online ahead of print September 5, 2012]. J Am Acad Dermatol. 2012;67:531-550.
6. ACR Radiology Coding Source: CPT 2016 anticipated code changes. American College of Radiology Web site. http://www.acr.org/Advocacy/Economics-Health-Policy /Billing-Coding/Coding-Source-List/2015/Mar-Apr-2015 /CPT-2016-Anticipated-Code-Changes. Published March 2015. Accessed August 21, 2015.
The introduction of high-density radiation electronic brachytherapy (eBX) for the treatment of nonmelanoma skin cancers has induced great angst within the dermatology community.1 The Current Procedural Terminology (CPT) code 0182T (high dose rate eBX) reimburses at an extraordinarily high rate, which has drawn a substantial amount of attention. Some critics see it as another case of overutilization, of sucking more money out of a bleeding Medicare system. The financial opportunity afforded by eBX has even led some entrepreneurs to purchase dermatology clinics so that skin cancer patients can be treated via this modality instead of more traditional and less costly techniques (personal communication, 2014).
Among radiation oncologists, high-density radiation eBX is considered to be an important treatment option for select patients who have skin cancers staged as T1 or T2 tumors that are 4 cm or smaller in diameter and 5 mm or less in depth.2 Additionally, ideal candidates for nonsurgical treatment options such as eBX include patients with lesions in cosmetically challenging areas (eg, ears, nose), those who may experience problematic wound healing due to tumor location (eg, lower extremities) or medical conditions (eg, diabetes mellitus, peripheral vascular disease), those with medical comorbidities that may preclude them from surgery, those currently taking anticoagulants, and those who are not interested in undergoing surgery.
A common criticism of eBX is that there is little data on long-term treatment outcomes, which will soon be addressed by a 5-year multicenter, prospective, randomized study of 720 patients with basal cell carcinoma and squamous cell carcinoma led by the University of California, Irvine, and the University of California, San Diego (study protocol currently with institutional review board). Another criticism is that some manufacturers of eBX devices gained the less rigorous US Food and Drug Administration Premarket Notification 510(k) certification; however, this certification is quite commonplace in the United States, and an examination of the data actually shows a lower recall rate with this method when compared to the longer premarket approval application process.3 A more important criticism of eBX might be that radiation therapy is associated with a substantial increase in skin cancers that may occur decades later in irradiated areas; however, there remains a paucity of studies examining the safety data on eBX during the posttreatment period when such effects would be expected.
In practice, the forces for good and evil are not only limited to those who utilize eBX. It is widely known that CPT codes for Mohs micrographic surgery also have been abused—that is, the procedure has been used in circumstances where it was not absolutely necessary4—which led to an effort by dermatologic surgery organizations to agree on appropriate use criteria for Mohs surgery.5 These criteria are not perfect but should help curb the misuse of a valuable technique, which is one that is recognized as being optimal for the treatment of complex skin cancers. One might suggest forming similar appropriate use criteria for eBX and limiting this treatment to patients who either are older than 65 years, have serious medical issues, are currently taking anticoagulants, are immobile, or simply cannot handle further dermatologic surgeries.
The American Medical Association has developed new Category III CPT codes for treatment of the skin with eBX that will become effective January 2016.6 These codes take into consideration the need for a radiation oncologist and a physicist to be present for planning, dosimetry, simulation, and selection of parameters for the appropriate depth. Although I do not know the reimbursement rates for these new codes yet, they will likely be substantially less than the current payment for treatment with eBX. That said, the gravy train has left the station, and those who have invested in the devices for eBX will either see the benefit of continued treatment for their patients or divest themselves of eBX now that the reimbursement will be more modest.
Some of my dermatology colleagues, who also are some of my very good friends, have a visceral and absolute objection to the use of any form of radiation therapy, and I respect their opinions. However, eBX does play a role in treating cutaneous malignancies, and our radiation oncology colleagues—many who treat patients with extensive, aggressive, and recurrent skin cancers—also have a place at the table.
Speaking as a fellowship-trained dermatologic surgeon and a department chair, I am very aware that the teaching we provide today for our dermatology residents and fellows is likely to be their modus operandi for the future, a future in which the Patient Protection and Affordable Care Act will force physicians to carefully choose quality of care over personal gain and where financial rewards will be based on appropriate utilization and measurable outcomes. Electronic brachytherapy is one tool amongst many. I have a plethora of patients in their 70s and 80s who have given up on surgery for skin cancer and who would prefer painless treatment with eBX, which allows for the appropriate use of such a controversial therapy.
Acknowledgments—I would like to thank Janellen Smith, MD (Irvine, California), Joshua Spanogle, MD (Saint Augustine, Florida), and Jordan V. Wang, MBE (Philadelphia, Pennsylvania), for their constructive comments.
The introduction of high-density radiation electronic brachytherapy (eBX) for the treatment of nonmelanoma skin cancers has induced great angst within the dermatology community.1 The Current Procedural Terminology (CPT) code 0182T (high dose rate eBX) reimburses at an extraordinarily high rate, which has drawn a substantial amount of attention. Some critics see it as another case of overutilization, of sucking more money out of a bleeding Medicare system. The financial opportunity afforded by eBX has even led some entrepreneurs to purchase dermatology clinics so that skin cancer patients can be treated via this modality instead of more traditional and less costly techniques (personal communication, 2014).
Among radiation oncologists, high-density radiation eBX is considered to be an important treatment option for select patients who have skin cancers staged as T1 or T2 tumors that are 4 cm or smaller in diameter and 5 mm or less in depth.2 Additionally, ideal candidates for nonsurgical treatment options such as eBX include patients with lesions in cosmetically challenging areas (eg, ears, nose), those who may experience problematic wound healing due to tumor location (eg, lower extremities) or medical conditions (eg, diabetes mellitus, peripheral vascular disease), those with medical comorbidities that may preclude them from surgery, those currently taking anticoagulants, and those who are not interested in undergoing surgery.
A common criticism of eBX is that there is little data on long-term treatment outcomes, which will soon be addressed by a 5-year multicenter, prospective, randomized study of 720 patients with basal cell carcinoma and squamous cell carcinoma led by the University of California, Irvine, and the University of California, San Diego (study protocol currently with institutional review board). Another criticism is that some manufacturers of eBX devices gained the less rigorous US Food and Drug Administration Premarket Notification 510(k) certification; however, this certification is quite commonplace in the United States, and an examination of the data actually shows a lower recall rate with this method when compared to the longer premarket approval application process.3 A more important criticism of eBX might be that radiation therapy is associated with a substantial increase in skin cancers that may occur decades later in irradiated areas; however, there remains a paucity of studies examining the safety data on eBX during the posttreatment period when such effects would be expected.
In practice, the forces for good and evil are not only limited to those who utilize eBX. It is widely known that CPT codes for Mohs micrographic surgery also have been abused—that is, the procedure has been used in circumstances where it was not absolutely necessary4—which led to an effort by dermatologic surgery organizations to agree on appropriate use criteria for Mohs surgery.5 These criteria are not perfect but should help curb the misuse of a valuable technique, which is one that is recognized as being optimal for the treatment of complex skin cancers. One might suggest forming similar appropriate use criteria for eBX and limiting this treatment to patients who either are older than 65 years, have serious medical issues, are currently taking anticoagulants, are immobile, or simply cannot handle further dermatologic surgeries.
The American Medical Association has developed new Category III CPT codes for treatment of the skin with eBX that will become effective January 2016.6 These codes take into consideration the need for a radiation oncologist and a physicist to be present for planning, dosimetry, simulation, and selection of parameters for the appropriate depth. Although I do not know the reimbursement rates for these new codes yet, they will likely be substantially less than the current payment for treatment with eBX. That said, the gravy train has left the station, and those who have invested in the devices for eBX will either see the benefit of continued treatment for their patients or divest themselves of eBX now that the reimbursement will be more modest.
Some of my dermatology colleagues, who also are some of my very good friends, have a visceral and absolute objection to the use of any form of radiation therapy, and I respect their opinions. However, eBX does play a role in treating cutaneous malignancies, and our radiation oncology colleagues—many who treat patients with extensive, aggressive, and recurrent skin cancers—also have a place at the table.
Speaking as a fellowship-trained dermatologic surgeon and a department chair, I am very aware that the teaching we provide today for our dermatology residents and fellows is likely to be their modus operandi for the future, a future in which the Patient Protection and Affordable Care Act will force physicians to carefully choose quality of care over personal gain and where financial rewards will be based on appropriate utilization and measurable outcomes. Electronic brachytherapy is one tool amongst many. I have a plethora of patients in their 70s and 80s who have given up on surgery for skin cancer and who would prefer painless treatment with eBX, which allows for the appropriate use of such a controversial therapy.
Acknowledgments—I would like to thank Janellen Smith, MD (Irvine, California), Joshua Spanogle, MD (Saint Augustine, Florida), and Jordan V. Wang, MBE (Philadelphia, Pennsylvania), for their constructive comments.
1. Linos E, VanBeek M, Resneck JS Jr. A sudden and concerning increase in the use of electronic brachytherapy for skin cancer. JAMA Dermatol. 2015;151:699-700.
2. Bhatnagar A. Nonmelanoma skin cancer treated with electronic brachytherapy: results at 1 year [published online ahead of print January 9, 2013]. Brachytherapy. 2013;12:134-140.
3. Connor JT, Lewis RJ, Berry DA, et al. FDA recalls not as alarming as they seem. Arch Intern Med. 2011;171:1044-1046.
4. Goldman G. Mohs surgery comes under the microscope. Member to Member American Academy of Dermatology E-newsletter. https://www.aad.org/members/publications /member-to-member/2013-archive/november-8-2013 /mohs-surgery-comes-under-the-microscope. Published November 8, 2013. Accessed August 10, 2015.
5. Ad Hoc Task Force, Connolly SM, Baker DR, et al. AAD/ACMS/ASDSA/ASMS 2012 appropriate use criteria for Mohs micrographic surgery: a report of the American Academy of Dermatology, American College of Mohs Surgery, American Society for Dermatologic Surgery Association, and the American Society for Mohs Surgery [published online ahead of print September 5, 2012]. J Am Acad Dermatol. 2012;67:531-550.
6. ACR Radiology Coding Source: CPT 2016 anticipated code changes. American College of Radiology Web site. http://www.acr.org/Advocacy/Economics-Health-Policy /Billing-Coding/Coding-Source-List/2015/Mar-Apr-2015 /CPT-2016-Anticipated-Code-Changes. Published March 2015. Accessed August 21, 2015.
1. Linos E, VanBeek M, Resneck JS Jr. A sudden and concerning increase in the use of electronic brachytherapy for skin cancer. JAMA Dermatol. 2015;151:699-700.
2. Bhatnagar A. Nonmelanoma skin cancer treated with electronic brachytherapy: results at 1 year [published online ahead of print January 9, 2013]. Brachytherapy. 2013;12:134-140.
3. Connor JT, Lewis RJ, Berry DA, et al. FDA recalls not as alarming as they seem. Arch Intern Med. 2011;171:1044-1046.
4. Goldman G. Mohs surgery comes under the microscope. Member to Member American Academy of Dermatology E-newsletter. https://www.aad.org/members/publications /member-to-member/2013-archive/november-8-2013 /mohs-surgery-comes-under-the-microscope. Published November 8, 2013. Accessed August 10, 2015.
5. Ad Hoc Task Force, Connolly SM, Baker DR, et al. AAD/ACMS/ASDSA/ASMS 2012 appropriate use criteria for Mohs micrographic surgery: a report of the American Academy of Dermatology, American College of Mohs Surgery, American Society for Dermatologic Surgery Association, and the American Society for Mohs Surgery [published online ahead of print September 5, 2012]. J Am Acad Dermatol. 2012;67:531-550.
6. ACR Radiology Coding Source: CPT 2016 anticipated code changes. American College of Radiology Web site. http://www.acr.org/Advocacy/Economics-Health-Policy /Billing-Coding/Coding-Source-List/2015/Mar-Apr-2015 /CPT-2016-Anticipated-Code-Changes. Published March 2015. Accessed August 21, 2015.
Tiering dermatologists without the benefit of true quality measures
Tiering is the “ranking” of physicians by insurance companies. These rankings are used to decide who gets to participate in the networks, how you get paid, the patient’s copay, and on and on. The rankings are also published. Insurance companies want to save money, and are attempting to do this under the guise of enhancing quality.
Fine, you say, I am an efficient dermatologist and ready to be ranked against anyone.
No, it is not fine, because there are no validated quality measures for dermatologists.
Well great, you say, then dermatologists can’t be ranked.
No, unfortunately, dermatologists are getting ranked anyway, and the process is little more than just making up a ranking.
Let me give you an example. Cigna has a two star system and ranks specialists according to “practice of evidence-based medicine” and “quality of care.” (See “How are specialists chosen for Cigna Care Designation” on Frequently Asked Questions on the Cigna web site). If there aren’t any quality measures for dermatologists, how can they do it? Well, they give the first star to a dermatologist if primary care doctors in their medical group check glycosylated hemoglobins and blood pressures.
Yes, some dermatologists get credit and a star for something that has nothing to do with them.
The second measure of quality is even more preposterous. Cigna uses cost-per-patient software, and the least expensive dermatologist gets the second star – no matter who or what they are treating, or what procedures they are performing.
This approach introduces multiple perversions into the system. First, the primary care doctors are under huge pressure to get their patients to comply with testing measures. Consequently, the systems they work for are insisting that they “fire” patients who do not come in for their checkups and get their blood checks.
Closer to home, dermatologists who do Mohs surgery full time, or who are in solo or small practices, or who prescribe expensive medications are penalized.
Cigna is one of six health insurers tiering dermatologists, but soon all insurers will be doing the same. Representatives from the American Academy of Dermatology, including myself, have met with Cigna and pointed out how meaningless it is to rank dermatologists without having specialty-specific quality parameters. The less-than-adequate response has been that “the lack of quality measures is a problem with several specialties.”
Given the lack of validated quality measures for dermatology, I find it bizarre that Health and Human Services Secretary Sylvia M. Burwell has set the goal of tying 85% of all traditional Medicare payments to quality or value by 2016 and 90% by 2018. I’m afraid this is going to be a very blunt axe resulting in splintered health care.
The AAD is doing its best to delay this deadline, at least until there are some relevant quality measures for dermatology, and has launched a major data collection initiative – DataDerm. Amassing that information should give us some decent benchmarks in a few years. DataDerm will ultimately provide benchmark reports, access to clinically relevant data, quality measurement, and information to improve patient care.
Until then we will argue, reason, and cajole as best we can. Meanwhile, the AAD will need your help with DataDerm, and it won’t do any good for you to stomp your feet and just say ‘no.’ In future columns, I will discuss the impacts of UnitedHealth Group’s misguided “lab benefit program” and the unfortunate Optum360 physician profiling software.
Dr. Coldiron is a past president of the American Academy of Dermatology. He is currently in private practice, but maintains a clinical assistant professorship at the University of Cincinnati. He cares for patients, teaches medical students and residents, and has several active clinical research projects. Dr. Coldiron is the author of more than 80 scientific letters, papers, and several book chapters, and he speaks frequently on a variety of topics. Reach him at [email protected]
Tiering is the “ranking” of physicians by insurance companies. These rankings are used to decide who gets to participate in the networks, how you get paid, the patient’s copay, and on and on. The rankings are also published. Insurance companies want to save money, and are attempting to do this under the guise of enhancing quality.
Fine, you say, I am an efficient dermatologist and ready to be ranked against anyone.
No, it is not fine, because there are no validated quality measures for dermatologists.
Well great, you say, then dermatologists can’t be ranked.
No, unfortunately, dermatologists are getting ranked anyway, and the process is little more than just making up a ranking.
Let me give you an example. Cigna has a two star system and ranks specialists according to “practice of evidence-based medicine” and “quality of care.” (See “How are specialists chosen for Cigna Care Designation” on Frequently Asked Questions on the Cigna web site). If there aren’t any quality measures for dermatologists, how can they do it? Well, they give the first star to a dermatologist if primary care doctors in their medical group check glycosylated hemoglobins and blood pressures.
Yes, some dermatologists get credit and a star for something that has nothing to do with them.
The second measure of quality is even more preposterous. Cigna uses cost-per-patient software, and the least expensive dermatologist gets the second star – no matter who or what they are treating, or what procedures they are performing.
This approach introduces multiple perversions into the system. First, the primary care doctors are under huge pressure to get their patients to comply with testing measures. Consequently, the systems they work for are insisting that they “fire” patients who do not come in for their checkups and get their blood checks.
Closer to home, dermatologists who do Mohs surgery full time, or who are in solo or small practices, or who prescribe expensive medications are penalized.
Cigna is one of six health insurers tiering dermatologists, but soon all insurers will be doing the same. Representatives from the American Academy of Dermatology, including myself, have met with Cigna and pointed out how meaningless it is to rank dermatologists without having specialty-specific quality parameters. The less-than-adequate response has been that “the lack of quality measures is a problem with several specialties.”
Given the lack of validated quality measures for dermatology, I find it bizarre that Health and Human Services Secretary Sylvia M. Burwell has set the goal of tying 85% of all traditional Medicare payments to quality or value by 2016 and 90% by 2018. I’m afraid this is going to be a very blunt axe resulting in splintered health care.
The AAD is doing its best to delay this deadline, at least until there are some relevant quality measures for dermatology, and has launched a major data collection initiative – DataDerm. Amassing that information should give us some decent benchmarks in a few years. DataDerm will ultimately provide benchmark reports, access to clinically relevant data, quality measurement, and information to improve patient care.
Until then we will argue, reason, and cajole as best we can. Meanwhile, the AAD will need your help with DataDerm, and it won’t do any good for you to stomp your feet and just say ‘no.’ In future columns, I will discuss the impacts of UnitedHealth Group’s misguided “lab benefit program” and the unfortunate Optum360 physician profiling software.
Dr. Coldiron is a past president of the American Academy of Dermatology. He is currently in private practice, but maintains a clinical assistant professorship at the University of Cincinnati. He cares for patients, teaches medical students and residents, and has several active clinical research projects. Dr. Coldiron is the author of more than 80 scientific letters, papers, and several book chapters, and he speaks frequently on a variety of topics. Reach him at [email protected]
Tiering is the “ranking” of physicians by insurance companies. These rankings are used to decide who gets to participate in the networks, how you get paid, the patient’s copay, and on and on. The rankings are also published. Insurance companies want to save money, and are attempting to do this under the guise of enhancing quality.
Fine, you say, I am an efficient dermatologist and ready to be ranked against anyone.
No, it is not fine, because there are no validated quality measures for dermatologists.
Well great, you say, then dermatologists can’t be ranked.
No, unfortunately, dermatologists are getting ranked anyway, and the process is little more than just making up a ranking.
Let me give you an example. Cigna has a two star system and ranks specialists according to “practice of evidence-based medicine” and “quality of care.” (See “How are specialists chosen for Cigna Care Designation” on Frequently Asked Questions on the Cigna web site). If there aren’t any quality measures for dermatologists, how can they do it? Well, they give the first star to a dermatologist if primary care doctors in their medical group check glycosylated hemoglobins and blood pressures.
Yes, some dermatologists get credit and a star for something that has nothing to do with them.
The second measure of quality is even more preposterous. Cigna uses cost-per-patient software, and the least expensive dermatologist gets the second star – no matter who or what they are treating, or what procedures they are performing.
This approach introduces multiple perversions into the system. First, the primary care doctors are under huge pressure to get their patients to comply with testing measures. Consequently, the systems they work for are insisting that they “fire” patients who do not come in for their checkups and get their blood checks.
Closer to home, dermatologists who do Mohs surgery full time, or who are in solo or small practices, or who prescribe expensive medications are penalized.
Cigna is one of six health insurers tiering dermatologists, but soon all insurers will be doing the same. Representatives from the American Academy of Dermatology, including myself, have met with Cigna and pointed out how meaningless it is to rank dermatologists without having specialty-specific quality parameters. The less-than-adequate response has been that “the lack of quality measures is a problem with several specialties.”
Given the lack of validated quality measures for dermatology, I find it bizarre that Health and Human Services Secretary Sylvia M. Burwell has set the goal of tying 85% of all traditional Medicare payments to quality or value by 2016 and 90% by 2018. I’m afraid this is going to be a very blunt axe resulting in splintered health care.
The AAD is doing its best to delay this deadline, at least until there are some relevant quality measures for dermatology, and has launched a major data collection initiative – DataDerm. Amassing that information should give us some decent benchmarks in a few years. DataDerm will ultimately provide benchmark reports, access to clinically relevant data, quality measurement, and information to improve patient care.
Until then we will argue, reason, and cajole as best we can. Meanwhile, the AAD will need your help with DataDerm, and it won’t do any good for you to stomp your feet and just say ‘no.’ In future columns, I will discuss the impacts of UnitedHealth Group’s misguided “lab benefit program” and the unfortunate Optum360 physician profiling software.
Dr. Coldiron is a past president of the American Academy of Dermatology. He is currently in private practice, but maintains a clinical assistant professorship at the University of Cincinnati. He cares for patients, teaches medical students and residents, and has several active clinical research projects. Dr. Coldiron is the author of more than 80 scientific letters, papers, and several book chapters, and he speaks frequently on a variety of topics. Reach him at [email protected]
Solitary confinement
A recent study released by the Association of State Correctional Administrators and researchers from Yale Law School has found that federal and state prisons are holding as many as 100,000 inmates in solitary confinement or isolated housing (“Large Number of Inmates in Solitary Poses Problem for Justice System, Study Says,” by Jess Bravin, Wall Street Journal, Sept. 2, 2015). This new data has turned up the volume of voices calling for abolishment of solitary confinement on the grounds that not only is it inhumane but also counterproductive.
Do you agree with abolitionists or are you sympathetic to some prison workers and administrators who say that there are situations in which social isolation is the best and maybe the only solution when a prisoner is a serious threat to the safety of his fellow inmates and staff?
While you are mulling over your answer, here is a related question more relevant to your own situation. How do you feel about solitary confinement (a.k.a., time-out) as a consequence for a misbehaving preschooler?
Do you think it is cruel and inhumane? Do you recommend it to parents as part of a comprehensive behavior-management strategy? Will many parents try it? Or, do they recoil and wonder why you would suggest that they become prison wardens in their own homes? If parents try it, is it effective?
In my experience, if done correctly in the right circumstances, time-out for a young child in his room – even if it requires latching the door – can be a safe, humane, and effective consequence for misbehavior. Sometimes, it is the only thing that works. But the devil is in the “ifs.”
First, time-out should be the last step in a comprehensive behavior-management strategy that begins with prevention – by assuring that the child is getting enough sleep and the right kind of attention from his parents who have expectations for their child that are appropriate for his age and temperament. The child’s environment and schedule should be structured to minimize the temptation to misbehave. Other less-drastic-sounding consequences must have been tried unsuccessfully. And ... both parent and child must be psychologically and developmentally normal.
Will brief episodes of solitary confinement make a young child feel insecure or unloved? Not if his parents make it clear by their behavior that she is loved and living in a stable environment, regardless of whether she is in time-out or not. Will time-out make a child hate her room? I’ve never seen it happen. If the child plays happily in her room during her sentence, does this render time-out ineffective? No, that’s a win-win situation. The misbehavior has stopped and the child is happy. Does this mean that time-out may not be a good deterrent? It might. But I have found that the only effective deterrent is consistent follow-up of every threat with the promised consequence – regardless of the consequence.
What if the child “destroys” his room during time-out? And is it safe to leave a child alone in his room? The solutions to these challenges can be found in Lowes or Home Depot.
I’m not going to take up any more of your recreational reading time describing the details of how time-out can be made more effective and palatable for parents. But it can be done and may require purchasing a latch or some kind of child-resistant door closure device. It will most likely be used briefly – if at all – but it can remain as a tangible reminder to the child that his parent follows up on his threats.
I won’t be surprised if some of you are shocked that I would advocate solitary confinement for young children. I am interested to hear what you recommend to parents who are struggling to keep their child’s behavior in bounds.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “Coping With a Picky Eater.”
A recent study released by the Association of State Correctional Administrators and researchers from Yale Law School has found that federal and state prisons are holding as many as 100,000 inmates in solitary confinement or isolated housing (“Large Number of Inmates in Solitary Poses Problem for Justice System, Study Says,” by Jess Bravin, Wall Street Journal, Sept. 2, 2015). This new data has turned up the volume of voices calling for abolishment of solitary confinement on the grounds that not only is it inhumane but also counterproductive.
Do you agree with abolitionists or are you sympathetic to some prison workers and administrators who say that there are situations in which social isolation is the best and maybe the only solution when a prisoner is a serious threat to the safety of his fellow inmates and staff?
While you are mulling over your answer, here is a related question more relevant to your own situation. How do you feel about solitary confinement (a.k.a., time-out) as a consequence for a misbehaving preschooler?
Do you think it is cruel and inhumane? Do you recommend it to parents as part of a comprehensive behavior-management strategy? Will many parents try it? Or, do they recoil and wonder why you would suggest that they become prison wardens in their own homes? If parents try it, is it effective?
In my experience, if done correctly in the right circumstances, time-out for a young child in his room – even if it requires latching the door – can be a safe, humane, and effective consequence for misbehavior. Sometimes, it is the only thing that works. But the devil is in the “ifs.”
First, time-out should be the last step in a comprehensive behavior-management strategy that begins with prevention – by assuring that the child is getting enough sleep and the right kind of attention from his parents who have expectations for their child that are appropriate for his age and temperament. The child’s environment and schedule should be structured to minimize the temptation to misbehave. Other less-drastic-sounding consequences must have been tried unsuccessfully. And ... both parent and child must be psychologically and developmentally normal.
Will brief episodes of solitary confinement make a young child feel insecure or unloved? Not if his parents make it clear by their behavior that she is loved and living in a stable environment, regardless of whether she is in time-out or not. Will time-out make a child hate her room? I’ve never seen it happen. If the child plays happily in her room during her sentence, does this render time-out ineffective? No, that’s a win-win situation. The misbehavior has stopped and the child is happy. Does this mean that time-out may not be a good deterrent? It might. But I have found that the only effective deterrent is consistent follow-up of every threat with the promised consequence – regardless of the consequence.
What if the child “destroys” his room during time-out? And is it safe to leave a child alone in his room? The solutions to these challenges can be found in Lowes or Home Depot.
I’m not going to take up any more of your recreational reading time describing the details of how time-out can be made more effective and palatable for parents. But it can be done and may require purchasing a latch or some kind of child-resistant door closure device. It will most likely be used briefly – if at all – but it can remain as a tangible reminder to the child that his parent follows up on his threats.
I won’t be surprised if some of you are shocked that I would advocate solitary confinement for young children. I am interested to hear what you recommend to parents who are struggling to keep their child’s behavior in bounds.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “Coping With a Picky Eater.”
A recent study released by the Association of State Correctional Administrators and researchers from Yale Law School has found that federal and state prisons are holding as many as 100,000 inmates in solitary confinement or isolated housing (“Large Number of Inmates in Solitary Poses Problem for Justice System, Study Says,” by Jess Bravin, Wall Street Journal, Sept. 2, 2015). This new data has turned up the volume of voices calling for abolishment of solitary confinement on the grounds that not only is it inhumane but also counterproductive.
Do you agree with abolitionists or are you sympathetic to some prison workers and administrators who say that there are situations in which social isolation is the best and maybe the only solution when a prisoner is a serious threat to the safety of his fellow inmates and staff?
While you are mulling over your answer, here is a related question more relevant to your own situation. How do you feel about solitary confinement (a.k.a., time-out) as a consequence for a misbehaving preschooler?
Do you think it is cruel and inhumane? Do you recommend it to parents as part of a comprehensive behavior-management strategy? Will many parents try it? Or, do they recoil and wonder why you would suggest that they become prison wardens in their own homes? If parents try it, is it effective?
In my experience, if done correctly in the right circumstances, time-out for a young child in his room – even if it requires latching the door – can be a safe, humane, and effective consequence for misbehavior. Sometimes, it is the only thing that works. But the devil is in the “ifs.”
First, time-out should be the last step in a comprehensive behavior-management strategy that begins with prevention – by assuring that the child is getting enough sleep and the right kind of attention from his parents who have expectations for their child that are appropriate for his age and temperament. The child’s environment and schedule should be structured to minimize the temptation to misbehave. Other less-drastic-sounding consequences must have been tried unsuccessfully. And ... both parent and child must be psychologically and developmentally normal.
Will brief episodes of solitary confinement make a young child feel insecure or unloved? Not if his parents make it clear by their behavior that she is loved and living in a stable environment, regardless of whether she is in time-out or not. Will time-out make a child hate her room? I’ve never seen it happen. If the child plays happily in her room during her sentence, does this render time-out ineffective? No, that’s a win-win situation. The misbehavior has stopped and the child is happy. Does this mean that time-out may not be a good deterrent? It might. But I have found that the only effective deterrent is consistent follow-up of every threat with the promised consequence – regardless of the consequence.
What if the child “destroys” his room during time-out? And is it safe to leave a child alone in his room? The solutions to these challenges can be found in Lowes or Home Depot.
I’m not going to take up any more of your recreational reading time describing the details of how time-out can be made more effective and palatable for parents. But it can be done and may require purchasing a latch or some kind of child-resistant door closure device. It will most likely be used briefly – if at all – but it can remain as a tangible reminder to the child that his parent follows up on his threats.
I won’t be surprised if some of you are shocked that I would advocate solitary confinement for young children. I am interested to hear what you recommend to parents who are struggling to keep their child’s behavior in bounds.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “Coping With a Picky Eater.”
Commentary to "CDC Will Soon Issue Guidelines for the Prevention of Surgical Site Infection"
Analyzing the Guidelines: It Can't All Be Level I
The demand for total joint arthroplasty continues to rise, resulting in a steady increase in the number of primary total hip and knee replacements every year. Unfortunately, as these numbers rise, so will the number of periprosthetic joint infections (PJIs). The economic burden and patient morbidity associated with PJI has resulted in the creation of multiple orthopedic societies and committees focused on formulating “best practice” guidelines in order to reduce the rates of PJI as much as possible.
The new guidelines for surgical site infection (SSI) prevention by the Centers for Disease Control and Prevention (CDC) recently forced the orthopedic community to critically analyze the current literature. Dr. Javad Parvizi’s editorial elegantly notes that many areas of infection prevention and treatment are not well evaluated, and many of our day-to-day practices are based on low levels of evidence. Level I studies continue to be a costly and time-consuming challenge due to the already very low SSI rate, and, in order to show an improvement in this rate, thousands of patients are required for study. This makes a multicenter approach necessary to ensure adequate power, and a multicenter study often requires significant resources and funding outlets. These requirements have resulted in many of our practice recommendations being based on retrospective reviews, which have inherent methodological limitations. The retrospective nature of these studies lacks the experimental design necessary to confidently make treatment recommendations; however, they do allow us to look at what strategies have been tried, and in essence, how well they worked. Although level III and IV studies do not allow us to compare treatments head to head, they do give us some insights into viable treatment strategies and should not be completely disregarded. The results of retrospective studies allow us to design prospective experiments based on what we have observed as successful treatment modalities in particular patient cohorts.
An alternative approach for evaluating new and existing treatment strategies is through basic science translational research. Future advancements in PJI diagnosis and treatment will likely be founded upon translational research efforts from clinician scientists testing treatment protocols both on the benchtop and in animal models. The most glaring knowledge gaps in PJI should be identified through the combined efforts of the CDC, the Musculoskeletal Infection Society, the American Academy of Orthopaedic Surgeons, and the Orthopaedic Research Society. Coordinated efforts should be made and strategies executed to systematically fund translational projects that answer these questions. Translational studies will be able to safely and methodically evaluate new and even established treatment protocols for PJI in a cost-effective manner.
We have made great strides in the prevention and treatment of PJI over the past 2 decades. When working together as a cohesive profession, we will undoubtedly continue to advance our knowledge base and improve treatment recommendations for our patients.
Analyzing the Guidelines: It Can't All Be Level I
The demand for total joint arthroplasty continues to rise, resulting in a steady increase in the number of primary total hip and knee replacements every year. Unfortunately, as these numbers rise, so will the number of periprosthetic joint infections (PJIs). The economic burden and patient morbidity associated with PJI has resulted in the creation of multiple orthopedic societies and committees focused on formulating “best practice” guidelines in order to reduce the rates of PJI as much as possible.
The new guidelines for surgical site infection (SSI) prevention by the Centers for Disease Control and Prevention (CDC) recently forced the orthopedic community to critically analyze the current literature. Dr. Javad Parvizi’s editorial elegantly notes that many areas of infection prevention and treatment are not well evaluated, and many of our day-to-day practices are based on low levels of evidence. Level I studies continue to be a costly and time-consuming challenge due to the already very low SSI rate, and, in order to show an improvement in this rate, thousands of patients are required for study. This makes a multicenter approach necessary to ensure adequate power, and a multicenter study often requires significant resources and funding outlets. These requirements have resulted in many of our practice recommendations being based on retrospective reviews, which have inherent methodological limitations. The retrospective nature of these studies lacks the experimental design necessary to confidently make treatment recommendations; however, they do allow us to look at what strategies have been tried, and in essence, how well they worked. Although level III and IV studies do not allow us to compare treatments head to head, they do give us some insights into viable treatment strategies and should not be completely disregarded. The results of retrospective studies allow us to design prospective experiments based on what we have observed as successful treatment modalities in particular patient cohorts.
An alternative approach for evaluating new and existing treatment strategies is through basic science translational research. Future advancements in PJI diagnosis and treatment will likely be founded upon translational research efforts from clinician scientists testing treatment protocols both on the benchtop and in animal models. The most glaring knowledge gaps in PJI should be identified through the combined efforts of the CDC, the Musculoskeletal Infection Society, the American Academy of Orthopaedic Surgeons, and the Orthopaedic Research Society. Coordinated efforts should be made and strategies executed to systematically fund translational projects that answer these questions. Translational studies will be able to safely and methodically evaluate new and even established treatment protocols for PJI in a cost-effective manner.
We have made great strides in the prevention and treatment of PJI over the past 2 decades. When working together as a cohesive profession, we will undoubtedly continue to advance our knowledge base and improve treatment recommendations for our patients.
Analyzing the Guidelines: It Can't All Be Level I
The demand for total joint arthroplasty continues to rise, resulting in a steady increase in the number of primary total hip and knee replacements every year. Unfortunately, as these numbers rise, so will the number of periprosthetic joint infections (PJIs). The economic burden and patient morbidity associated with PJI has resulted in the creation of multiple orthopedic societies and committees focused on formulating “best practice” guidelines in order to reduce the rates of PJI as much as possible.
The new guidelines for surgical site infection (SSI) prevention by the Centers for Disease Control and Prevention (CDC) recently forced the orthopedic community to critically analyze the current literature. Dr. Javad Parvizi’s editorial elegantly notes that many areas of infection prevention and treatment are not well evaluated, and many of our day-to-day practices are based on low levels of evidence. Level I studies continue to be a costly and time-consuming challenge due to the already very low SSI rate, and, in order to show an improvement in this rate, thousands of patients are required for study. This makes a multicenter approach necessary to ensure adequate power, and a multicenter study often requires significant resources and funding outlets. These requirements have resulted in many of our practice recommendations being based on retrospective reviews, which have inherent methodological limitations. The retrospective nature of these studies lacks the experimental design necessary to confidently make treatment recommendations; however, they do allow us to look at what strategies have been tried, and in essence, how well they worked. Although level III and IV studies do not allow us to compare treatments head to head, they do give us some insights into viable treatment strategies and should not be completely disregarded. The results of retrospective studies allow us to design prospective experiments based on what we have observed as successful treatment modalities in particular patient cohorts.
An alternative approach for evaluating new and existing treatment strategies is through basic science translational research. Future advancements in PJI diagnosis and treatment will likely be founded upon translational research efforts from clinician scientists testing treatment protocols both on the benchtop and in animal models. The most glaring knowledge gaps in PJI should be identified through the combined efforts of the CDC, the Musculoskeletal Infection Society, the American Academy of Orthopaedic Surgeons, and the Orthopaedic Research Society. Coordinated efforts should be made and strategies executed to systematically fund translational projects that answer these questions. Translational studies will be able to safely and methodically evaluate new and even established treatment protocols for PJI in a cost-effective manner.
We have made great strides in the prevention and treatment of PJI over the past 2 decades. When working together as a cohesive profession, we will undoubtedly continue to advance our knowledge base and improve treatment recommendations for our patients.
Doctor, monitor thyself: The promise and perils of self-monitoring apps
I walked into my primary care doctor’s office the other day. I’m still young and healthy and a doctor, so making a doctor’s appointment is a rare event. As with most patients, it was symptoms that motivated me. I’m having a common, yet annoying problem: PVCs or premature ventricular contractions. I’ve had them on and off for a while, but now every time I push to my limit when exercising or double my espresso, they come back.
“Do you have them right now?” my doc asked me. “No. Just had them yesterday, though,” I replied. Dr. A is about my age and perhaps in even better shape than I am. He’s certainly smarter than I. Tall and athletic, he doesn’t wear a lab coat but is always immaculately dressed in a button-down shirt and light sweater. He walks from around his standing desk and hands me an iPhone cover. “Why don’t you try this?” Being the director of innovation, I recognized the device: It was a heart monitor. “Just download the app and track your EKG when you get symptoms,” he said.
I turned it over in my hands. It’s flimsier than I remembered from tech conferences. It’s even too small to fit on my iPhone 6+, although it doesn’t technically have to be on the phone to work. When I got home I downloaded the app and uploaded my first tracing. While right next to my phone, I gently touched the two sensors with my fingers. My tracing appeared on the screen. Wow, those are PQRS waves. (Indeed, I was a intern, too, once). The app requires that you submit the first recording for review before you can use it to verify that the tracing is normal.
The next morning, I hit the bike with everything I had, driving my heart rate to more than 170. (150 is working hard, 160 is painful, 170 is unsustainable for me. Sure enough, my PVCs returned later that day. Later that night, they were driving me crazy. I got out of bed and grabbed my phone. There, at 2 a.m., the glow of my iPhone lighting my bedroom, I could see my EKG: 1,2,3, PVC, 1,2,3, PVC. Wow! This is cool.
As the innovation director, most of the devices I review are from the viewpoint of a physician. This was different. I was clearly the patient in this story, and the device was meant to help me.
We talk about how digital medicine empowers our patients, and I suppose this is the idea. I now have access to diagnostic tools that ordinarily only my doctor would have. Yet, even though I clearly had PVCs this time, the app sends me back the same note as the first time I used it: “Normal EKG.” That’s true, technically. However, it’s easy for even a dermatologist to see that this tracing was different from the first.
I knew that quadrigeminy was a common and benign tracing, but if I wasn’t a physician (or hadn’t been trained by a great upper-level resident as an intern), then I might have been too anxious to fall back asleep.
Elizabeth Holmes in a recent Wall Street Journal article advocated for patients to be able to choose their own blood tests (and someday check their own blood, using her device, one presumes). Health care technology conferences abound with devices that promise to put the power of diagnostics in patients’ hands. But, as we all know, getting data is the easy part. It’s interpreting data – that’s why docs get the big bucks.
We also understand that often the best test is no test at all. If we randomly sampled EKGs from a population of everyone, we might find a few interesting tracings, most of which would have no meaningful consequences. Except if you’re a patient and your EKG has a funny blip on your at-home EKG device, or your iPhone dermatology app incorrectly reports a seborrheic keratosis as a possible melanoma. In such cases, these technologies have not empowered the user; rather, they’ve created needless anxiety, none of which existed before. The result is often more work for us physicians who must now spend time explaining why the patient’s finding is not important, and worse, might end up ordering more (real) tests to disconfirm what the at-home home test found.
Later, I brought my iPhone to my follow-up appointment and shared the tracings with my primary care doctor. “Looks like PVCs,” he confirmed, “and it looks normal.” But I already knew that.
Dr. Benabio is a partner physician in the department of dermatology of the Southern California Permanente Group in San Diego, and a volunteer clinical assistant professor at the University of California, San Diego. Dr. Benabio is @dermdoc on Twitter.
I walked into my primary care doctor’s office the other day. I’m still young and healthy and a doctor, so making a doctor’s appointment is a rare event. As with most patients, it was symptoms that motivated me. I’m having a common, yet annoying problem: PVCs or premature ventricular contractions. I’ve had them on and off for a while, but now every time I push to my limit when exercising or double my espresso, they come back.
“Do you have them right now?” my doc asked me. “No. Just had them yesterday, though,” I replied. Dr. A is about my age and perhaps in even better shape than I am. He’s certainly smarter than I. Tall and athletic, he doesn’t wear a lab coat but is always immaculately dressed in a button-down shirt and light sweater. He walks from around his standing desk and hands me an iPhone cover. “Why don’t you try this?” Being the director of innovation, I recognized the device: It was a heart monitor. “Just download the app and track your EKG when you get symptoms,” he said.
I turned it over in my hands. It’s flimsier than I remembered from tech conferences. It’s even too small to fit on my iPhone 6+, although it doesn’t technically have to be on the phone to work. When I got home I downloaded the app and uploaded my first tracing. While right next to my phone, I gently touched the two sensors with my fingers. My tracing appeared on the screen. Wow, those are PQRS waves. (Indeed, I was a intern, too, once). The app requires that you submit the first recording for review before you can use it to verify that the tracing is normal.
The next morning, I hit the bike with everything I had, driving my heart rate to more than 170. (150 is working hard, 160 is painful, 170 is unsustainable for me. Sure enough, my PVCs returned later that day. Later that night, they were driving me crazy. I got out of bed and grabbed my phone. There, at 2 a.m., the glow of my iPhone lighting my bedroom, I could see my EKG: 1,2,3, PVC, 1,2,3, PVC. Wow! This is cool.
As the innovation director, most of the devices I review are from the viewpoint of a physician. This was different. I was clearly the patient in this story, and the device was meant to help me.
We talk about how digital medicine empowers our patients, and I suppose this is the idea. I now have access to diagnostic tools that ordinarily only my doctor would have. Yet, even though I clearly had PVCs this time, the app sends me back the same note as the first time I used it: “Normal EKG.” That’s true, technically. However, it’s easy for even a dermatologist to see that this tracing was different from the first.
I knew that quadrigeminy was a common and benign tracing, but if I wasn’t a physician (or hadn’t been trained by a great upper-level resident as an intern), then I might have been too anxious to fall back asleep.
Elizabeth Holmes in a recent Wall Street Journal article advocated for patients to be able to choose their own blood tests (and someday check their own blood, using her device, one presumes). Health care technology conferences abound with devices that promise to put the power of diagnostics in patients’ hands. But, as we all know, getting data is the easy part. It’s interpreting data – that’s why docs get the big bucks.
We also understand that often the best test is no test at all. If we randomly sampled EKGs from a population of everyone, we might find a few interesting tracings, most of which would have no meaningful consequences. Except if you’re a patient and your EKG has a funny blip on your at-home EKG device, or your iPhone dermatology app incorrectly reports a seborrheic keratosis as a possible melanoma. In such cases, these technologies have not empowered the user; rather, they’ve created needless anxiety, none of which existed before. The result is often more work for us physicians who must now spend time explaining why the patient’s finding is not important, and worse, might end up ordering more (real) tests to disconfirm what the at-home home test found.
Later, I brought my iPhone to my follow-up appointment and shared the tracings with my primary care doctor. “Looks like PVCs,” he confirmed, “and it looks normal.” But I already knew that.
Dr. Benabio is a partner physician in the department of dermatology of the Southern California Permanente Group in San Diego, and a volunteer clinical assistant professor at the University of California, San Diego. Dr. Benabio is @dermdoc on Twitter.
I walked into my primary care doctor’s office the other day. I’m still young and healthy and a doctor, so making a doctor’s appointment is a rare event. As with most patients, it was symptoms that motivated me. I’m having a common, yet annoying problem: PVCs or premature ventricular contractions. I’ve had them on and off for a while, but now every time I push to my limit when exercising or double my espresso, they come back.
“Do you have them right now?” my doc asked me. “No. Just had them yesterday, though,” I replied. Dr. A is about my age and perhaps in even better shape than I am. He’s certainly smarter than I. Tall and athletic, he doesn’t wear a lab coat but is always immaculately dressed in a button-down shirt and light sweater. He walks from around his standing desk and hands me an iPhone cover. “Why don’t you try this?” Being the director of innovation, I recognized the device: It was a heart monitor. “Just download the app and track your EKG when you get symptoms,” he said.
I turned it over in my hands. It’s flimsier than I remembered from tech conferences. It’s even too small to fit on my iPhone 6+, although it doesn’t technically have to be on the phone to work. When I got home I downloaded the app and uploaded my first tracing. While right next to my phone, I gently touched the two sensors with my fingers. My tracing appeared on the screen. Wow, those are PQRS waves. (Indeed, I was a intern, too, once). The app requires that you submit the first recording for review before you can use it to verify that the tracing is normal.
The next morning, I hit the bike with everything I had, driving my heart rate to more than 170. (150 is working hard, 160 is painful, 170 is unsustainable for me. Sure enough, my PVCs returned later that day. Later that night, they were driving me crazy. I got out of bed and grabbed my phone. There, at 2 a.m., the glow of my iPhone lighting my bedroom, I could see my EKG: 1,2,3, PVC, 1,2,3, PVC. Wow! This is cool.
As the innovation director, most of the devices I review are from the viewpoint of a physician. This was different. I was clearly the patient in this story, and the device was meant to help me.
We talk about how digital medicine empowers our patients, and I suppose this is the idea. I now have access to diagnostic tools that ordinarily only my doctor would have. Yet, even though I clearly had PVCs this time, the app sends me back the same note as the first time I used it: “Normal EKG.” That’s true, technically. However, it’s easy for even a dermatologist to see that this tracing was different from the first.
I knew that quadrigeminy was a common and benign tracing, but if I wasn’t a physician (or hadn’t been trained by a great upper-level resident as an intern), then I might have been too anxious to fall back asleep.
Elizabeth Holmes in a recent Wall Street Journal article advocated for patients to be able to choose their own blood tests (and someday check their own blood, using her device, one presumes). Health care technology conferences abound with devices that promise to put the power of diagnostics in patients’ hands. But, as we all know, getting data is the easy part. It’s interpreting data – that’s why docs get the big bucks.
We also understand that often the best test is no test at all. If we randomly sampled EKGs from a population of everyone, we might find a few interesting tracings, most of which would have no meaningful consequences. Except if you’re a patient and your EKG has a funny blip on your at-home EKG device, or your iPhone dermatology app incorrectly reports a seborrheic keratosis as a possible melanoma. In such cases, these technologies have not empowered the user; rather, they’ve created needless anxiety, none of which existed before. The result is often more work for us physicians who must now spend time explaining why the patient’s finding is not important, and worse, might end up ordering more (real) tests to disconfirm what the at-home home test found.
Later, I brought my iPhone to my follow-up appointment and shared the tracings with my primary care doctor. “Looks like PVCs,” he confirmed, “and it looks normal.” But I already knew that.
Dr. Benabio is a partner physician in the department of dermatology of the Southern California Permanente Group in San Diego, and a volunteer clinical assistant professor at the University of California, San Diego. Dr. Benabio is @dermdoc on Twitter.
Death and dying
Learning about death and dying in residency is perhaps one of the hardest things about being a doctor. ... This list might make it a tiny bit easier.
1. The Hippocratic oath challenges us to be teachers not only to students, but also to our patients – especially to our dying patients. Remember you are teachers.
2. Nurses spend the most time with your patients; utilize them and learn from them. Nurses will make you better teachers and physicians.
3. When a patient is dying, hold that person’s hand if family isn’t around. Touch your patient.
4. Accompany your residents, fellows, or attending physicians to deliver bad news.
5. Ask to debrief after a patient dies.
6. While discussing treatment or prognosis with families, pay attention to the emotional data in the room. Tears should prompt tissues or hand holding. A wrinkled forehead or fearful face warrants a pause in conversation for the family to absorb the content. Tears don’t mean to hurry.
7. Attempt to understand your patient’s expectations. In other words, learn what the family’s goals are for treatment.
8. When a patient dies, reflect upon it in moderation. Don’t just move on to the next task. It’s okay to feel and to grieve … you are human.
9. When families declare DNR [do not resuscitate], don’t ask them repeatedly if they are sure. Also, make certain that they know they can change their minds at any time. Respect a patient’s values and wishes.
10. Take the time to have the difficult conversations early in diagnosis so families know what to expect. This empowers decisions that are proactive as opposed to reactive. Be proactive in your role as a teacher.
11. When discussing options, talk about what you CAN do before you talk about what you CAN’T do.
12. Withdrawing treatment and forgoing treatment are the same thing ethically and legally, but not emotionally.
13. When your patient is actively dying, see it out. Stay with the family, even if it’s time to go home.
14. When the family prays, be present.
15. Palliative care is neither hospice nor social work.
16. Ask your dying patients if they are afraid of anything – if the moment presents itself. Answer questions about death or find someone who can answer their questions.
17. No patient should die in pain. The doctrine of double effect allows a caregiver to provide medication for pain even though it may hasten death.
18. For the dying child, ask the family where they want their child to die. Don’t assume the family wants the death of their child to be at home or in the hospital. Ask.
19. Transitioning from treatment-oriented management to comfort care does not ever mean “there is nothing we can do.”
20. Lastly, and most importantly, I leave you with a question that should be in the back of our minds regarding quality of life and treatment options: Just because we can, should we?
Dr. Morvant is a second-year pediatric resident at Monroe Carell Jr. Children’s Hospital at Vanderbilt, Nashville, Tenn. E-mail her at [email protected].
Learning about death and dying in residency is perhaps one of the hardest things about being a doctor. ... This list might make it a tiny bit easier.
1. The Hippocratic oath challenges us to be teachers not only to students, but also to our patients – especially to our dying patients. Remember you are teachers.
2. Nurses spend the most time with your patients; utilize them and learn from them. Nurses will make you better teachers and physicians.
3. When a patient is dying, hold that person’s hand if family isn’t around. Touch your patient.
4. Accompany your residents, fellows, or attending physicians to deliver bad news.
5. Ask to debrief after a patient dies.
6. While discussing treatment or prognosis with families, pay attention to the emotional data in the room. Tears should prompt tissues or hand holding. A wrinkled forehead or fearful face warrants a pause in conversation for the family to absorb the content. Tears don’t mean to hurry.
7. Attempt to understand your patient’s expectations. In other words, learn what the family’s goals are for treatment.
8. When a patient dies, reflect upon it in moderation. Don’t just move on to the next task. It’s okay to feel and to grieve … you are human.
9. When families declare DNR [do not resuscitate], don’t ask them repeatedly if they are sure. Also, make certain that they know they can change their minds at any time. Respect a patient’s values and wishes.
10. Take the time to have the difficult conversations early in diagnosis so families know what to expect. This empowers decisions that are proactive as opposed to reactive. Be proactive in your role as a teacher.
11. When discussing options, talk about what you CAN do before you talk about what you CAN’T do.
12. Withdrawing treatment and forgoing treatment are the same thing ethically and legally, but not emotionally.
13. When your patient is actively dying, see it out. Stay with the family, even if it’s time to go home.
14. When the family prays, be present.
15. Palliative care is neither hospice nor social work.
16. Ask your dying patients if they are afraid of anything – if the moment presents itself. Answer questions about death or find someone who can answer their questions.
17. No patient should die in pain. The doctrine of double effect allows a caregiver to provide medication for pain even though it may hasten death.
18. For the dying child, ask the family where they want their child to die. Don’t assume the family wants the death of their child to be at home or in the hospital. Ask.
19. Transitioning from treatment-oriented management to comfort care does not ever mean “there is nothing we can do.”
20. Lastly, and most importantly, I leave you with a question that should be in the back of our minds regarding quality of life and treatment options: Just because we can, should we?
Dr. Morvant is a second-year pediatric resident at Monroe Carell Jr. Children’s Hospital at Vanderbilt, Nashville, Tenn. E-mail her at [email protected].
Learning about death and dying in residency is perhaps one of the hardest things about being a doctor. ... This list might make it a tiny bit easier.
1. The Hippocratic oath challenges us to be teachers not only to students, but also to our patients – especially to our dying patients. Remember you are teachers.
2. Nurses spend the most time with your patients; utilize them and learn from them. Nurses will make you better teachers and physicians.
3. When a patient is dying, hold that person’s hand if family isn’t around. Touch your patient.
4. Accompany your residents, fellows, or attending physicians to deliver bad news.
5. Ask to debrief after a patient dies.
6. While discussing treatment or prognosis with families, pay attention to the emotional data in the room. Tears should prompt tissues or hand holding. A wrinkled forehead or fearful face warrants a pause in conversation for the family to absorb the content. Tears don’t mean to hurry.
7. Attempt to understand your patient’s expectations. In other words, learn what the family’s goals are for treatment.
8. When a patient dies, reflect upon it in moderation. Don’t just move on to the next task. It’s okay to feel and to grieve … you are human.
9. When families declare DNR [do not resuscitate], don’t ask them repeatedly if they are sure. Also, make certain that they know they can change their minds at any time. Respect a patient’s values and wishes.
10. Take the time to have the difficult conversations early in diagnosis so families know what to expect. This empowers decisions that are proactive as opposed to reactive. Be proactive in your role as a teacher.
11. When discussing options, talk about what you CAN do before you talk about what you CAN’T do.
12. Withdrawing treatment and forgoing treatment are the same thing ethically and legally, but not emotionally.
13. When your patient is actively dying, see it out. Stay with the family, even if it’s time to go home.
14. When the family prays, be present.
15. Palliative care is neither hospice nor social work.
16. Ask your dying patients if they are afraid of anything – if the moment presents itself. Answer questions about death or find someone who can answer their questions.
17. No patient should die in pain. The doctrine of double effect allows a caregiver to provide medication for pain even though it may hasten death.
18. For the dying child, ask the family where they want their child to die. Don’t assume the family wants the death of their child to be at home or in the hospital. Ask.
19. Transitioning from treatment-oriented management to comfort care does not ever mean “there is nothing we can do.”
20. Lastly, and most importantly, I leave you with a question that should be in the back of our minds regarding quality of life and treatment options: Just because we can, should we?
Dr. Morvant is a second-year pediatric resident at Monroe Carell Jr. Children’s Hospital at Vanderbilt, Nashville, Tenn. E-mail her at [email protected].
Seeing the ob.gyn. field through a med student’s eyes
Each fall, as part of their residency applications, medical students around the country struggle to describe the reasons they have picked their chosen specialty. We all have a sense of what attracts us to a field, or to anything for that matter, and it is often difficult to put into words. That is why the personal essay, as a part of the application, is so challenging and often so bland.
Occasionally though, we are privileged to read an essay that connects with the deeper motivations that lead us to choose the paths we follow. When we read such an essay, it can serve to refresh and replenish the idealism that we all have and that is sometimes a struggle to maintain amid concerns about ACOs, RVUs, EHRs, ICD-10, and the rest of the alphabet soup that requires attention and effort, but that can distract us from our core mission of caring for patients and block us from participating in the wonder and majesty that such care can bring.
This is such an essay, and to read it is like drinking a refreshing glass of water on a hot day.
BY ALIZA MACHEFSKY
In Judaism, a baby is named within the context of a prayer for the mother and child’s health: “May He who blessed our fathers ... bless the woman who has given birth (mother’s name) together with the daughter who was born to her in an auspicious time, her name shall be called in Israel: (child’s name) ...” This prayer simultaneously acknowledges the risks and the possibility of labor – on one side the birth of a new life and continued health of the mother; on the other side the possibility of death and sadness.
Family planning and safe delivery impact not only the individual woman and her family but also society as a whole. The United Nations prioritized this concern in their fifth Millennium Development Goal of improving maternal health and decreasing maternal mortality by increasing access to reproductive health services, family planning, and skilled antenatal care in the developing world.
The obstetrician delivering a baby practices medicine at the edge of opposites: the promise of new life and the possibility of impending death; the end of intrauterine existence for the fetus and the beginning of life outside the womb; the end of singlehood and the beginning of parenthood. All physicians are privy to vulnerable aspects of their patients’ lives, all will see them naked and listen to their fears, but it is rare to share in the joy that comes from shepherding a successful pregnancy and guiding the simultaneously joyous and terrifying event of birth. The assisting physician operates at the place where scientific knowledge and medical skills meet the mystery of human existence.
What draws me to the field of obstetrics and gynecology is the unique combination of being the physician who can provide counseling and primary care throughout a woman’s reproductive and postmenopausal life, while at the same time provide surgical and interventional procedures at critical times in a woman’s life. Ob.gyns. straddle the best possibilities medicine has to offer.
What I find so appealing about ob.gyn. – what had me scuttling off to the labor and delivery floor during slow afternoons on internal medicine, or requesting opportunities to have more exposure to the ob.gyn. subspecialties – is how unique, cutting edge, and imperative each aspect of ob.gyn. and its subspecialties are.
On the labor and delivery floor, I felt privileged to be a part of the birth and safe delivery of a new life. While working with the reproductive endocrinology and infertility team, I saw physicians help infertile patients have a chance of beginning a family. On urogynecology, I witnessed a skilled surgeon perform a precise procedure that enabled a marathoner to race again without fear of urinary incontinence. Rotating through gynecology-oncology, I saw the combination of cutting edge robotic surgery and compassionate care drastically improve the lives of oncology patients. While watching anatomy scans in the maternal-fetal medicine clinic, I was in awe of the beating chambers of each baby’s heart. And at the vaginitis clinic I learned how careful questioning, complete exams, and meticulous study of specimens could reveal vulvar and vaginal pathology that is often overlooked, but when discovered can have a huge impact on quality of life.
I want to be an ob.gyn. who has the capacity to council and teach women about their own health care and to provide comfort and calm during the excitement, anxiety, and pain of birth. But I also want to have the knowledge and skills to make difficult decisions, the capacity to recognize what needs to be done in times of crisis, and the surgical skills to intervene in the right way. I look forward to being a part of a specialty that is filled with compassionate learning, teamwork, and empathy worthy of the women who seek our care.
Ms. Machefsky is a fourth-year medical student at Drexel University in Philadelphia and a Gold Humanism Honor Society member. She recently welcomed the birth of her first child. Dr. Skolnick is a professor of family and community medicine at Temple University in Philadelphia and associate director of the Family Medicine Residency Program at Abington Jefferson Health.
Each fall, as part of their residency applications, medical students around the country struggle to describe the reasons they have picked their chosen specialty. We all have a sense of what attracts us to a field, or to anything for that matter, and it is often difficult to put into words. That is why the personal essay, as a part of the application, is so challenging and often so bland.
Occasionally though, we are privileged to read an essay that connects with the deeper motivations that lead us to choose the paths we follow. When we read such an essay, it can serve to refresh and replenish the idealism that we all have and that is sometimes a struggle to maintain amid concerns about ACOs, RVUs, EHRs, ICD-10, and the rest of the alphabet soup that requires attention and effort, but that can distract us from our core mission of caring for patients and block us from participating in the wonder and majesty that such care can bring.
This is such an essay, and to read it is like drinking a refreshing glass of water on a hot day.
BY ALIZA MACHEFSKY
In Judaism, a baby is named within the context of a prayer for the mother and child’s health: “May He who blessed our fathers ... bless the woman who has given birth (mother’s name) together with the daughter who was born to her in an auspicious time, her name shall be called in Israel: (child’s name) ...” This prayer simultaneously acknowledges the risks and the possibility of labor – on one side the birth of a new life and continued health of the mother; on the other side the possibility of death and sadness.
Family planning and safe delivery impact not only the individual woman and her family but also society as a whole. The United Nations prioritized this concern in their fifth Millennium Development Goal of improving maternal health and decreasing maternal mortality by increasing access to reproductive health services, family planning, and skilled antenatal care in the developing world.
The obstetrician delivering a baby practices medicine at the edge of opposites: the promise of new life and the possibility of impending death; the end of intrauterine existence for the fetus and the beginning of life outside the womb; the end of singlehood and the beginning of parenthood. All physicians are privy to vulnerable aspects of their patients’ lives, all will see them naked and listen to their fears, but it is rare to share in the joy that comes from shepherding a successful pregnancy and guiding the simultaneously joyous and terrifying event of birth. The assisting physician operates at the place where scientific knowledge and medical skills meet the mystery of human existence.
What draws me to the field of obstetrics and gynecology is the unique combination of being the physician who can provide counseling and primary care throughout a woman’s reproductive and postmenopausal life, while at the same time provide surgical and interventional procedures at critical times in a woman’s life. Ob.gyns. straddle the best possibilities medicine has to offer.
What I find so appealing about ob.gyn. – what had me scuttling off to the labor and delivery floor during slow afternoons on internal medicine, or requesting opportunities to have more exposure to the ob.gyn. subspecialties – is how unique, cutting edge, and imperative each aspect of ob.gyn. and its subspecialties are.
On the labor and delivery floor, I felt privileged to be a part of the birth and safe delivery of a new life. While working with the reproductive endocrinology and infertility team, I saw physicians help infertile patients have a chance of beginning a family. On urogynecology, I witnessed a skilled surgeon perform a precise procedure that enabled a marathoner to race again without fear of urinary incontinence. Rotating through gynecology-oncology, I saw the combination of cutting edge robotic surgery and compassionate care drastically improve the lives of oncology patients. While watching anatomy scans in the maternal-fetal medicine clinic, I was in awe of the beating chambers of each baby’s heart. And at the vaginitis clinic I learned how careful questioning, complete exams, and meticulous study of specimens could reveal vulvar and vaginal pathology that is often overlooked, but when discovered can have a huge impact on quality of life.
I want to be an ob.gyn. who has the capacity to council and teach women about their own health care and to provide comfort and calm during the excitement, anxiety, and pain of birth. But I also want to have the knowledge and skills to make difficult decisions, the capacity to recognize what needs to be done in times of crisis, and the surgical skills to intervene in the right way. I look forward to being a part of a specialty that is filled with compassionate learning, teamwork, and empathy worthy of the women who seek our care.
Ms. Machefsky is a fourth-year medical student at Drexel University in Philadelphia and a Gold Humanism Honor Society member. She recently welcomed the birth of her first child. Dr. Skolnick is a professor of family and community medicine at Temple University in Philadelphia and associate director of the Family Medicine Residency Program at Abington Jefferson Health.
Each fall, as part of their residency applications, medical students around the country struggle to describe the reasons they have picked their chosen specialty. We all have a sense of what attracts us to a field, or to anything for that matter, and it is often difficult to put into words. That is why the personal essay, as a part of the application, is so challenging and often so bland.
Occasionally though, we are privileged to read an essay that connects with the deeper motivations that lead us to choose the paths we follow. When we read such an essay, it can serve to refresh and replenish the idealism that we all have and that is sometimes a struggle to maintain amid concerns about ACOs, RVUs, EHRs, ICD-10, and the rest of the alphabet soup that requires attention and effort, but that can distract us from our core mission of caring for patients and block us from participating in the wonder and majesty that such care can bring.
This is such an essay, and to read it is like drinking a refreshing glass of water on a hot day.
BY ALIZA MACHEFSKY
In Judaism, a baby is named within the context of a prayer for the mother and child’s health: “May He who blessed our fathers ... bless the woman who has given birth (mother’s name) together with the daughter who was born to her in an auspicious time, her name shall be called in Israel: (child’s name) ...” This prayer simultaneously acknowledges the risks and the possibility of labor – on one side the birth of a new life and continued health of the mother; on the other side the possibility of death and sadness.
Family planning and safe delivery impact not only the individual woman and her family but also society as a whole. The United Nations prioritized this concern in their fifth Millennium Development Goal of improving maternal health and decreasing maternal mortality by increasing access to reproductive health services, family planning, and skilled antenatal care in the developing world.
The obstetrician delivering a baby practices medicine at the edge of opposites: the promise of new life and the possibility of impending death; the end of intrauterine existence for the fetus and the beginning of life outside the womb; the end of singlehood and the beginning of parenthood. All physicians are privy to vulnerable aspects of their patients’ lives, all will see them naked and listen to their fears, but it is rare to share in the joy that comes from shepherding a successful pregnancy and guiding the simultaneously joyous and terrifying event of birth. The assisting physician operates at the place where scientific knowledge and medical skills meet the mystery of human existence.
What draws me to the field of obstetrics and gynecology is the unique combination of being the physician who can provide counseling and primary care throughout a woman’s reproductive and postmenopausal life, while at the same time provide surgical and interventional procedures at critical times in a woman’s life. Ob.gyns. straddle the best possibilities medicine has to offer.
What I find so appealing about ob.gyn. – what had me scuttling off to the labor and delivery floor during slow afternoons on internal medicine, or requesting opportunities to have more exposure to the ob.gyn. subspecialties – is how unique, cutting edge, and imperative each aspect of ob.gyn. and its subspecialties are.
On the labor and delivery floor, I felt privileged to be a part of the birth and safe delivery of a new life. While working with the reproductive endocrinology and infertility team, I saw physicians help infertile patients have a chance of beginning a family. On urogynecology, I witnessed a skilled surgeon perform a precise procedure that enabled a marathoner to race again without fear of urinary incontinence. Rotating through gynecology-oncology, I saw the combination of cutting edge robotic surgery and compassionate care drastically improve the lives of oncology patients. While watching anatomy scans in the maternal-fetal medicine clinic, I was in awe of the beating chambers of each baby’s heart. And at the vaginitis clinic I learned how careful questioning, complete exams, and meticulous study of specimens could reveal vulvar and vaginal pathology that is often overlooked, but when discovered can have a huge impact on quality of life.
I want to be an ob.gyn. who has the capacity to council and teach women about their own health care and to provide comfort and calm during the excitement, anxiety, and pain of birth. But I also want to have the knowledge and skills to make difficult decisions, the capacity to recognize what needs to be done in times of crisis, and the surgical skills to intervene in the right way. I look forward to being a part of a specialty that is filled with compassionate learning, teamwork, and empathy worthy of the women who seek our care.
Ms. Machefsky is a fourth-year medical student at Drexel University in Philadelphia and a Gold Humanism Honor Society member. She recently welcomed the birth of her first child. Dr. Skolnick is a professor of family and community medicine at Temple University in Philadelphia and associate director of the Family Medicine Residency Program at Abington Jefferson Health.
Carnosine
A powerful endogenous antioxidant found most abundantly in mammalian tissues, especially brain and skeletal muscle tissue, carnosine is a dipeptide of alanine and histidine.1,2,3,4,5.
Carnosine was first isolated in 1900 by the Russian scientist Gulewitsch as a substance extracted from muscle tissue.6,4. L-carnosine (beta-alanyl-L-histidine) is the synthetic version identical to the natural form alpha-alanyl-L-histidine.7 Carnosine has long been reputed to confer immunomodulating, wound healing, antiglycating, and antineoplastic effects.2 Several reports have shown that carnosine can accelerate the healing of surface skin wounds and burns.4,8
Wound healing
An early study by Nagai et al. in 1986 on carnosine in wound healing showed that rats treated locally with carnosine exhibited greater tensile skin strength at an incision site after hydrocortisone had been administered to hinder healing. The investigators concluded that carnosine bolsters wound healing by stimulating early effusion by histamine and of collagen biosynthesis by beta-alanine. They also found that the compound significantly augmented granulation inhibited by cortisone, mitomycin C, 5-fluorouracil, and bleomycin.9
Studies by Fitzpatrick and Fisher in the early 1980s revealed that carnosine acts as a histidine reserve in relation to histamine production during trauma, suggesting a role for carnosine in wound healing.10,11
In 2012, Ansurudeen et al. examined the effects of carnosine in wound healing in a diabetic mouse model. Carnosine was applied locally and injected daily, yielding significant amelioration in wound healing, with analysis revealing elevated expression of growth factors and cytokines implicated in wound healing. The investigators also observed that carnosine supported cell viability in the presence of high glucose in human dermal fibroblasts and microvascular endothelial cells in vitro.2
Other findings with implications for cutaneous therapy
In 2006, Babizhayev reported that the L-carnosine-related peptidomimetic N-acetylcarnosine (N-acetyl-beta-alanyl-L-histidine) can act as a timed-release (carrier) stable version of L-carnosine in cosmetic preparations, including lubricants.6 Babizhayev et al. have since claimed that they have developed a technology using imidazole-containing dipeptide-based compounds (including L-carnosine and derivatives) that enhances protein hydration in photoaged skin.12,13,14
A double-blind comparative study conducted by Dieamant et al. in 2008 in 124 volunteers with sensitive skin aimed to evaluate the therapeutic potential of the combination of the antioxidant L-carnosine and neuromodulatory Rhodiola rosea. For 28 days, the groups of 62 received twice-daily applications of the 1% combination formulation or placebo. Skin barrier function (reduction of transepidermal water loss) improved in the treatment group, and favorable subjective responses regarding skin dryness were reported. Discomfort after the stinging test was also reduced. In vitro results showed that the release of proopiomelanocortin peptides was spurred by treatment, with the elevated levels of neuropeptides and cytokines produced by keratinocytes exposed to UV radiation returning to normal.15
Two years later, Renner et al. showed that carnosine hindered tumor growth in vivo in an NIH3T3-HER2/neu mouse model. They contended that this naturally occurring dipeptide warrants increased consideration and study for its potential as an anticancer agent.16
In 2012, Federici et al. conducted a randomized, evaluator-blinded, controlled comparative trial over 1month to assess the efficacy of twice-daily topical urea 5% with arginine and carnosine (Ureadin Rx) as compared with twice-daily application of a glycerol-based emollient topical product (Dexeryl) in treating xerosis in 40 type 2 diabetes patients (40-75 years of age). Use of the carnosine-containing formulation yielded significantly greater hydration and an 89% decline in Dryness Areas Severity Index (DASI) scores, compared with baseline. The DASI score after 4 weeks of treatment was much lower in the treatment group than the control group. The Visual Analog Scale (VAS) score was also significantly higher in the Ureadin group than the Dexeryl group. The investigators concluded that the topical application of a urea 5%, arginine, and carnosine cream enhances skin hydration and relieves dryness in type 2 diabetic patients in comparison with a control glycerol-based emollient formulation.17
Antiaging potential
In 1993, Reeve et al. showed that dietary or topically applied carnosine potentiated the contact hypersensitivity reaction in hairless mice and prevented the systemic inhibition of this reaction after dorsal skin exposure to UVB. Carnosine was found to also prevent the systemic suppression provoked by the topical application of a lotion containing cis-urocanic acid.3
Carnosine was a key active ingredient in antiaging products evaluated by Kaczvinsky et al. in 2009 in two double-blind, randomized, controlled, split-face studies. The researchers used the Fast Optical in vivo Topometry of Human Skin (FOITS) technique to measure changes in periorbital wrinkles in the two studies in women between the ages of 30 and 70 years old (study 1, n = 42; study 2, n = 35). They reported that 4 weeks of treatment with the test products, which contained niacinamide, the peptides Pal-KT and Pal-KTTKS, and carnosine, ameliorated periorbital skin, enhancing smoothness and diminishing larger wrinkle depth.18
In 2012, Babizhayev et al. conducted a 4-month randomized, double-blind, controlled study with 42 subjects to evaluate the effects on skin aging of oral nonhydrolyzed carnosine (Can-C Plus formulation). Skin parameters exhibited a consistent and significant improvement during 3 months of supplementation in the treatment group, compared with the placebo group, with overall skin appearance enhanced and fine lines diminished based on visual inspection. There were no reports of adverse effects. The investigators concluded that supplementation with nonhydrolyzed carnosine or carcinine in patented oral formulations has potential as an agent for antiaging purposes.19
Two years later, Emanuele et al. conducted an experimental double-blind irradiation study to compare a complex novel topical product (TPF50) consisting of three active ingredients (traditional physical sunscreens, SPF 50; a liposome-encapsulated DNA repair enzymes complex – photolyase, endonuclease, and 8-oxoguanine glycosylase [OGG1]; and a robust antioxidant complex containing carnosine, arazine, and ergothionine) to available DNA repair and antioxidant and growth factor topical products. They found that the new topical agent was the most effective product in reducing three molecular markers (cyclobutane pyrimidine dimers, protein carbonylation, and 8-oxo-7,8-dihydro-2’-deoxyguanosine) in human skin biopsies. The researchers concluded that the carnosine-containing formulation enhances the genomic and proteomic integrity of skin cells after continual UV exposure, suggesting its potential efficacy in lowering the risk of UV-induced cutaneous aging and nonmelanoma skin cancer.20
Conclusion
Carnosine is an intriguing compound with well-documented antioxidant and wound healing activity. While more research is necessary to determine its wider applications in dermatology, recent work in formulating topical products to impart antiaging effects appears to show promise.
References
1. Nutr. Res. Pract. 2011;5:421-8.
2. Amino Acids 2012;43:127-34.
4. Mol. Aspects Med. 1992;13:379-444.
5. Am. J. Ther. 2012;19:e69-89.
7. J. Cosmet. Dermatol. 2004;3:26-34.
8. Nihon Yakurigaku Zasshi. 1992;100:165-72.
12. Int. J. Cosmet. Sci. 2011;33:1-16.
13. Crit. Rev. Ther. Drug Carrier Syst. 2011;28:203-53.
14. Crit. Rev. Ther. Drug Carrier Syst. 2010;27:85-154.
15. J. Cosmet. Dermatol. 2008;7:112-9.
18. J. Cosmet. Dermatol. 2009;8:228-33.
19. J. Dermatolog. Treat. 2012;23:345-84.
20. J. Drugs Dermatol. 2014;13:309-14.
Dr. Baumann is chief executive officer of the Baumann Cosmetic & Research Institute in the Design District in Miami. She founded the Cosmetic Dermatology Center at the University of Miami in 1997. Dr. Baumann wrote the textbook, “Cosmetic Dermatology: Principles and Practice” (New York: McGraw-Hill, 2002), and a book for consumers, “The Skin Type Solution” (New York: Bantam Dell, 2006). She has contributed to the Cosmeceutical Critique column in Dermatology News since January 2001. Her latest book, “Cosmeceuticals and Cosmetic Ingredients,” was published in November 2014. Dr. Baumann has received funding for clinical grants from Allergan, Aveeno, Avon Products, Evolus, Galderma, GlaxoSmithKline, Kythera Biopharmaceuticals, Mary Kay, Medicis Pharmaceuticals, Neutrogena, Philosophy, Topix Pharmaceuticals, and Unilever.
A powerful endogenous antioxidant found most abundantly in mammalian tissues, especially brain and skeletal muscle tissue, carnosine is a dipeptide of alanine and histidine.1,2,3,4,5.
Carnosine was first isolated in 1900 by the Russian scientist Gulewitsch as a substance extracted from muscle tissue.6,4. L-carnosine (beta-alanyl-L-histidine) is the synthetic version identical to the natural form alpha-alanyl-L-histidine.7 Carnosine has long been reputed to confer immunomodulating, wound healing, antiglycating, and antineoplastic effects.2 Several reports have shown that carnosine can accelerate the healing of surface skin wounds and burns.4,8
Wound healing
An early study by Nagai et al. in 1986 on carnosine in wound healing showed that rats treated locally with carnosine exhibited greater tensile skin strength at an incision site after hydrocortisone had been administered to hinder healing. The investigators concluded that carnosine bolsters wound healing by stimulating early effusion by histamine and of collagen biosynthesis by beta-alanine. They also found that the compound significantly augmented granulation inhibited by cortisone, mitomycin C, 5-fluorouracil, and bleomycin.9
Studies by Fitzpatrick and Fisher in the early 1980s revealed that carnosine acts as a histidine reserve in relation to histamine production during trauma, suggesting a role for carnosine in wound healing.10,11
In 2012, Ansurudeen et al. examined the effects of carnosine in wound healing in a diabetic mouse model. Carnosine was applied locally and injected daily, yielding significant amelioration in wound healing, with analysis revealing elevated expression of growth factors and cytokines implicated in wound healing. The investigators also observed that carnosine supported cell viability in the presence of high glucose in human dermal fibroblasts and microvascular endothelial cells in vitro.2
Other findings with implications for cutaneous therapy
In 2006, Babizhayev reported that the L-carnosine-related peptidomimetic N-acetylcarnosine (N-acetyl-beta-alanyl-L-histidine) can act as a timed-release (carrier) stable version of L-carnosine in cosmetic preparations, including lubricants.6 Babizhayev et al. have since claimed that they have developed a technology using imidazole-containing dipeptide-based compounds (including L-carnosine and derivatives) that enhances protein hydration in photoaged skin.12,13,14
A double-blind comparative study conducted by Dieamant et al. in 2008 in 124 volunteers with sensitive skin aimed to evaluate the therapeutic potential of the combination of the antioxidant L-carnosine and neuromodulatory Rhodiola rosea. For 28 days, the groups of 62 received twice-daily applications of the 1% combination formulation or placebo. Skin barrier function (reduction of transepidermal water loss) improved in the treatment group, and favorable subjective responses regarding skin dryness were reported. Discomfort after the stinging test was also reduced. In vitro results showed that the release of proopiomelanocortin peptides was spurred by treatment, with the elevated levels of neuropeptides and cytokines produced by keratinocytes exposed to UV radiation returning to normal.15
Two years later, Renner et al. showed that carnosine hindered tumor growth in vivo in an NIH3T3-HER2/neu mouse model. They contended that this naturally occurring dipeptide warrants increased consideration and study for its potential as an anticancer agent.16
In 2012, Federici et al. conducted a randomized, evaluator-blinded, controlled comparative trial over 1month to assess the efficacy of twice-daily topical urea 5% with arginine and carnosine (Ureadin Rx) as compared with twice-daily application of a glycerol-based emollient topical product (Dexeryl) in treating xerosis in 40 type 2 diabetes patients (40-75 years of age). Use of the carnosine-containing formulation yielded significantly greater hydration and an 89% decline in Dryness Areas Severity Index (DASI) scores, compared with baseline. The DASI score after 4 weeks of treatment was much lower in the treatment group than the control group. The Visual Analog Scale (VAS) score was also significantly higher in the Ureadin group than the Dexeryl group. The investigators concluded that the topical application of a urea 5%, arginine, and carnosine cream enhances skin hydration and relieves dryness in type 2 diabetic patients in comparison with a control glycerol-based emollient formulation.17
Antiaging potential
In 1993, Reeve et al. showed that dietary or topically applied carnosine potentiated the contact hypersensitivity reaction in hairless mice and prevented the systemic inhibition of this reaction after dorsal skin exposure to UVB. Carnosine was found to also prevent the systemic suppression provoked by the topical application of a lotion containing cis-urocanic acid.3
Carnosine was a key active ingredient in antiaging products evaluated by Kaczvinsky et al. in 2009 in two double-blind, randomized, controlled, split-face studies. The researchers used the Fast Optical in vivo Topometry of Human Skin (FOITS) technique to measure changes in periorbital wrinkles in the two studies in women between the ages of 30 and 70 years old (study 1, n = 42; study 2, n = 35). They reported that 4 weeks of treatment with the test products, which contained niacinamide, the peptides Pal-KT and Pal-KTTKS, and carnosine, ameliorated periorbital skin, enhancing smoothness and diminishing larger wrinkle depth.18
In 2012, Babizhayev et al. conducted a 4-month randomized, double-blind, controlled study with 42 subjects to evaluate the effects on skin aging of oral nonhydrolyzed carnosine (Can-C Plus formulation). Skin parameters exhibited a consistent and significant improvement during 3 months of supplementation in the treatment group, compared with the placebo group, with overall skin appearance enhanced and fine lines diminished based on visual inspection. There were no reports of adverse effects. The investigators concluded that supplementation with nonhydrolyzed carnosine or carcinine in patented oral formulations has potential as an agent for antiaging purposes.19
Two years later, Emanuele et al. conducted an experimental double-blind irradiation study to compare a complex novel topical product (TPF50) consisting of three active ingredients (traditional physical sunscreens, SPF 50; a liposome-encapsulated DNA repair enzymes complex – photolyase, endonuclease, and 8-oxoguanine glycosylase [OGG1]; and a robust antioxidant complex containing carnosine, arazine, and ergothionine) to available DNA repair and antioxidant and growth factor topical products. They found that the new topical agent was the most effective product in reducing three molecular markers (cyclobutane pyrimidine dimers, protein carbonylation, and 8-oxo-7,8-dihydro-2’-deoxyguanosine) in human skin biopsies. The researchers concluded that the carnosine-containing formulation enhances the genomic and proteomic integrity of skin cells after continual UV exposure, suggesting its potential efficacy in lowering the risk of UV-induced cutaneous aging and nonmelanoma skin cancer.20
Conclusion
Carnosine is an intriguing compound with well-documented antioxidant and wound healing activity. While more research is necessary to determine its wider applications in dermatology, recent work in formulating topical products to impart antiaging effects appears to show promise.
References
1. Nutr. Res. Pract. 2011;5:421-8.
2. Amino Acids 2012;43:127-34.
4. Mol. Aspects Med. 1992;13:379-444.
5. Am. J. Ther. 2012;19:e69-89.
7. J. Cosmet. Dermatol. 2004;3:26-34.
8. Nihon Yakurigaku Zasshi. 1992;100:165-72.
12. Int. J. Cosmet. Sci. 2011;33:1-16.
13. Crit. Rev. Ther. Drug Carrier Syst. 2011;28:203-53.
14. Crit. Rev. Ther. Drug Carrier Syst. 2010;27:85-154.
15. J. Cosmet. Dermatol. 2008;7:112-9.
18. J. Cosmet. Dermatol. 2009;8:228-33.
19. J. Dermatolog. Treat. 2012;23:345-84.
20. J. Drugs Dermatol. 2014;13:309-14.
Dr. Baumann is chief executive officer of the Baumann Cosmetic & Research Institute in the Design District in Miami. She founded the Cosmetic Dermatology Center at the University of Miami in 1997. Dr. Baumann wrote the textbook, “Cosmetic Dermatology: Principles and Practice” (New York: McGraw-Hill, 2002), and a book for consumers, “The Skin Type Solution” (New York: Bantam Dell, 2006). She has contributed to the Cosmeceutical Critique column in Dermatology News since January 2001. Her latest book, “Cosmeceuticals and Cosmetic Ingredients,” was published in November 2014. Dr. Baumann has received funding for clinical grants from Allergan, Aveeno, Avon Products, Evolus, Galderma, GlaxoSmithKline, Kythera Biopharmaceuticals, Mary Kay, Medicis Pharmaceuticals, Neutrogena, Philosophy, Topix Pharmaceuticals, and Unilever.
A powerful endogenous antioxidant found most abundantly in mammalian tissues, especially brain and skeletal muscle tissue, carnosine is a dipeptide of alanine and histidine.1,2,3,4,5.
Carnosine was first isolated in 1900 by the Russian scientist Gulewitsch as a substance extracted from muscle tissue.6,4. L-carnosine (beta-alanyl-L-histidine) is the synthetic version identical to the natural form alpha-alanyl-L-histidine.7 Carnosine has long been reputed to confer immunomodulating, wound healing, antiglycating, and antineoplastic effects.2 Several reports have shown that carnosine can accelerate the healing of surface skin wounds and burns.4,8
Wound healing
An early study by Nagai et al. in 1986 on carnosine in wound healing showed that rats treated locally with carnosine exhibited greater tensile skin strength at an incision site after hydrocortisone had been administered to hinder healing. The investigators concluded that carnosine bolsters wound healing by stimulating early effusion by histamine and of collagen biosynthesis by beta-alanine. They also found that the compound significantly augmented granulation inhibited by cortisone, mitomycin C, 5-fluorouracil, and bleomycin.9
Studies by Fitzpatrick and Fisher in the early 1980s revealed that carnosine acts as a histidine reserve in relation to histamine production during trauma, suggesting a role for carnosine in wound healing.10,11
In 2012, Ansurudeen et al. examined the effects of carnosine in wound healing in a diabetic mouse model. Carnosine was applied locally and injected daily, yielding significant amelioration in wound healing, with analysis revealing elevated expression of growth factors and cytokines implicated in wound healing. The investigators also observed that carnosine supported cell viability in the presence of high glucose in human dermal fibroblasts and microvascular endothelial cells in vitro.2
Other findings with implications for cutaneous therapy
In 2006, Babizhayev reported that the L-carnosine-related peptidomimetic N-acetylcarnosine (N-acetyl-beta-alanyl-L-histidine) can act as a timed-release (carrier) stable version of L-carnosine in cosmetic preparations, including lubricants.6 Babizhayev et al. have since claimed that they have developed a technology using imidazole-containing dipeptide-based compounds (including L-carnosine and derivatives) that enhances protein hydration in photoaged skin.12,13,14
A double-blind comparative study conducted by Dieamant et al. in 2008 in 124 volunteers with sensitive skin aimed to evaluate the therapeutic potential of the combination of the antioxidant L-carnosine and neuromodulatory Rhodiola rosea. For 28 days, the groups of 62 received twice-daily applications of the 1% combination formulation or placebo. Skin barrier function (reduction of transepidermal water loss) improved in the treatment group, and favorable subjective responses regarding skin dryness were reported. Discomfort after the stinging test was also reduced. In vitro results showed that the release of proopiomelanocortin peptides was spurred by treatment, with the elevated levels of neuropeptides and cytokines produced by keratinocytes exposed to UV radiation returning to normal.15
Two years later, Renner et al. showed that carnosine hindered tumor growth in vivo in an NIH3T3-HER2/neu mouse model. They contended that this naturally occurring dipeptide warrants increased consideration and study for its potential as an anticancer agent.16
In 2012, Federici et al. conducted a randomized, evaluator-blinded, controlled comparative trial over 1month to assess the efficacy of twice-daily topical urea 5% with arginine and carnosine (Ureadin Rx) as compared with twice-daily application of a glycerol-based emollient topical product (Dexeryl) in treating xerosis in 40 type 2 diabetes patients (40-75 years of age). Use of the carnosine-containing formulation yielded significantly greater hydration and an 89% decline in Dryness Areas Severity Index (DASI) scores, compared with baseline. The DASI score after 4 weeks of treatment was much lower in the treatment group than the control group. The Visual Analog Scale (VAS) score was also significantly higher in the Ureadin group than the Dexeryl group. The investigators concluded that the topical application of a urea 5%, arginine, and carnosine cream enhances skin hydration and relieves dryness in type 2 diabetic patients in comparison with a control glycerol-based emollient formulation.17
Antiaging potential
In 1993, Reeve et al. showed that dietary or topically applied carnosine potentiated the contact hypersensitivity reaction in hairless mice and prevented the systemic inhibition of this reaction after dorsal skin exposure to UVB. Carnosine was found to also prevent the systemic suppression provoked by the topical application of a lotion containing cis-urocanic acid.3
Carnosine was a key active ingredient in antiaging products evaluated by Kaczvinsky et al. in 2009 in two double-blind, randomized, controlled, split-face studies. The researchers used the Fast Optical in vivo Topometry of Human Skin (FOITS) technique to measure changes in periorbital wrinkles in the two studies in women between the ages of 30 and 70 years old (study 1, n = 42; study 2, n = 35). They reported that 4 weeks of treatment with the test products, which contained niacinamide, the peptides Pal-KT and Pal-KTTKS, and carnosine, ameliorated periorbital skin, enhancing smoothness and diminishing larger wrinkle depth.18
In 2012, Babizhayev et al. conducted a 4-month randomized, double-blind, controlled study with 42 subjects to evaluate the effects on skin aging of oral nonhydrolyzed carnosine (Can-C Plus formulation). Skin parameters exhibited a consistent and significant improvement during 3 months of supplementation in the treatment group, compared with the placebo group, with overall skin appearance enhanced and fine lines diminished based on visual inspection. There were no reports of adverse effects. The investigators concluded that supplementation with nonhydrolyzed carnosine or carcinine in patented oral formulations has potential as an agent for antiaging purposes.19
Two years later, Emanuele et al. conducted an experimental double-blind irradiation study to compare a complex novel topical product (TPF50) consisting of three active ingredients (traditional physical sunscreens, SPF 50; a liposome-encapsulated DNA repair enzymes complex – photolyase, endonuclease, and 8-oxoguanine glycosylase [OGG1]; and a robust antioxidant complex containing carnosine, arazine, and ergothionine) to available DNA repair and antioxidant and growth factor topical products. They found that the new topical agent was the most effective product in reducing three molecular markers (cyclobutane pyrimidine dimers, protein carbonylation, and 8-oxo-7,8-dihydro-2’-deoxyguanosine) in human skin biopsies. The researchers concluded that the carnosine-containing formulation enhances the genomic and proteomic integrity of skin cells after continual UV exposure, suggesting its potential efficacy in lowering the risk of UV-induced cutaneous aging and nonmelanoma skin cancer.20
Conclusion
Carnosine is an intriguing compound with well-documented antioxidant and wound healing activity. While more research is necessary to determine its wider applications in dermatology, recent work in formulating topical products to impart antiaging effects appears to show promise.
References
1. Nutr. Res. Pract. 2011;5:421-8.
2. Amino Acids 2012;43:127-34.
4. Mol. Aspects Med. 1992;13:379-444.
5. Am. J. Ther. 2012;19:e69-89.
7. J. Cosmet. Dermatol. 2004;3:26-34.
8. Nihon Yakurigaku Zasshi. 1992;100:165-72.
12. Int. J. Cosmet. Sci. 2011;33:1-16.
13. Crit. Rev. Ther. Drug Carrier Syst. 2011;28:203-53.
14. Crit. Rev. Ther. Drug Carrier Syst. 2010;27:85-154.
15. J. Cosmet. Dermatol. 2008;7:112-9.
18. J. Cosmet. Dermatol. 2009;8:228-33.
19. J. Dermatolog. Treat. 2012;23:345-84.
20. J. Drugs Dermatol. 2014;13:309-14.
Dr. Baumann is chief executive officer of the Baumann Cosmetic & Research Institute in the Design District in Miami. She founded the Cosmetic Dermatology Center at the University of Miami in 1997. Dr. Baumann wrote the textbook, “Cosmetic Dermatology: Principles and Practice” (New York: McGraw-Hill, 2002), and a book for consumers, “The Skin Type Solution” (New York: Bantam Dell, 2006). She has contributed to the Cosmeceutical Critique column in Dermatology News since January 2001. Her latest book, “Cosmeceuticals and Cosmetic Ingredients,” was published in November 2014. Dr. Baumann has received funding for clinical grants from Allergan, Aveeno, Avon Products, Evolus, Galderma, GlaxoSmithKline, Kythera Biopharmaceuticals, Mary Kay, Medicis Pharmaceuticals, Neutrogena, Philosophy, Topix Pharmaceuticals, and Unilever.
