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Here’s what we can do to minimize the daily hassle of prior authorizations
Insistence on prior authorization (PA) when prescribing certain pharmaceuticals has grown considerably over the past 5 years. Most requests for PA are issued by pharmacy benefit management (PBM) companies that have been contracted by an insurer. A PA can be triggered when a physician orders:
• a brand-name medication
• a medication not on the formulary of the PBM
• a quantity above an arbitrary ceiling
• a medication that has multiple indications (that is, the PBM won’t pay for indication X but will pay for indication Y).
What are the problems caused by PAs? I outline a number of them, and their potential consequences, in this “Commentary.” What can we do, in our practices, to lessen the disruption they cause and the time and money they cost us (Box)? 
’Prior authorization’—a misleading, disingenuous term
The physician’s prescription is legal authorization for the patient to receive the medicine. It would be more accurate if PBMs labeled what they do “prior approval for reimbursement.”
PBMs exist to manipulate and coordinate the demand for medication generated, on one hand, by patients and their physician and, on the other, by the cost of supplying portion of that demand. The cost of a medication to the PBM is controlled by:
• negotiating rebates with drug manufacturers
• advantageous contracting with pharmacies
• denying payment, when feasible, using the PA system.
The goal of the PA is to boost the profits of the PBM—not to pay for the best fit between the needs of the patient and the medications available, as determined by the treating physician.
The games begin!
The PA process usually begins when the patient goes to the pharmacy, prescription in hand, and gives it to the pharmacist, who enters it into the computer. At that point, if the PBM has put a block on paying for the medication, 3 things happen in sequence:
1. The computer alerts the pharmacist about the block (or that a higher copay is required).
2. The pharmacist tells the patient something about the block—although not necessarily the whole story.
3. The pharmacist tells the physician’s office (by fax, e-mail, or telephone) that the PBM wants authorization and that the physician must call a toll-free telephone number to obtain that authorization.
The physician’s office then makes the initial call to the PBM. That call can take 10 to 20 minutes, answering preliminary questions. The call generates a questionnaire from the PBM that is faxed to the office, filled with questions that one could characterize as loaded. The questionnaire is intended to provide grounds for disapproval or approval—not to obtain in-depth understanding of the individual patient’s needs.
Playing pieces on a chessboard
Note that the physician and pharmacist, thrust unwillingly into the middle of this gambit, spend considerable uncompensated time on the PA process. (Primary care physicians and their nursing and clerical staff, spent, on average, 19.8 hours a week obtaining PAs in 2006.1)
PBMs have shifted responsibility for communication to physicians and pharmacists by requiring that the physician always contact the PBM. A PBM will not contact a physician directly, either to begin the PA or ask questions during the process.
If the request for authorization is denied, what’s the outcome? The physician’s office and the pharmacist have spent uncompensated time taking action that resulted in the PBM and the insurer improving their bottom line without benefit to anyone else.
Communication breakdown. The cumbersome, multistep PA process opens the door to miscommunication. This happens often, I’ve found: The physician wastes time because the pharmacist passed along an incomplete message, or a patient gives vague or confusing information in trying to transmit what the pharmacist said. Sometimes, when physicians get through to a live person at the PBM, they are told that the pharmacist misinformed the office: No, the medication didn’t require PA after all.
Why can’t PBMs streamline the process, sparing busy physicians’ offices the time spent on initial telephone calls, by installing software that would allow the pharmacist who first encounters a payment block to, with a few keystrokes, instantly send the relevant questionnaire to the physician’s fax machine or computer?
Obstacles to satisfaction
From the perspective of the patient, the word that probably best characterizes his emotional response to the PA process is “helpless.” He wasn’t expecting a denial; it’s likely that he hadn’t been fully or clearly informed at the time he selected the insurer that he might someday face such an obstacle. Even though he had a legal prescription, written by a physician, any attempt to go back to the insurer or the PBM to complain is rarely successful. If he tried, he would likely get no satisfaction: The clerk at the other end of the telephone would swiftly inform him that there were a number of complicated rules, policies, or “step programs” that must be adhered to before the PBM pays for a prescription.
Even if the medication is covered, the patient might be told that there are “quantity limits” that prevent reimbursement for the prescription as written—limits that were not made explicit when he signed up for the insurance plan. All these obstacles can generate confusion, anxiety, frustration, and anger—understandably so.
The ‘safety’ catch. Obstacles do not necessarily end when the medication is approved; such approval is merely a “coverage eligibility review.” In addition, PBMs make it clear that every prescription also undergoes a so-called safety review by a pharmacist before it is dispensed. If the PBM’s pharmacist identifies a safety concern, the medication “might not be dispensed,” Express Scripts says, “or your patient could receive less than what you prescribed.”
That is an ominous statement: The PBM is openly and arrogantly taking for itself the right to unilaterally determine what is safe and to override the physician’s judgment as it sees fit. We all know that there are relative risks in taking most medications that we prescribe; the degree of that risk needs to be carefully calculated against the likely benefits for a given patient, whose detailed history is known to the treating physician. History and risk-benefit calculation are not available to the reviewing pharmacist. The existence of “safety concerns” by itself, outside of the full context of care, is insufficient justification for a PBM to stop payment for a medication.
“Approved”—but… Equally ominous is that, after a medication has been approved through the PA process, some PBMs add these words in their notification to the physician:
This medication is approved for coverage until [insert date],
or until coverage for the medication is no longer available
under the benefit plan or the medication becomes subject
to a pharmacy benefit coverage requirement, such as supply
limits or notification, whichever occurs first.
In other words, the approval is provisional, and shouldn’t be counted on to remain in place for the entire period for which dispensing has been approved. Imagine the uncertainty and anxiety of a patient who reads that statement and realizes that the medication that, at last, has relieved her symptoms might be withdrawn from coverage at any time for reasons unrelated to effectiveness.
The patient can appeal the decision of a PBM or insurer that refuses to pay for a medication, but that patient, and his physician, might ask themselves whether the considerable time required to appeal is justified, given that the criteria used for denials are arbitrary and one-sided.
Serious consequences can ensue after a PBM denies coverage for a medication. Some patients cannot afford hundreds of dollars out of pocket for 1 month of 1 medicine. When their supply runs out, they become vulnerable to symptoms of withdrawal or exacerbation of underlying illness.
Armchair care. A PBM, after it has denied approval of payment, might “ask” the physician to choose another medication that the PBM does cover. For a non-physician administrator who has never seen the patient to propose such a switch is micromanagement—to say the least. Such an action is also disrespectful of the physician’s judgment.
Loss of possible placebo effect. If the physician goes along and makes the switch proposed by the PBM, the patient will know that the new medication is the physician’s second (or third) choice. Any potential positive placebo effect is thus lost. Does that matter? It might—a lot.
Most physicians would be glad to have a positive placebo effect assist or augment the physiologic effects of a medication, especially at the start of treatment when the patient might feel helpless or hopeless. Such negative feelings are likely to be magnified if the patient knows that he has been coerced into taking a second-line therapy. A positive placebo effect, on the other hand, might well have lowered levels of his stress hormones for a few weeks—and that effect could have made a positive difference.
Casualties for the physician are time, money, and morale. PAs consume large chunks of time. Some of the PA forms require that 20 or more questions be answered; a few of those questions can take significant time to answer, having to look through a thick chart to research prior medications.
PAs also cost money: directly to pay the salary of staff that share the PA work, indirectly by crowding out the doctor’s potential billing time and replacing it with uncompensated PA work.
Worse, in my opinion, is the cost to morale. Physicians express their annoyance, aggravation, frustration, and anger at meetings and in postings at the end of journal articles on the subject. Some speak of becoming numb from the daily hassle of dealing with PAs.2 The disrespect for the physician’s decisions inherent in the PA process, the implicit humiliation of appealing to someone who doesn’t know the patient to approve payment for a medication that’s been legally prescribed, and the cost in time and money all provoke emotions that are damaging to morale.
Much to do in limited time
Time isn’t elastic; setting priorities is vital. Most physicians would, I think, agree that their priorities are:
• giving patients adequate time at office visits
• returning calls from patients with urgent messages
• communicating with professional colleagues about shared patients
• returning calls from pharmacists who have questions about prescriptions
• researching solutions to clinical problems
• keeping up with the literature.
Physicians must decide where completing PAs—intrusive, time-consuming, and a threat to morale—fits in that list. Should PAs be allowed to supplant, or delay, the completion of other vital, positive clinical priorities?
Until we are able to introduce improvements that speed up the PA process, patients will have the supply of their medications disrupted and physicians will pay in time, money, and morale.
Disclosure
Dr. Mode reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.
1. Casalino L, Nicholson S, Gans DN, et al. What does it cost physician practices to interact with health insurance plans? Health Aff (Millwood). 2009;28(4):533-542.
2. Bendix J. Curing the prior authorization headache. Med Econ. October 10, 2013. http://medicaleconomics.modernmedicine.com/medical-economics/content/ tags/americas-health-insurance-plans/curing-priorauthorization-headache?page=full. Accessed December 2, 2014.
Insistence on prior authorization (PA) when prescribing certain pharmaceuticals has grown considerably over the past 5 years. Most requests for PA are issued by pharmacy benefit management (PBM) companies that have been contracted by an insurer. A PA can be triggered when a physician orders:
• a brand-name medication
• a medication not on the formulary of the PBM
• a quantity above an arbitrary ceiling
• a medication that has multiple indications (that is, the PBM won’t pay for indication X but will pay for indication Y).
What are the problems caused by PAs? I outline a number of them, and their potential consequences, in this “Commentary.” What can we do, in our practices, to lessen the disruption they cause and the time and money they cost us (Box)?
’Prior authorization’—a misleading, disingenuous term
The physician’s prescription is legal authorization for the patient to receive the medicine. It would be more accurate if PBMs labeled what they do “prior approval for reimbursement.”
PBMs exist to manipulate and coordinate the demand for medication generated, on one hand, by patients and their physician and, on the other, by the cost of supplying portion of that demand. The cost of a medication to the PBM is controlled by:
• negotiating rebates with drug manufacturers
• advantageous contracting with pharmacies
• denying payment, when feasible, using the PA system.
The goal of the PA is to boost the profits of the PBM—not to pay for the best fit between the needs of the patient and the medications available, as determined by the treating physician.
The games begin!
The PA process usually begins when the patient goes to the pharmacy, prescription in hand, and gives it to the pharmacist, who enters it into the computer. At that point, if the PBM has put a block on paying for the medication, 3 things happen in sequence:
1. The computer alerts the pharmacist about the block (or that a higher copay is required).
2. The pharmacist tells the patient something about the block—although not necessarily the whole story.
3. The pharmacist tells the physician’s office (by fax, e-mail, or telephone) that the PBM wants authorization and that the physician must call a toll-free telephone number to obtain that authorization.
The physician’s office then makes the initial call to the PBM. That call can take 10 to 20 minutes, answering preliminary questions. The call generates a questionnaire from the PBM that is faxed to the office, filled with questions that one could characterize as loaded. The questionnaire is intended to provide grounds for disapproval or approval—not to obtain in-depth understanding of the individual patient’s needs.
Playing pieces on a chessboard
Note that the physician and pharmacist, thrust unwillingly into the middle of this gambit, spend considerable uncompensated time on the PA process. (Primary care physicians and their nursing and clerical staff, spent, on average, 19.8 hours a week obtaining PAs in 2006.1)
PBMs have shifted responsibility for communication to physicians and pharmacists by requiring that the physician always contact the PBM. A PBM will not contact a physician directly, either to begin the PA or ask questions during the process.
If the request for authorization is denied, what’s the outcome? The physician’s office and the pharmacist have spent uncompensated time taking action that resulted in the PBM and the insurer improving their bottom line without benefit to anyone else.
Communication breakdown. The cumbersome, multistep PA process opens the door to miscommunication. This happens often, I’ve found: The physician wastes time because the pharmacist passed along an incomplete message, or a patient gives vague or confusing information in trying to transmit what the pharmacist said. Sometimes, when physicians get through to a live person at the PBM, they are told that the pharmacist misinformed the office: No, the medication didn’t require PA after all.
Why can’t PBMs streamline the process, sparing busy physicians’ offices the time spent on initial telephone calls, by installing software that would allow the pharmacist who first encounters a payment block to, with a few keystrokes, instantly send the relevant questionnaire to the physician’s fax machine or computer?
Obstacles to satisfaction
From the perspective of the patient, the word that probably best characterizes his emotional response to the PA process is “helpless.” He wasn’t expecting a denial; it’s likely that he hadn’t been fully or clearly informed at the time he selected the insurer that he might someday face such an obstacle. Even though he had a legal prescription, written by a physician, any attempt to go back to the insurer or the PBM to complain is rarely successful. If he tried, he would likely get no satisfaction: The clerk at the other end of the telephone would swiftly inform him that there were a number of complicated rules, policies, or “step programs” that must be adhered to before the PBM pays for a prescription.
Even if the medication is covered, the patient might be told that there are “quantity limits” that prevent reimbursement for the prescription as written—limits that were not made explicit when he signed up for the insurance plan. All these obstacles can generate confusion, anxiety, frustration, and anger—understandably so.
The ‘safety’ catch. Obstacles do not necessarily end when the medication is approved; such approval is merely a “coverage eligibility review.” In addition, PBMs make it clear that every prescription also undergoes a so-called safety review by a pharmacist before it is dispensed. If the PBM’s pharmacist identifies a safety concern, the medication “might not be dispensed,” Express Scripts says, “or your patient could receive less than what you prescribed.”
That is an ominous statement: The PBM is openly and arrogantly taking for itself the right to unilaterally determine what is safe and to override the physician’s judgment as it sees fit. We all know that there are relative risks in taking most medications that we prescribe; the degree of that risk needs to be carefully calculated against the likely benefits for a given patient, whose detailed history is known to the treating physician. History and risk-benefit calculation are not available to the reviewing pharmacist. The existence of “safety concerns” by itself, outside of the full context of care, is insufficient justification for a PBM to stop payment for a medication.
“Approved”—but… Equally ominous is that, after a medication has been approved through the PA process, some PBMs add these words in their notification to the physician:
This medication is approved for coverage until [insert date],
or until coverage for the medication is no longer available
under the benefit plan or the medication becomes subject
to a pharmacy benefit coverage requirement, such as supply
limits or notification, whichever occurs first.
In other words, the approval is provisional, and shouldn’t be counted on to remain in place for the entire period for which dispensing has been approved. Imagine the uncertainty and anxiety of a patient who reads that statement and realizes that the medication that, at last, has relieved her symptoms might be withdrawn from coverage at any time for reasons unrelated to effectiveness.
The patient can appeal the decision of a PBM or insurer that refuses to pay for a medication, but that patient, and his physician, might ask themselves whether the considerable time required to appeal is justified, given that the criteria used for denials are arbitrary and one-sided.
Serious consequences can ensue after a PBM denies coverage for a medication. Some patients cannot afford hundreds of dollars out of pocket for 1 month of 1 medicine. When their supply runs out, they become vulnerable to symptoms of withdrawal or exacerbation of underlying illness.
Armchair care. A PBM, after it has denied approval of payment, might “ask” the physician to choose another medication that the PBM does cover. For a non-physician administrator who has never seen the patient to propose such a switch is micromanagement—to say the least. Such an action is also disrespectful of the physician’s judgment.
Loss of possible placebo effect. If the physician goes along and makes the switch proposed by the PBM, the patient will know that the new medication is the physician’s second (or third) choice. Any potential positive placebo effect is thus lost. Does that matter? It might—a lot.
Most physicians would be glad to have a positive placebo effect assist or augment the physiologic effects of a medication, especially at the start of treatment when the patient might feel helpless or hopeless. Such negative feelings are likely to be magnified if the patient knows that he has been coerced into taking a second-line therapy. A positive placebo effect, on the other hand, might well have lowered levels of his stress hormones for a few weeks—and that effect could have made a positive difference.
Casualties for the physician are time, money, and morale. PAs consume large chunks of time. Some of the PA forms require that 20 or more questions be answered; a few of those questions can take significant time to answer, having to look through a thick chart to research prior medications.
PAs also cost money: directly to pay the salary of staff that share the PA work, indirectly by crowding out the doctor’s potential billing time and replacing it with uncompensated PA work.
Worse, in my opinion, is the cost to morale. Physicians express their annoyance, aggravation, frustration, and anger at meetings and in postings at the end of journal articles on the subject. Some speak of becoming numb from the daily hassle of dealing with PAs.2 The disrespect for the physician’s decisions inherent in the PA process, the implicit humiliation of appealing to someone who doesn’t know the patient to approve payment for a medication that’s been legally prescribed, and the cost in time and money all provoke emotions that are damaging to morale.
Much to do in limited time
Time isn’t elastic; setting priorities is vital. Most physicians would, I think, agree that their priorities are:
• giving patients adequate time at office visits
• returning calls from patients with urgent messages
• communicating with professional colleagues about shared patients
• returning calls from pharmacists who have questions about prescriptions
• researching solutions to clinical problems
• keeping up with the literature.
Physicians must decide where completing PAs—intrusive, time-consuming, and a threat to morale—fits in that list. Should PAs be allowed to supplant, or delay, the completion of other vital, positive clinical priorities?
Until we are able to introduce improvements that speed up the PA process, patients will have the supply of their medications disrupted and physicians will pay in time, money, and morale.
Disclosure
Dr. Mode reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.
Insistence on prior authorization (PA) when prescribing certain pharmaceuticals has grown considerably over the past 5 years. Most requests for PA are issued by pharmacy benefit management (PBM) companies that have been contracted by an insurer. A PA can be triggered when a physician orders:
• a brand-name medication
• a medication not on the formulary of the PBM
• a quantity above an arbitrary ceiling
• a medication that has multiple indications (that is, the PBM won’t pay for indication X but will pay for indication Y).
What are the problems caused by PAs? I outline a number of them, and their potential consequences, in this “Commentary.” What can we do, in our practices, to lessen the disruption they cause and the time and money they cost us (Box)?
’Prior authorization’—a misleading, disingenuous term
The physician’s prescription is legal authorization for the patient to receive the medicine. It would be more accurate if PBMs labeled what they do “prior approval for reimbursement.”
PBMs exist to manipulate and coordinate the demand for medication generated, on one hand, by patients and their physician and, on the other, by the cost of supplying portion of that demand. The cost of a medication to the PBM is controlled by:
• negotiating rebates with drug manufacturers
• advantageous contracting with pharmacies
• denying payment, when feasible, using the PA system.
The goal of the PA is to boost the profits of the PBM—not to pay for the best fit between the needs of the patient and the medications available, as determined by the treating physician.
The games begin!
The PA process usually begins when the patient goes to the pharmacy, prescription in hand, and gives it to the pharmacist, who enters it into the computer. At that point, if the PBM has put a block on paying for the medication, 3 things happen in sequence:
1. The computer alerts the pharmacist about the block (or that a higher copay is required).
2. The pharmacist tells the patient something about the block—although not necessarily the whole story.
3. The pharmacist tells the physician’s office (by fax, e-mail, or telephone) that the PBM wants authorization and that the physician must call a toll-free telephone number to obtain that authorization.
The physician’s office then makes the initial call to the PBM. That call can take 10 to 20 minutes, answering preliminary questions. The call generates a questionnaire from the PBM that is faxed to the office, filled with questions that one could characterize as loaded. The questionnaire is intended to provide grounds for disapproval or approval—not to obtain in-depth understanding of the individual patient’s needs.
Playing pieces on a chessboard
Note that the physician and pharmacist, thrust unwillingly into the middle of this gambit, spend considerable uncompensated time on the PA process. (Primary care physicians and their nursing and clerical staff, spent, on average, 19.8 hours a week obtaining PAs in 2006.1)
PBMs have shifted responsibility for communication to physicians and pharmacists by requiring that the physician always contact the PBM. A PBM will not contact a physician directly, either to begin the PA or ask questions during the process.
If the request for authorization is denied, what’s the outcome? The physician’s office and the pharmacist have spent uncompensated time taking action that resulted in the PBM and the insurer improving their bottom line without benefit to anyone else.
Communication breakdown. The cumbersome, multistep PA process opens the door to miscommunication. This happens often, I’ve found: The physician wastes time because the pharmacist passed along an incomplete message, or a patient gives vague or confusing information in trying to transmit what the pharmacist said. Sometimes, when physicians get through to a live person at the PBM, they are told that the pharmacist misinformed the office: No, the medication didn’t require PA after all.
Why can’t PBMs streamline the process, sparing busy physicians’ offices the time spent on initial telephone calls, by installing software that would allow the pharmacist who first encounters a payment block to, with a few keystrokes, instantly send the relevant questionnaire to the physician’s fax machine or computer?
Obstacles to satisfaction
From the perspective of the patient, the word that probably best characterizes his emotional response to the PA process is “helpless.” He wasn’t expecting a denial; it’s likely that he hadn’t been fully or clearly informed at the time he selected the insurer that he might someday face such an obstacle. Even though he had a legal prescription, written by a physician, any attempt to go back to the insurer or the PBM to complain is rarely successful. If he tried, he would likely get no satisfaction: The clerk at the other end of the telephone would swiftly inform him that there were a number of complicated rules, policies, or “step programs” that must be adhered to before the PBM pays for a prescription.
Even if the medication is covered, the patient might be told that there are “quantity limits” that prevent reimbursement for the prescription as written—limits that were not made explicit when he signed up for the insurance plan. All these obstacles can generate confusion, anxiety, frustration, and anger—understandably so.
The ‘safety’ catch. Obstacles do not necessarily end when the medication is approved; such approval is merely a “coverage eligibility review.” In addition, PBMs make it clear that every prescription also undergoes a so-called safety review by a pharmacist before it is dispensed. If the PBM’s pharmacist identifies a safety concern, the medication “might not be dispensed,” Express Scripts says, “or your patient could receive less than what you prescribed.”
That is an ominous statement: The PBM is openly and arrogantly taking for itself the right to unilaterally determine what is safe and to override the physician’s judgment as it sees fit. We all know that there are relative risks in taking most medications that we prescribe; the degree of that risk needs to be carefully calculated against the likely benefits for a given patient, whose detailed history is known to the treating physician. History and risk-benefit calculation are not available to the reviewing pharmacist. The existence of “safety concerns” by itself, outside of the full context of care, is insufficient justification for a PBM to stop payment for a medication.
“Approved”—but… Equally ominous is that, after a medication has been approved through the PA process, some PBMs add these words in their notification to the physician:
This medication is approved for coverage until [insert date],
or until coverage for the medication is no longer available
under the benefit plan or the medication becomes subject
to a pharmacy benefit coverage requirement, such as supply
limits or notification, whichever occurs first.
In other words, the approval is provisional, and shouldn’t be counted on to remain in place for the entire period for which dispensing has been approved. Imagine the uncertainty and anxiety of a patient who reads that statement and realizes that the medication that, at last, has relieved her symptoms might be withdrawn from coverage at any time for reasons unrelated to effectiveness.
The patient can appeal the decision of a PBM or insurer that refuses to pay for a medication, but that patient, and his physician, might ask themselves whether the considerable time required to appeal is justified, given that the criteria used for denials are arbitrary and one-sided.
Serious consequences can ensue after a PBM denies coverage for a medication. Some patients cannot afford hundreds of dollars out of pocket for 1 month of 1 medicine. When their supply runs out, they become vulnerable to symptoms of withdrawal or exacerbation of underlying illness.
Armchair care. A PBM, after it has denied approval of payment, might “ask” the physician to choose another medication that the PBM does cover. For a non-physician administrator who has never seen the patient to propose such a switch is micromanagement—to say the least. Such an action is also disrespectful of the physician’s judgment.
Loss of possible placebo effect. If the physician goes along and makes the switch proposed by the PBM, the patient will know that the new medication is the physician’s second (or third) choice. Any potential positive placebo effect is thus lost. Does that matter? It might—a lot.
Most physicians would be glad to have a positive placebo effect assist or augment the physiologic effects of a medication, especially at the start of treatment when the patient might feel helpless or hopeless. Such negative feelings are likely to be magnified if the patient knows that he has been coerced into taking a second-line therapy. A positive placebo effect, on the other hand, might well have lowered levels of his stress hormones for a few weeks—and that effect could have made a positive difference.
Casualties for the physician are time, money, and morale. PAs consume large chunks of time. Some of the PA forms require that 20 or more questions be answered; a few of those questions can take significant time to answer, having to look through a thick chart to research prior medications.
PAs also cost money: directly to pay the salary of staff that share the PA work, indirectly by crowding out the doctor’s potential billing time and replacing it with uncompensated PA work.
Worse, in my opinion, is the cost to morale. Physicians express their annoyance, aggravation, frustration, and anger at meetings and in postings at the end of journal articles on the subject. Some speak of becoming numb from the daily hassle of dealing with PAs.2 The disrespect for the physician’s decisions inherent in the PA process, the implicit humiliation of appealing to someone who doesn’t know the patient to approve payment for a medication that’s been legally prescribed, and the cost in time and money all provoke emotions that are damaging to morale.
Much to do in limited time
Time isn’t elastic; setting priorities is vital. Most physicians would, I think, agree that their priorities are:
• giving patients adequate time at office visits
• returning calls from patients with urgent messages
• communicating with professional colleagues about shared patients
• returning calls from pharmacists who have questions about prescriptions
• researching solutions to clinical problems
• keeping up with the literature.
Physicians must decide where completing PAs—intrusive, time-consuming, and a threat to morale—fits in that list. Should PAs be allowed to supplant, or delay, the completion of other vital, positive clinical priorities?
Until we are able to introduce improvements that speed up the PA process, patients will have the supply of their medications disrupted and physicians will pay in time, money, and morale.
Disclosure
Dr. Mode reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.
1. Casalino L, Nicholson S, Gans DN, et al. What does it cost physician practices to interact with health insurance plans? Health Aff (Millwood). 2009;28(4):533-542.
2. Bendix J. Curing the prior authorization headache. Med Econ. October 10, 2013. http://medicaleconomics.modernmedicine.com/medical-economics/content/ tags/americas-health-insurance-plans/curing-priorauthorization-headache?page=full. Accessed December 2, 2014.
1. Casalino L, Nicholson S, Gans DN, et al. What does it cost physician practices to interact with health insurance plans? Health Aff (Millwood). 2009;28(4):533-542.
2. Bendix J. Curing the prior authorization headache. Med Econ. October 10, 2013. http://medicaleconomics.modernmedicine.com/medical-economics/content/ tags/americas-health-insurance-plans/curing-priorauthorization-headache?page=full. Accessed December 2, 2014.
Inflammatory Acne: New Developments in Pathogenesis and Treatment
Acne vulgaris is a chronic inflammatory disease that affects the majority of the population at some point in their lifetime. It is characterized by comedones, pustules, and papules. Acne pathogenesis is multifactorial with 4 primary factors that play a pivotal role in the formation of acne lesions: excess sebum production, abnormal keratinization, inflammation, and bacterial colonization of Propionibacterium acnes in the pilosebaceous unit.1 Although there is a general consensus on the pathogenic factors, the sequence of events in acne development is controversial. Traditionally it was believed that abnormal keratinization resulted in the creation of the microcomedone, the earliest subclinical acne lesion.2 Activation of sebaceous glands by androgens, excess sebum production, and keratin plug formation then were followed by P acnes colonization, with induction of the innate immune system culminating in inflammation.2 Androgen-induced sebum production and follicular hyperkeratinization and plugging have been cited as initial events that alter the pilosebaceous milieu, favoring the proliferation of P acnes1,3; however, evidence suggests inflammation as the inciting factor, with proof of significant inflammatory factors surrounding the pilosebaceous unit even in clinically uninvolved skin units in acne patients.4 Herein we will briefly review the most recent data and translational applications pertaining to the P acnes–triggered innate immune response via activation of toll-like receptor 2 (TLR2)5 and importantly the inflammasome.6,7
A new understanding of how P acnes induces the inflammatory cascade may represent a paradigm shift in the management of acne. Recognition of microbes, namely P acnes, by the innate immune system is the body’s first line of defense against pathogen-associated molecular patterns (PAMPs) and damage-associated molecular patterns (DAMPs).6 Although these pathways combat infection and prevent foreign invasion, they also result in inflammation and tissue injury. The inflammatory response to PAMPs and DAMPs is mediated by the inflammasome, a caspase 1–activating cytoplasmic complex that induces the secretion of crucial proinflammatory cytokines.7 The exact mechanism by which P acnes exerts its proinflammatory activity has been somewhat unclear, though P acnes–induced inflammation has been shown to be mediated by proinflammatory cytokines tumor necrosis factor α, IL-1, IL-6, IL-8, and IL-12.5,8 However, remarkable evidence recently was presented regarding triggers of inflammation and the precise mechanism involved. Qin et al9 showed that P acnes is a potent trigger of IL-1β generation via activation of the NLRP3 (NOD-like receptor family, pyrin domain containing 3) inflammasome. Specifically, the study showed that human monocytes respond to P acnes by upregulating caspase 1, an inflammatory caspase required for proteolytic cleavage of IL-1β. The authors correlated their in vitro findings with clinical evidence of caspase 1 and NLRP3 expression in the dermis surrounding the pilosebaceous units of biopsied lesions.9 Kistowska et al6 confirmed and expanded on these data by showing the inability of NLRP3-deficient myeloid cells to secrete IL-1β and induce an inflammatory response in vivo. A recent investigation demonstrated that human sebocytes can function as constituents of the innate immune response, with P acnes triggering sebocyte NLRP3-inflammasome activation and subsequent IL-1β secretion. These observations were further confirmed in vivo with NLRP3-deficient mice displaying an impaired inflammatory response to P acnes.10
Our understanding of TLR2 signaling in the pathogenesis of acne also has expanded. It is well established that recognition of extracellular PAMPs and DAMPs is mediated by the expression of toll-like receptors on the surface of a variety of cells within the skin.11 Prior research demonstrated how P acnes increases TLR2 expression in keratinocytes, even in vivo.12 Stimulation by P acnes was shown to induce secretion of IL-8 (promoting a TH1 response) and IL-12 (promoting neutrophil chemotaxis) via TLR2 activation.5 Selway et al11 validated this finding by demonstrating that infundibular keratinocytes secrete IL-1α in response to the peptidoglycan cell wall of P acnes. Interestingly, Qin et al9 determined TLR2 inhibition resulted in partial suppression of IL-1β, possibly providing new evidence of TLR2-mediated activation of the NLRP3 inflammasome. Therefore, P acnes activates both extracellular and intracellular triggers of the innate immune response: TLR2 activation (requiring extracellular recognition of pathogens) and inflammasome-mediated activation (requiring internalization and access of the bacterium to the interior compartments of the cells).
Overall, these findings suggest that P acnes–induced inflammation can be selectively targeted by agents directed at inflammasome components, IL-1β, or toll-like receptors. A phase 2 double-blind, placebo-controlled trial assessing the efficacy of the anti–IL-1β monoclonal antibody gevokizumab found that 0.6 mg/kg administered subcutaneously resulted in a significant reduction in mean inflammatory lesion count compared to placebo (P=.077).13 The success of the IL-1 receptor antagonist anakinra against rare genetic autoinflammatory syndromes such as PAPA (pyogenic sterile arthritis, pyoderma gangrenosum, and acne) syndrome, an NLRP3 inflammasomopathy, sheds light onto new therapeutics that may be used to target acne vulgaris.14 Current topical therapies such as retinoids, which have already proven efficacious in the treatment of inflammatory acne, target these pathways. In vivo data revealed that treatment with isotretinoin significantly decreased TLR2 expression in monocytes (P<.001) and suppressed inflammatory cytokine responses to P acnes (P<.001).15 Adapalene, with or without benzoyl peroxide, also was shown to exert anti-inflammatory effects via TLR2 downregulation.16
These data and observations highlight a paradigm shift in our perception of acne. All acne is truly inflammatory, and by identifying aberrations in the immune response, we can develop targeted treatments for this chronic debilitating disease.
1. Kurokawa I, Danby FW, Ju Q, et al. New developments in our understanding of acne pathogenesis and treatment. Exp Dermatol. 2009;18:821-832.
2. Cunliffe WJ, Holland DB, Clark SM, et al. Comedogenesis: some aetiological, clinical and therapeutic strategies. Dermatology. 2003;206:11-16.
3. Bowe W, Kober M. Therapeutic update: acne. J Drugs Dermatol. 2014;13:235-238.
4. Jeremy AH, Holland DB, Roberts SG, et al. Inflammatory events are involved in acne lesion initiation. J Invest Dermatol. 2003;121:20-27.
5. Kim J, Ochoa MT, Krutzik SR, et al. Activation of toll-like receptor 2 in acne triggers inflammatory cytokine responses. J Immunol. 2002;169:1535-1541.
6. Kistowska M, Gehrke S, Jankovic D, et al. IL-1beta drives inflammatory responses to Propionibacterium acnes in vitro and in vivo. J Invest Dermatol. 2014;134:677-685.
7. Contassot E, French LE. New insights into acne pathogenesis: Propionibacterium acnes activates the inflammasome. J Invest Dermatol. 2014;134:310-313.
8. Vowels BR, Yang S, Leyden JJ. Induction of proinflammatory cytokines by a soluble factor of Propionibacterium acnes: implications for chronic inflammatory acne. Infect Immun. 1995;63:3158-3165.
9. Qin M, Pirouz A, Kim MH, et al. Propionibacterium acnes induces IL-1beta secretion via the NLRP3 inflammasome in human monocytes. J Invest Dermatol. 2014;134:381-388.
10. Li ZJ, Choi DK, Sohn KC, et al. Propionibacterium acnes activates the NLRP3 inflammasome in human sebocytes. J Invest Dermatol. 2014;134:2747-2756.
11. Selway JL, Kurczab T, Kealey T, et al. Toll-like receptor 2 activation and comedogenesis: implications for the pathogenesis of acne. BMC Dermatol. 2013;13:10.
12. Jugeau S, Tenaud I, Knol AC, et al. Induction of toll-like receptors by Propionibacterium acnes. Br J Dermatol. 2005;153:1105-1113.
13. XOMA announces encouraging interim results from gevokizumab phase 2 study for moderate to severe acne vulgaris [press release]. Berkley, CA: XOMA Corporation; January 7, 2013. http://www.servier.com/content/xoma-announces-encouraging-interim-results-gevokizumab-phase-2-study-moderate-severe-acne. Accessed November 5, 2014.
14. Leemans JC, Cassel SL, Sutterwala FS. Sensing damage by the NLRP3 inflammasome. Immunol Rev. 2011;243:152-162.
15. Dispenza MC, Wolpert EB, Gilliland KL, et al. Systemic isotretinoin therapy normalizes exaggerated TLR-2-mediated innate immune responses in acne patients. J Invest Dermatol. 2012;132:2198-2205.
16. Zuliani T, Khammari A, Chaussy H, et al. Ex vivo demonstration of a synergistic effect of adapalene and benzoyl peroxide on inflammatory acne lesions. Exp Dermatol. 2011;20:850-853.
Acne vulgaris is a chronic inflammatory disease that affects the majority of the population at some point in their lifetime. It is characterized by comedones, pustules, and papules. Acne pathogenesis is multifactorial with 4 primary factors that play a pivotal role in the formation of acne lesions: excess sebum production, abnormal keratinization, inflammation, and bacterial colonization of Propionibacterium acnes in the pilosebaceous unit.1 Although there is a general consensus on the pathogenic factors, the sequence of events in acne development is controversial. Traditionally it was believed that abnormal keratinization resulted in the creation of the microcomedone, the earliest subclinical acne lesion.2 Activation of sebaceous glands by androgens, excess sebum production, and keratin plug formation then were followed by P acnes colonization, with induction of the innate immune system culminating in inflammation.2 Androgen-induced sebum production and follicular hyperkeratinization and plugging have been cited as initial events that alter the pilosebaceous milieu, favoring the proliferation of P acnes1,3; however, evidence suggests inflammation as the inciting factor, with proof of significant inflammatory factors surrounding the pilosebaceous unit even in clinically uninvolved skin units in acne patients.4 Herein we will briefly review the most recent data and translational applications pertaining to the P acnes–triggered innate immune response via activation of toll-like receptor 2 (TLR2)5 and importantly the inflammasome.6,7
A new understanding of how P acnes induces the inflammatory cascade may represent a paradigm shift in the management of acne. Recognition of microbes, namely P acnes, by the innate immune system is the body’s first line of defense against pathogen-associated molecular patterns (PAMPs) and damage-associated molecular patterns (DAMPs).6 Although these pathways combat infection and prevent foreign invasion, they also result in inflammation and tissue injury. The inflammatory response to PAMPs and DAMPs is mediated by the inflammasome, a caspase 1–activating cytoplasmic complex that induces the secretion of crucial proinflammatory cytokines.7 The exact mechanism by which P acnes exerts its proinflammatory activity has been somewhat unclear, though P acnes–induced inflammation has been shown to be mediated by proinflammatory cytokines tumor necrosis factor α, IL-1, IL-6, IL-8, and IL-12.5,8 However, remarkable evidence recently was presented regarding triggers of inflammation and the precise mechanism involved. Qin et al9 showed that P acnes is a potent trigger of IL-1β generation via activation of the NLRP3 (NOD-like receptor family, pyrin domain containing 3) inflammasome. Specifically, the study showed that human monocytes respond to P acnes by upregulating caspase 1, an inflammatory caspase required for proteolytic cleavage of IL-1β. The authors correlated their in vitro findings with clinical evidence of caspase 1 and NLRP3 expression in the dermis surrounding the pilosebaceous units of biopsied lesions.9 Kistowska et al6 confirmed and expanded on these data by showing the inability of NLRP3-deficient myeloid cells to secrete IL-1β and induce an inflammatory response in vivo. A recent investigation demonstrated that human sebocytes can function as constituents of the innate immune response, with P acnes triggering sebocyte NLRP3-inflammasome activation and subsequent IL-1β secretion. These observations were further confirmed in vivo with NLRP3-deficient mice displaying an impaired inflammatory response to P acnes.10
Our understanding of TLR2 signaling in the pathogenesis of acne also has expanded. It is well established that recognition of extracellular PAMPs and DAMPs is mediated by the expression of toll-like receptors on the surface of a variety of cells within the skin.11 Prior research demonstrated how P acnes increases TLR2 expression in keratinocytes, even in vivo.12 Stimulation by P acnes was shown to induce secretion of IL-8 (promoting a TH1 response) and IL-12 (promoting neutrophil chemotaxis) via TLR2 activation.5 Selway et al11 validated this finding by demonstrating that infundibular keratinocytes secrete IL-1α in response to the peptidoglycan cell wall of P acnes. Interestingly, Qin et al9 determined TLR2 inhibition resulted in partial suppression of IL-1β, possibly providing new evidence of TLR2-mediated activation of the NLRP3 inflammasome. Therefore, P acnes activates both extracellular and intracellular triggers of the innate immune response: TLR2 activation (requiring extracellular recognition of pathogens) and inflammasome-mediated activation (requiring internalization and access of the bacterium to the interior compartments of the cells).
Overall, these findings suggest that P acnes–induced inflammation can be selectively targeted by agents directed at inflammasome components, IL-1β, or toll-like receptors. A phase 2 double-blind, placebo-controlled trial assessing the efficacy of the anti–IL-1β monoclonal antibody gevokizumab found that 0.6 mg/kg administered subcutaneously resulted in a significant reduction in mean inflammatory lesion count compared to placebo (P=.077).13 The success of the IL-1 receptor antagonist anakinra against rare genetic autoinflammatory syndromes such as PAPA (pyogenic sterile arthritis, pyoderma gangrenosum, and acne) syndrome, an NLRP3 inflammasomopathy, sheds light onto new therapeutics that may be used to target acne vulgaris.14 Current topical therapies such as retinoids, which have already proven efficacious in the treatment of inflammatory acne, target these pathways. In vivo data revealed that treatment with isotretinoin significantly decreased TLR2 expression in monocytes (P<.001) and suppressed inflammatory cytokine responses to P acnes (P<.001).15 Adapalene, with or without benzoyl peroxide, also was shown to exert anti-inflammatory effects via TLR2 downregulation.16
These data and observations highlight a paradigm shift in our perception of acne. All acne is truly inflammatory, and by identifying aberrations in the immune response, we can develop targeted treatments for this chronic debilitating disease.
Acne vulgaris is a chronic inflammatory disease that affects the majority of the population at some point in their lifetime. It is characterized by comedones, pustules, and papules. Acne pathogenesis is multifactorial with 4 primary factors that play a pivotal role in the formation of acne lesions: excess sebum production, abnormal keratinization, inflammation, and bacterial colonization of Propionibacterium acnes in the pilosebaceous unit.1 Although there is a general consensus on the pathogenic factors, the sequence of events in acne development is controversial. Traditionally it was believed that abnormal keratinization resulted in the creation of the microcomedone, the earliest subclinical acne lesion.2 Activation of sebaceous glands by androgens, excess sebum production, and keratin plug formation then were followed by P acnes colonization, with induction of the innate immune system culminating in inflammation.2 Androgen-induced sebum production and follicular hyperkeratinization and plugging have been cited as initial events that alter the pilosebaceous milieu, favoring the proliferation of P acnes1,3; however, evidence suggests inflammation as the inciting factor, with proof of significant inflammatory factors surrounding the pilosebaceous unit even in clinically uninvolved skin units in acne patients.4 Herein we will briefly review the most recent data and translational applications pertaining to the P acnes–triggered innate immune response via activation of toll-like receptor 2 (TLR2)5 and importantly the inflammasome.6,7
A new understanding of how P acnes induces the inflammatory cascade may represent a paradigm shift in the management of acne. Recognition of microbes, namely P acnes, by the innate immune system is the body’s first line of defense against pathogen-associated molecular patterns (PAMPs) and damage-associated molecular patterns (DAMPs).6 Although these pathways combat infection and prevent foreign invasion, they also result in inflammation and tissue injury. The inflammatory response to PAMPs and DAMPs is mediated by the inflammasome, a caspase 1–activating cytoplasmic complex that induces the secretion of crucial proinflammatory cytokines.7 The exact mechanism by which P acnes exerts its proinflammatory activity has been somewhat unclear, though P acnes–induced inflammation has been shown to be mediated by proinflammatory cytokines tumor necrosis factor α, IL-1, IL-6, IL-8, and IL-12.5,8 However, remarkable evidence recently was presented regarding triggers of inflammation and the precise mechanism involved. Qin et al9 showed that P acnes is a potent trigger of IL-1β generation via activation of the NLRP3 (NOD-like receptor family, pyrin domain containing 3) inflammasome. Specifically, the study showed that human monocytes respond to P acnes by upregulating caspase 1, an inflammatory caspase required for proteolytic cleavage of IL-1β. The authors correlated their in vitro findings with clinical evidence of caspase 1 and NLRP3 expression in the dermis surrounding the pilosebaceous units of biopsied lesions.9 Kistowska et al6 confirmed and expanded on these data by showing the inability of NLRP3-deficient myeloid cells to secrete IL-1β and induce an inflammatory response in vivo. A recent investigation demonstrated that human sebocytes can function as constituents of the innate immune response, with P acnes triggering sebocyte NLRP3-inflammasome activation and subsequent IL-1β secretion. These observations were further confirmed in vivo with NLRP3-deficient mice displaying an impaired inflammatory response to P acnes.10
Our understanding of TLR2 signaling in the pathogenesis of acne also has expanded. It is well established that recognition of extracellular PAMPs and DAMPs is mediated by the expression of toll-like receptors on the surface of a variety of cells within the skin.11 Prior research demonstrated how P acnes increases TLR2 expression in keratinocytes, even in vivo.12 Stimulation by P acnes was shown to induce secretion of IL-8 (promoting a TH1 response) and IL-12 (promoting neutrophil chemotaxis) via TLR2 activation.5 Selway et al11 validated this finding by demonstrating that infundibular keratinocytes secrete IL-1α in response to the peptidoglycan cell wall of P acnes. Interestingly, Qin et al9 determined TLR2 inhibition resulted in partial suppression of IL-1β, possibly providing new evidence of TLR2-mediated activation of the NLRP3 inflammasome. Therefore, P acnes activates both extracellular and intracellular triggers of the innate immune response: TLR2 activation (requiring extracellular recognition of pathogens) and inflammasome-mediated activation (requiring internalization and access of the bacterium to the interior compartments of the cells).
Overall, these findings suggest that P acnes–induced inflammation can be selectively targeted by agents directed at inflammasome components, IL-1β, or toll-like receptors. A phase 2 double-blind, placebo-controlled trial assessing the efficacy of the anti–IL-1β monoclonal antibody gevokizumab found that 0.6 mg/kg administered subcutaneously resulted in a significant reduction in mean inflammatory lesion count compared to placebo (P=.077).13 The success of the IL-1 receptor antagonist anakinra against rare genetic autoinflammatory syndromes such as PAPA (pyogenic sterile arthritis, pyoderma gangrenosum, and acne) syndrome, an NLRP3 inflammasomopathy, sheds light onto new therapeutics that may be used to target acne vulgaris.14 Current topical therapies such as retinoids, which have already proven efficacious in the treatment of inflammatory acne, target these pathways. In vivo data revealed that treatment with isotretinoin significantly decreased TLR2 expression in monocytes (P<.001) and suppressed inflammatory cytokine responses to P acnes (P<.001).15 Adapalene, with or without benzoyl peroxide, also was shown to exert anti-inflammatory effects via TLR2 downregulation.16
These data and observations highlight a paradigm shift in our perception of acne. All acne is truly inflammatory, and by identifying aberrations in the immune response, we can develop targeted treatments for this chronic debilitating disease.
1. Kurokawa I, Danby FW, Ju Q, et al. New developments in our understanding of acne pathogenesis and treatment. Exp Dermatol. 2009;18:821-832.
2. Cunliffe WJ, Holland DB, Clark SM, et al. Comedogenesis: some aetiological, clinical and therapeutic strategies. Dermatology. 2003;206:11-16.
3. Bowe W, Kober M. Therapeutic update: acne. J Drugs Dermatol. 2014;13:235-238.
4. Jeremy AH, Holland DB, Roberts SG, et al. Inflammatory events are involved in acne lesion initiation. J Invest Dermatol. 2003;121:20-27.
5. Kim J, Ochoa MT, Krutzik SR, et al. Activation of toll-like receptor 2 in acne triggers inflammatory cytokine responses. J Immunol. 2002;169:1535-1541.
6. Kistowska M, Gehrke S, Jankovic D, et al. IL-1beta drives inflammatory responses to Propionibacterium acnes in vitro and in vivo. J Invest Dermatol. 2014;134:677-685.
7. Contassot E, French LE. New insights into acne pathogenesis: Propionibacterium acnes activates the inflammasome. J Invest Dermatol. 2014;134:310-313.
8. Vowels BR, Yang S, Leyden JJ. Induction of proinflammatory cytokines by a soluble factor of Propionibacterium acnes: implications for chronic inflammatory acne. Infect Immun. 1995;63:3158-3165.
9. Qin M, Pirouz A, Kim MH, et al. Propionibacterium acnes induces IL-1beta secretion via the NLRP3 inflammasome in human monocytes. J Invest Dermatol. 2014;134:381-388.
10. Li ZJ, Choi DK, Sohn KC, et al. Propionibacterium acnes activates the NLRP3 inflammasome in human sebocytes. J Invest Dermatol. 2014;134:2747-2756.
11. Selway JL, Kurczab T, Kealey T, et al. Toll-like receptor 2 activation and comedogenesis: implications for the pathogenesis of acne. BMC Dermatol. 2013;13:10.
12. Jugeau S, Tenaud I, Knol AC, et al. Induction of toll-like receptors by Propionibacterium acnes. Br J Dermatol. 2005;153:1105-1113.
13. XOMA announces encouraging interim results from gevokizumab phase 2 study for moderate to severe acne vulgaris [press release]. Berkley, CA: XOMA Corporation; January 7, 2013. http://www.servier.com/content/xoma-announces-encouraging-interim-results-gevokizumab-phase-2-study-moderate-severe-acne. Accessed November 5, 2014.
14. Leemans JC, Cassel SL, Sutterwala FS. Sensing damage by the NLRP3 inflammasome. Immunol Rev. 2011;243:152-162.
15. Dispenza MC, Wolpert EB, Gilliland KL, et al. Systemic isotretinoin therapy normalizes exaggerated TLR-2-mediated innate immune responses in acne patients. J Invest Dermatol. 2012;132:2198-2205.
16. Zuliani T, Khammari A, Chaussy H, et al. Ex vivo demonstration of a synergistic effect of adapalene and benzoyl peroxide on inflammatory acne lesions. Exp Dermatol. 2011;20:850-853.
1. Kurokawa I, Danby FW, Ju Q, et al. New developments in our understanding of acne pathogenesis and treatment. Exp Dermatol. 2009;18:821-832.
2. Cunliffe WJ, Holland DB, Clark SM, et al. Comedogenesis: some aetiological, clinical and therapeutic strategies. Dermatology. 2003;206:11-16.
3. Bowe W, Kober M. Therapeutic update: acne. J Drugs Dermatol. 2014;13:235-238.
4. Jeremy AH, Holland DB, Roberts SG, et al. Inflammatory events are involved in acne lesion initiation. J Invest Dermatol. 2003;121:20-27.
5. Kim J, Ochoa MT, Krutzik SR, et al. Activation of toll-like receptor 2 in acne triggers inflammatory cytokine responses. J Immunol. 2002;169:1535-1541.
6. Kistowska M, Gehrke S, Jankovic D, et al. IL-1beta drives inflammatory responses to Propionibacterium acnes in vitro and in vivo. J Invest Dermatol. 2014;134:677-685.
7. Contassot E, French LE. New insights into acne pathogenesis: Propionibacterium acnes activates the inflammasome. J Invest Dermatol. 2014;134:310-313.
8. Vowels BR, Yang S, Leyden JJ. Induction of proinflammatory cytokines by a soluble factor of Propionibacterium acnes: implications for chronic inflammatory acne. Infect Immun. 1995;63:3158-3165.
9. Qin M, Pirouz A, Kim MH, et al. Propionibacterium acnes induces IL-1beta secretion via the NLRP3 inflammasome in human monocytes. J Invest Dermatol. 2014;134:381-388.
10. Li ZJ, Choi DK, Sohn KC, et al. Propionibacterium acnes activates the NLRP3 inflammasome in human sebocytes. J Invest Dermatol. 2014;134:2747-2756.
11. Selway JL, Kurczab T, Kealey T, et al. Toll-like receptor 2 activation and comedogenesis: implications for the pathogenesis of acne. BMC Dermatol. 2013;13:10.
12. Jugeau S, Tenaud I, Knol AC, et al. Induction of toll-like receptors by Propionibacterium acnes. Br J Dermatol. 2005;153:1105-1113.
13. XOMA announces encouraging interim results from gevokizumab phase 2 study for moderate to severe acne vulgaris [press release]. Berkley, CA: XOMA Corporation; January 7, 2013. http://www.servier.com/content/xoma-announces-encouraging-interim-results-gevokizumab-phase-2-study-moderate-severe-acne. Accessed November 5, 2014.
14. Leemans JC, Cassel SL, Sutterwala FS. Sensing damage by the NLRP3 inflammasome. Immunol Rev. 2011;243:152-162.
15. Dispenza MC, Wolpert EB, Gilliland KL, et al. Systemic isotretinoin therapy normalizes exaggerated TLR-2-mediated innate immune responses in acne patients. J Invest Dermatol. 2012;132:2198-2205.
16. Zuliani T, Khammari A, Chaussy H, et al. Ex vivo demonstration of a synergistic effect of adapalene and benzoyl peroxide on inflammatory acne lesions. Exp Dermatol. 2011;20:850-853.
A defining Mom-ent
When you are making nursery rounds, how do you greet a woman who has just delivered her first child? If you welcome her into the realm of parenthood by addressing her as “Mom,” as I often did, you might want to rethink your opening lines.
In a letter to the editor by Camela Zarcone on Nov. 10 responding to an opinion piece in the New York Times (“Our Mommy Problem,” Heather Havrilesky, Sunday Review, Nov 9, 2014), Ms. Zarcone, who is from Seattle and has three sons, described a scenario in which you or I might have unwittingly played the role of villain. The pediatrician made two mistakes that I hope we wouldn’t have made. First, as she remembers it, he failed to introduce himself. And second, he walked in on her with her breasts fully exposed as she was struggling to nurse her newborn.
I have tried to avoid both of these errors by announcing, in my most manly voice, “It’s Dr. Wilkoff, the pediatrician. May I come in?” But I must say that the vast majority of nursing mothers are so focused on their babies that they rarely made any attempt to cover their breasts.
According to the author of the letter, the most serious misdeed the pediatrician committed was referring to a woman he had never met as “Mom.” I suspect, like me, he uttered this three-letter word believing that he was doing so out of respect for her new status as a mother. However, in her eyes this was the first assault in her more than 2-decade struggle to make it clear that being a mother does not define who she is.
Before we get into the deeper question of personal identity, I admit that I share some of her discomfort. If you aren’t going to refer to me by my first name, please refer to me as “doctor” not “doc” (another three-letter word). But, her overriding concern is that regardless of whether you address her as “Mother” or “Mom,” by making a reference to the fact that she has delivered a child, you are ignoring that she is a multifaceted person with talents, emotions, and sensibilities that are unrelated to her reproductive status.
The problem for us as pediatricians is that our primary interface with women who have delivered children is dominated by their role as mothers. By addressing a woman as “Mom,” a pediatrician is not ignoring the fact that she is a marketing analyst who sings in the church choir and whose father is dying of lung cancer. He is merely using a shorthand that connotes respect for one of her roles that includes a wide range of responsibilities and concerns.
Unfortunately, not everyone is a pediatrician, and many people do expect that when a woman becomes a mother she has entered a nunnery of sorts in which she has taken vows to forsake all of the other pleasures and aspirations of her former self. What makes it most difficult is that some of those folks with tunnel vision are mothers themselves who equate motherhood with a life of self-sacrifice.
But, that leaves us with the issue of identity. Regardless of how you address me and regardless of how society views me, I am the one who defines my own identity. For 40 years I defined myself as a pediatrician. I probably wasn’t as complete a father and I certainly wasn’t as good a husband as I could have been because of the way I chose to define my role as a pediatrician. I could have defined myself as something else (such as a chess master or a bicycle racer) who was also a pediatrician. But, I am lucky enough to be married to a woman who was willing to define herself as a mother. That made it much easier for me to define myself as a pediatrician in the way I did.
I no longer consider myself a pediatrician. In fact, I don’t even refer to myself as a retired pediatrician. If asked I merely reply, “I was a pediatrician, a former identity for which I have no regrets.”
Being a mother is a special case far more complex than being a pediatrician. But, a woman should still be able to choose how she weaves motherhood into the identity she crafts for herself. When we refer to her as “Mom,” we aren’t defining her. We are simply offering a token of our respect.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” E-mail him at [email protected].
When you are making nursery rounds, how do you greet a woman who has just delivered her first child? If you welcome her into the realm of parenthood by addressing her as “Mom,” as I often did, you might want to rethink your opening lines.
In a letter to the editor by Camela Zarcone on Nov. 10 responding to an opinion piece in the New York Times (“Our Mommy Problem,” Heather Havrilesky, Sunday Review, Nov 9, 2014), Ms. Zarcone, who is from Seattle and has three sons, described a scenario in which you or I might have unwittingly played the role of villain. The pediatrician made two mistakes that I hope we wouldn’t have made. First, as she remembers it, he failed to introduce himself. And second, he walked in on her with her breasts fully exposed as she was struggling to nurse her newborn.
I have tried to avoid both of these errors by announcing, in my most manly voice, “It’s Dr. Wilkoff, the pediatrician. May I come in?” But I must say that the vast majority of nursing mothers are so focused on their babies that they rarely made any attempt to cover their breasts.
According to the author of the letter, the most serious misdeed the pediatrician committed was referring to a woman he had never met as “Mom.” I suspect, like me, he uttered this three-letter word believing that he was doing so out of respect for her new status as a mother. However, in her eyes this was the first assault in her more than 2-decade struggle to make it clear that being a mother does not define who she is.
Before we get into the deeper question of personal identity, I admit that I share some of her discomfort. If you aren’t going to refer to me by my first name, please refer to me as “doctor” not “doc” (another three-letter word). But, her overriding concern is that regardless of whether you address her as “Mother” or “Mom,” by making a reference to the fact that she has delivered a child, you are ignoring that she is a multifaceted person with talents, emotions, and sensibilities that are unrelated to her reproductive status.
The problem for us as pediatricians is that our primary interface with women who have delivered children is dominated by their role as mothers. By addressing a woman as “Mom,” a pediatrician is not ignoring the fact that she is a marketing analyst who sings in the church choir and whose father is dying of lung cancer. He is merely using a shorthand that connotes respect for one of her roles that includes a wide range of responsibilities and concerns.
Unfortunately, not everyone is a pediatrician, and many people do expect that when a woman becomes a mother she has entered a nunnery of sorts in which she has taken vows to forsake all of the other pleasures and aspirations of her former self. What makes it most difficult is that some of those folks with tunnel vision are mothers themselves who equate motherhood with a life of self-sacrifice.
But, that leaves us with the issue of identity. Regardless of how you address me and regardless of how society views me, I am the one who defines my own identity. For 40 years I defined myself as a pediatrician. I probably wasn’t as complete a father and I certainly wasn’t as good a husband as I could have been because of the way I chose to define my role as a pediatrician. I could have defined myself as something else (such as a chess master or a bicycle racer) who was also a pediatrician. But, I am lucky enough to be married to a woman who was willing to define herself as a mother. That made it much easier for me to define myself as a pediatrician in the way I did.
I no longer consider myself a pediatrician. In fact, I don’t even refer to myself as a retired pediatrician. If asked I merely reply, “I was a pediatrician, a former identity for which I have no regrets.”
Being a mother is a special case far more complex than being a pediatrician. But, a woman should still be able to choose how she weaves motherhood into the identity she crafts for herself. When we refer to her as “Mom,” we aren’t defining her. We are simply offering a token of our respect.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” E-mail him at [email protected].
When you are making nursery rounds, how do you greet a woman who has just delivered her first child? If you welcome her into the realm of parenthood by addressing her as “Mom,” as I often did, you might want to rethink your opening lines.
In a letter to the editor by Camela Zarcone on Nov. 10 responding to an opinion piece in the New York Times (“Our Mommy Problem,” Heather Havrilesky, Sunday Review, Nov 9, 2014), Ms. Zarcone, who is from Seattle and has three sons, described a scenario in which you or I might have unwittingly played the role of villain. The pediatrician made two mistakes that I hope we wouldn’t have made. First, as she remembers it, he failed to introduce himself. And second, he walked in on her with her breasts fully exposed as she was struggling to nurse her newborn.
I have tried to avoid both of these errors by announcing, in my most manly voice, “It’s Dr. Wilkoff, the pediatrician. May I come in?” But I must say that the vast majority of nursing mothers are so focused on their babies that they rarely made any attempt to cover their breasts.
According to the author of the letter, the most serious misdeed the pediatrician committed was referring to a woman he had never met as “Mom.” I suspect, like me, he uttered this three-letter word believing that he was doing so out of respect for her new status as a mother. However, in her eyes this was the first assault in her more than 2-decade struggle to make it clear that being a mother does not define who she is.
Before we get into the deeper question of personal identity, I admit that I share some of her discomfort. If you aren’t going to refer to me by my first name, please refer to me as “doctor” not “doc” (another three-letter word). But, her overriding concern is that regardless of whether you address her as “Mother” or “Mom,” by making a reference to the fact that she has delivered a child, you are ignoring that she is a multifaceted person with talents, emotions, and sensibilities that are unrelated to her reproductive status.
The problem for us as pediatricians is that our primary interface with women who have delivered children is dominated by their role as mothers. By addressing a woman as “Mom,” a pediatrician is not ignoring the fact that she is a marketing analyst who sings in the church choir and whose father is dying of lung cancer. He is merely using a shorthand that connotes respect for one of her roles that includes a wide range of responsibilities and concerns.
Unfortunately, not everyone is a pediatrician, and many people do expect that when a woman becomes a mother she has entered a nunnery of sorts in which she has taken vows to forsake all of the other pleasures and aspirations of her former self. What makes it most difficult is that some of those folks with tunnel vision are mothers themselves who equate motherhood with a life of self-sacrifice.
But, that leaves us with the issue of identity. Regardless of how you address me and regardless of how society views me, I am the one who defines my own identity. For 40 years I defined myself as a pediatrician. I probably wasn’t as complete a father and I certainly wasn’t as good a husband as I could have been because of the way I chose to define my role as a pediatrician. I could have defined myself as something else (such as a chess master or a bicycle racer) who was also a pediatrician. But, I am lucky enough to be married to a woman who was willing to define herself as a mother. That made it much easier for me to define myself as a pediatrician in the way I did.
I no longer consider myself a pediatrician. In fact, I don’t even refer to myself as a retired pediatrician. If asked I merely reply, “I was a pediatrician, a former identity for which I have no regrets.”
Being a mother is a special case far more complex than being a pediatrician. But, a woman should still be able to choose how she weaves motherhood into the identity she crafts for herself. When we refer to her as “Mom,” we aren’t defining her. We are simply offering a token of our respect.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” E-mail him at [email protected].
From the Washington Office
Congress has returned for the lame duck session of the 113th Congress. As has been the case for as many years as many of your D.C. staff can remember, the repeal of the flawed Sustainable Growth Rate is a primary focus of our legislative efforts during this brief time that Congress has remaining before the end of the year.
As many will recall, in February 2014, Congress came to a bipartisan, bicameral agreement for repeal of the SGR formula and overhaul of the Medicare physician payment system. The SGR Repeal and Medicare Provider Payment Modernization Act of 2014 (S. 2000/H.R. 4015 – the SGR Repeal Act) was the product of a yearlong collaborative effort between Congress and key stakeholders, including the American College of Surgeons. In fact, ACS was the only physician group to testify before all three congressional committees of jurisdiction (House Ways and Means, House Energy and Commerce, and Senate Finance) during the process culminating in the legislation.
Congress was subsequently unable to agree on offsets to pay for the cost of the SGR Repeal Act. This is extremely unfortunate and, in sum, represents a classic example of partisanship trumping good policy. This is particularly significant when one considers the exemplary bipartisan and bicameral efforts that culminated in the legislation and the fact that the $170 billion cost of the 17 temporary “patches” Congress has utilized over the past 11 years far surpasses the estimated cost of the current agreed-upon policy.
In September, representatives from five major physician organizations, including ACS, made visits to offices of congressional leaders specifically to urge action on S. 2000/H.R. 4015 during the lame duck session. Subsequently, letters urging action on the SGR Repeal Act have been sent to House leaders by the Pennsylvania congressional delegation; the House Doctors’ Caucus; and 114 additional members who signed a bipartisan letter circulated by Rep. Reid Ribble (R-Wis.) and Rep. Kurt Schrader (D-Ore.). When the signatures on these three letters are combined with those from similar correspondence circulated by Rep. Bill Flores (R-Tex.) and Rep. Dan Maffei (D-N.Y.) and sent to House leaders in November 2013, a total of 287 of the 435 members of the House of Representatives have indicated their support for passage of H.R. 4015.
Fellows received an e-mail earlier in October requesting that they contact their individual member of Congress to urge action on the SGR Repeal Act. The message is simple: The physician community has united around a sound bicameral and bipartisan payment reform policy that will permanently repeal the flawed SGR formula and make sound reforms to modernize Medicare physician payment. It is now Congress’ job to develop bipartisan, bicameral offsets and pass the legislation. For Fellows who have not taken the opportunity to act, they can still do so by logging on to www.surgeonsvoice.org and following the links for “Take Action Now.”
There is certainly a compelling argument that action during this lame duck session represents a real opportunity to permanently address and resolve the SGR. All seem to agree that we are long past the time to address this chronic, festering issue. Lame duck sessions also present opportunities for legislators who will not be returning to proceed without the considerations of short-term political consequences. For those returning for the 114th Congress, an opportunity to address a recurrent problem, clean it off the plate, and start fresh with the new Congress in January is also very appealing. Finally, one can also argue, as was done by a prominent member of the House Doctors’ Caucus, that the lame duck session presents an opportunity to more palatably return to bipartisan cooperation on the issue – a sort of “Butch Cassidy and the Sundance Kid Theory” of jumping off the cliff together.
Without action, the latest short-term patch is scheduled to expire on March 31, 2015. At that time, another patch, the 18th, would be necessary to preclude the cuts to Medicare physician payment that all, even Medicare’s Board of Trustees, agree Congress is likely never to allow to take place for fear of the political repercussions following such cuts from seniors and the physician community. Short-term patches obviously do not solve the problem. It is reasonable to predict that any short-term patch put in place in March would be set to expire around the time of the next debt limit debate, currently predicted to be just before the August recess in the summer. That one would be the 19th. Thus, to quote a famous American philosopher and poet, “The road goes on forever and the party never ends.”
In closing, I urge all Fellows to contact the offices of their representatives and senators – whether by phone, e-mail, logging on to www.surgeonsvoice.org, or paying a personal visit to their local district office – and seize the opportunity to support favorable action on the SGR Repeal and Medicare Provider Payment Modernization Act of 2014 (S. 2000/H.R. 4015) during the lame duck session.
Until next month …
Dr. Bailey is a pediatric surgeon and Medical Director, Advocacy, for the Division of Advocacy and Health Policy, in the ACS offices in Washington, D.C.
Congress has returned for the lame duck session of the 113th Congress. As has been the case for as many years as many of your D.C. staff can remember, the repeal of the flawed Sustainable Growth Rate is a primary focus of our legislative efforts during this brief time that Congress has remaining before the end of the year.
As many will recall, in February 2014, Congress came to a bipartisan, bicameral agreement for repeal of the SGR formula and overhaul of the Medicare physician payment system. The SGR Repeal and Medicare Provider Payment Modernization Act of 2014 (S. 2000/H.R. 4015 – the SGR Repeal Act) was the product of a yearlong collaborative effort between Congress and key stakeholders, including the American College of Surgeons. In fact, ACS was the only physician group to testify before all three congressional committees of jurisdiction (House Ways and Means, House Energy and Commerce, and Senate Finance) during the process culminating in the legislation.
Congress was subsequently unable to agree on offsets to pay for the cost of the SGR Repeal Act. This is extremely unfortunate and, in sum, represents a classic example of partisanship trumping good policy. This is particularly significant when one considers the exemplary bipartisan and bicameral efforts that culminated in the legislation and the fact that the $170 billion cost of the 17 temporary “patches” Congress has utilized over the past 11 years far surpasses the estimated cost of the current agreed-upon policy.
In September, representatives from five major physician organizations, including ACS, made visits to offices of congressional leaders specifically to urge action on S. 2000/H.R. 4015 during the lame duck session. Subsequently, letters urging action on the SGR Repeal Act have been sent to House leaders by the Pennsylvania congressional delegation; the House Doctors’ Caucus; and 114 additional members who signed a bipartisan letter circulated by Rep. Reid Ribble (R-Wis.) and Rep. Kurt Schrader (D-Ore.). When the signatures on these three letters are combined with those from similar correspondence circulated by Rep. Bill Flores (R-Tex.) and Rep. Dan Maffei (D-N.Y.) and sent to House leaders in November 2013, a total of 287 of the 435 members of the House of Representatives have indicated their support for passage of H.R. 4015.
Fellows received an e-mail earlier in October requesting that they contact their individual member of Congress to urge action on the SGR Repeal Act. The message is simple: The physician community has united around a sound bicameral and bipartisan payment reform policy that will permanently repeal the flawed SGR formula and make sound reforms to modernize Medicare physician payment. It is now Congress’ job to develop bipartisan, bicameral offsets and pass the legislation. For Fellows who have not taken the opportunity to act, they can still do so by logging on to www.surgeonsvoice.org and following the links for “Take Action Now.”
There is certainly a compelling argument that action during this lame duck session represents a real opportunity to permanently address and resolve the SGR. All seem to agree that we are long past the time to address this chronic, festering issue. Lame duck sessions also present opportunities for legislators who will not be returning to proceed without the considerations of short-term political consequences. For those returning for the 114th Congress, an opportunity to address a recurrent problem, clean it off the plate, and start fresh with the new Congress in January is also very appealing. Finally, one can also argue, as was done by a prominent member of the House Doctors’ Caucus, that the lame duck session presents an opportunity to more palatably return to bipartisan cooperation on the issue – a sort of “Butch Cassidy and the Sundance Kid Theory” of jumping off the cliff together.
Without action, the latest short-term patch is scheduled to expire on March 31, 2015. At that time, another patch, the 18th, would be necessary to preclude the cuts to Medicare physician payment that all, even Medicare’s Board of Trustees, agree Congress is likely never to allow to take place for fear of the political repercussions following such cuts from seniors and the physician community. Short-term patches obviously do not solve the problem. It is reasonable to predict that any short-term patch put in place in March would be set to expire around the time of the next debt limit debate, currently predicted to be just before the August recess in the summer. That one would be the 19th. Thus, to quote a famous American philosopher and poet, “The road goes on forever and the party never ends.”
In closing, I urge all Fellows to contact the offices of their representatives and senators – whether by phone, e-mail, logging on to www.surgeonsvoice.org, or paying a personal visit to their local district office – and seize the opportunity to support favorable action on the SGR Repeal and Medicare Provider Payment Modernization Act of 2014 (S. 2000/H.R. 4015) during the lame duck session.
Until next month …
Dr. Bailey is a pediatric surgeon and Medical Director, Advocacy, for the Division of Advocacy and Health Policy, in the ACS offices in Washington, D.C.
Congress has returned for the lame duck session of the 113th Congress. As has been the case for as many years as many of your D.C. staff can remember, the repeal of the flawed Sustainable Growth Rate is a primary focus of our legislative efforts during this brief time that Congress has remaining before the end of the year.
As many will recall, in February 2014, Congress came to a bipartisan, bicameral agreement for repeal of the SGR formula and overhaul of the Medicare physician payment system. The SGR Repeal and Medicare Provider Payment Modernization Act of 2014 (S. 2000/H.R. 4015 – the SGR Repeal Act) was the product of a yearlong collaborative effort between Congress and key stakeholders, including the American College of Surgeons. In fact, ACS was the only physician group to testify before all three congressional committees of jurisdiction (House Ways and Means, House Energy and Commerce, and Senate Finance) during the process culminating in the legislation.
Congress was subsequently unable to agree on offsets to pay for the cost of the SGR Repeal Act. This is extremely unfortunate and, in sum, represents a classic example of partisanship trumping good policy. This is particularly significant when one considers the exemplary bipartisan and bicameral efforts that culminated in the legislation and the fact that the $170 billion cost of the 17 temporary “patches” Congress has utilized over the past 11 years far surpasses the estimated cost of the current agreed-upon policy.
In September, representatives from five major physician organizations, including ACS, made visits to offices of congressional leaders specifically to urge action on S. 2000/H.R. 4015 during the lame duck session. Subsequently, letters urging action on the SGR Repeal Act have been sent to House leaders by the Pennsylvania congressional delegation; the House Doctors’ Caucus; and 114 additional members who signed a bipartisan letter circulated by Rep. Reid Ribble (R-Wis.) and Rep. Kurt Schrader (D-Ore.). When the signatures on these three letters are combined with those from similar correspondence circulated by Rep. Bill Flores (R-Tex.) and Rep. Dan Maffei (D-N.Y.) and sent to House leaders in November 2013, a total of 287 of the 435 members of the House of Representatives have indicated their support for passage of H.R. 4015.
Fellows received an e-mail earlier in October requesting that they contact their individual member of Congress to urge action on the SGR Repeal Act. The message is simple: The physician community has united around a sound bicameral and bipartisan payment reform policy that will permanently repeal the flawed SGR formula and make sound reforms to modernize Medicare physician payment. It is now Congress’ job to develop bipartisan, bicameral offsets and pass the legislation. For Fellows who have not taken the opportunity to act, they can still do so by logging on to www.surgeonsvoice.org and following the links for “Take Action Now.”
There is certainly a compelling argument that action during this lame duck session represents a real opportunity to permanently address and resolve the SGR. All seem to agree that we are long past the time to address this chronic, festering issue. Lame duck sessions also present opportunities for legislators who will not be returning to proceed without the considerations of short-term political consequences. For those returning for the 114th Congress, an opportunity to address a recurrent problem, clean it off the plate, and start fresh with the new Congress in January is also very appealing. Finally, one can also argue, as was done by a prominent member of the House Doctors’ Caucus, that the lame duck session presents an opportunity to more palatably return to bipartisan cooperation on the issue – a sort of “Butch Cassidy and the Sundance Kid Theory” of jumping off the cliff together.
Without action, the latest short-term patch is scheduled to expire on March 31, 2015. At that time, another patch, the 18th, would be necessary to preclude the cuts to Medicare physician payment that all, even Medicare’s Board of Trustees, agree Congress is likely never to allow to take place for fear of the political repercussions following such cuts from seniors and the physician community. Short-term patches obviously do not solve the problem. It is reasonable to predict that any short-term patch put in place in March would be set to expire around the time of the next debt limit debate, currently predicted to be just before the August recess in the summer. That one would be the 19th. Thus, to quote a famous American philosopher and poet, “The road goes on forever and the party never ends.”
In closing, I urge all Fellows to contact the offices of their representatives and senators – whether by phone, e-mail, logging on to www.surgeonsvoice.org, or paying a personal visit to their local district office – and seize the opportunity to support favorable action on the SGR Repeal and Medicare Provider Payment Modernization Act of 2014 (S. 2000/H.R. 4015) during the lame duck session.
Until next month …
Dr. Bailey is a pediatric surgeon and Medical Director, Advocacy, for the Division of Advocacy and Health Policy, in the ACS offices in Washington, D.C.
From the Washington Office
This month, I would like to call Fellows’ attention to some pending changes in the quality measures landscape, which can impact Medicare payment. By the time this issue goes to press, all Fellows should have received e-mail from ACS leadership referencing the document, “How to Avoid Medicare Penalties” available at . This document highlights the penalties Fellows might face if they do not participate in the various Medicare quality incentive programs. It also summarizes an excellent article in the September issue of the ACS Bulletin (Vol. 99, No. 9, pp. 28-32), “The benefits of PQRS participation and what the College is doing on your behalf,” by Charles D. Mabry, MD, FACS, Chair, ACS Health Policy Advisory Council (HPAC) and Sana Z. Gokak, MPH, a member of the Quality Affairs team here in the Washington office.
As most are acutely aware, the last few years have seen a change in the quantity and types of data collected by the Centers for Medicare & Medicaid Services (CMS). As part of this change, a shift has been made from the collection of administrative data toward collection of clinical data. Medicare payment has begun to shift from pay for reporting with the Physician Quality Reporting System (PQRS) program to pay for performance with the Value-Based Payment Modifier (VM).
The current calendar year of 2014 is the last year in which physicians may earn PQRS and Electronic Health Record (EHR) Incentive Program bonus payments based on their participation in CMS programs. Based on their record from 2014 of either successful participation or nonparticipation in the PQRS, VM, and EHR programs, surgeons’ Medicare payment could be impacted by up to a –6% in 2016. Whether or not providers participate in PQRS will also be indicated on the PHYSICIAN COMPARE website. The deadline for submission of data to CMS for 2014 is Jan. 31, 2015.
Physicians and other providers must submit data to the PQRS program in order to have such indicated on the PHYSICIAN COMPARE website. In addition, the data submitted through PQRS will be utilized in future years to increase or decrease fee-for-service (FFS) payments based on the VM. The VM payment adjustment will begin in 2015, but the data utilized for the 2015 adjustment will be based on 2013 performance. Payment adjustment will apply to all physicians by 2017, based on their 2015 data. For most Medicare incentive programs, penalties will apply to the physician’s Medicare payments 2 years after their performance in the programs.
Providing data to PQRS is thus the key and may be submitted by physician group practices via the Group Practice Reporting Option (GPRO) or individually via claims, EHRs, or Qualified Registries, or Qualified Clinical Data Registries (QCDR). The ACS has two registries available to assist Fellows to be successful participants in the submission of data for the PQRS program. These are the Surgeon Specific Registry (SSR) Qualified Registry and the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) QCDR.
Many surgeons are familiar with the SSR as the ACS Case Log system whereby data was collected for the American Board of Surgery Maintenance of Certification program. Through this online program, surgeons can report on either the Perioperative Measures Group or the General Surgery Measures Group. To be successful for 2014, and thus avoid a penalty applied to payment in 2016, reports on 20 majority Medicare patients for either of the two measures groups seen during calendar year 2014 should be submitted to the SSR by Jan, 31, 2015. The SSR will submit the PQRS data to CMS.
The SSR is available at no cost to ACS members. For those not familiar with the Case Log, they may register for same at https://www.facs.org/quality-programs/ssr. Surgeons must consent to and sign up for PQRS reporting through the SSR if they want their data submitted to CMS.
In sum, it is frequently said that the only constant is change. Though the administrative requirements are much different than they were in the past, the ACS is working hard to make resources available to assist members in being successful in the ever-changing health care environment. The following ACS staff members are available to answer questions and assist members in participating in the 2014 PQRS program, EHR Incentive Program, the VM and to facilitate enrollment in the SSR and MBSAQIP:
• General PQRS, EHR, and VM questions: Sana Gokak, ACS Division of Advocacy and Health Policy, 202/337-2701 or [email protected].
• Information on the SSR: Bianca Reyes, ACS Division of Research and Optimal Patient Care, 312/202-5000 or [email protected].
• Information on MBSAQIP: Rasa Krapikas, ACS Division of Research and Optimal Patient Care, 312/202-5000 or [email protected].
Until next month …
This month, I would like to call Fellows’ attention to some pending changes in the quality measures landscape, which can impact Medicare payment. By the time this issue goes to press, all Fellows should have received e-mail from ACS leadership referencing the document, “How to Avoid Medicare Penalties” available at . This document highlights the penalties Fellows might face if they do not participate in the various Medicare quality incentive programs. It also summarizes an excellent article in the September issue of the ACS Bulletin (Vol. 99, No. 9, pp. 28-32), “The benefits of PQRS participation and what the College is doing on your behalf,” by Charles D. Mabry, MD, FACS, Chair, ACS Health Policy Advisory Council (HPAC) and Sana Z. Gokak, MPH, a member of the Quality Affairs team here in the Washington office.
As most are acutely aware, the last few years have seen a change in the quantity and types of data collected by the Centers for Medicare & Medicaid Services (CMS). As part of this change, a shift has been made from the collection of administrative data toward collection of clinical data. Medicare payment has begun to shift from pay for reporting with the Physician Quality Reporting System (PQRS) program to pay for performance with the Value-Based Payment Modifier (VM).
The current calendar year of 2014 is the last year in which physicians may earn PQRS and Electronic Health Record (EHR) Incentive Program bonus payments based on their participation in CMS programs. Based on their record from 2014 of either successful participation or nonparticipation in the PQRS, VM, and EHR programs, surgeons’ Medicare payment could be impacted by up to a –6% in 2016. Whether or not providers participate in PQRS will also be indicated on the PHYSICIAN COMPARE website. The deadline for submission of data to CMS for 2014 is Jan. 31, 2015.
Physicians and other providers must submit data to the PQRS program in order to have such indicated on the PHYSICIAN COMPARE website. In addition, the data submitted through PQRS will be utilized in future years to increase or decrease fee-for-service (FFS) payments based on the VM. The VM payment adjustment will begin in 2015, but the data utilized for the 2015 adjustment will be based on 2013 performance. Payment adjustment will apply to all physicians by 2017, based on their 2015 data. For most Medicare incentive programs, penalties will apply to the physician’s Medicare payments 2 years after their performance in the programs.
Providing data to PQRS is thus the key and may be submitted by physician group practices via the Group Practice Reporting Option (GPRO) or individually via claims, EHRs, or Qualified Registries, or Qualified Clinical Data Registries (QCDR). The ACS has two registries available to assist Fellows to be successful participants in the submission of data for the PQRS program. These are the Surgeon Specific Registry (SSR) Qualified Registry and the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) QCDR.
Many surgeons are familiar with the SSR as the ACS Case Log system whereby data was collected for the American Board of Surgery Maintenance of Certification program. Through this online program, surgeons can report on either the Perioperative Measures Group or the General Surgery Measures Group. To be successful for 2014, and thus avoid a penalty applied to payment in 2016, reports on 20 majority Medicare patients for either of the two measures groups seen during calendar year 2014 should be submitted to the SSR by Jan, 31, 2015. The SSR will submit the PQRS data to CMS.
The SSR is available at no cost to ACS members. For those not familiar with the Case Log, they may register for same at https://www.facs.org/quality-programs/ssr. Surgeons must consent to and sign up for PQRS reporting through the SSR if they want their data submitted to CMS.
In sum, it is frequently said that the only constant is change. Though the administrative requirements are much different than they were in the past, the ACS is working hard to make resources available to assist members in being successful in the ever-changing health care environment. The following ACS staff members are available to answer questions and assist members in participating in the 2014 PQRS program, EHR Incentive Program, the VM and to facilitate enrollment in the SSR and MBSAQIP:
• General PQRS, EHR, and VM questions: Sana Gokak, ACS Division of Advocacy and Health Policy, 202/337-2701 or [email protected].
• Information on the SSR: Bianca Reyes, ACS Division of Research and Optimal Patient Care, 312/202-5000 or [email protected].
• Information on MBSAQIP: Rasa Krapikas, ACS Division of Research and Optimal Patient Care, 312/202-5000 or [email protected].
Until next month …
This month, I would like to call Fellows’ attention to some pending changes in the quality measures landscape, which can impact Medicare payment. By the time this issue goes to press, all Fellows should have received e-mail from ACS leadership referencing the document, “How to Avoid Medicare Penalties” available at . This document highlights the penalties Fellows might face if they do not participate in the various Medicare quality incentive programs. It also summarizes an excellent article in the September issue of the ACS Bulletin (Vol. 99, No. 9, pp. 28-32), “The benefits of PQRS participation and what the College is doing on your behalf,” by Charles D. Mabry, MD, FACS, Chair, ACS Health Policy Advisory Council (HPAC) and Sana Z. Gokak, MPH, a member of the Quality Affairs team here in the Washington office.
As most are acutely aware, the last few years have seen a change in the quantity and types of data collected by the Centers for Medicare & Medicaid Services (CMS). As part of this change, a shift has been made from the collection of administrative data toward collection of clinical data. Medicare payment has begun to shift from pay for reporting with the Physician Quality Reporting System (PQRS) program to pay for performance with the Value-Based Payment Modifier (VM).
The current calendar year of 2014 is the last year in which physicians may earn PQRS and Electronic Health Record (EHR) Incentive Program bonus payments based on their participation in CMS programs. Based on their record from 2014 of either successful participation or nonparticipation in the PQRS, VM, and EHR programs, surgeons’ Medicare payment could be impacted by up to a –6% in 2016. Whether or not providers participate in PQRS will also be indicated on the PHYSICIAN COMPARE website. The deadline for submission of data to CMS for 2014 is Jan. 31, 2015.
Physicians and other providers must submit data to the PQRS program in order to have such indicated on the PHYSICIAN COMPARE website. In addition, the data submitted through PQRS will be utilized in future years to increase or decrease fee-for-service (FFS) payments based on the VM. The VM payment adjustment will begin in 2015, but the data utilized for the 2015 adjustment will be based on 2013 performance. Payment adjustment will apply to all physicians by 2017, based on their 2015 data. For most Medicare incentive programs, penalties will apply to the physician’s Medicare payments 2 years after their performance in the programs.
Providing data to PQRS is thus the key and may be submitted by physician group practices via the Group Practice Reporting Option (GPRO) or individually via claims, EHRs, or Qualified Registries, or Qualified Clinical Data Registries (QCDR). The ACS has two registries available to assist Fellows to be successful participants in the submission of data for the PQRS program. These are the Surgeon Specific Registry (SSR) Qualified Registry and the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) QCDR.
Many surgeons are familiar with the SSR as the ACS Case Log system whereby data was collected for the American Board of Surgery Maintenance of Certification program. Through this online program, surgeons can report on either the Perioperative Measures Group or the General Surgery Measures Group. To be successful for 2014, and thus avoid a penalty applied to payment in 2016, reports on 20 majority Medicare patients for either of the two measures groups seen during calendar year 2014 should be submitted to the SSR by Jan, 31, 2015. The SSR will submit the PQRS data to CMS.
The SSR is available at no cost to ACS members. For those not familiar with the Case Log, they may register for same at https://www.facs.org/quality-programs/ssr. Surgeons must consent to and sign up for PQRS reporting through the SSR if they want their data submitted to CMS.
In sum, it is frequently said that the only constant is change. Though the administrative requirements are much different than they were in the past, the ACS is working hard to make resources available to assist members in being successful in the ever-changing health care environment. The following ACS staff members are available to answer questions and assist members in participating in the 2014 PQRS program, EHR Incentive Program, the VM and to facilitate enrollment in the SSR and MBSAQIP:
• General PQRS, EHR, and VM questions: Sana Gokak, ACS Division of Advocacy and Health Policy, 202/337-2701 or [email protected].
• Information on the SSR: Bianca Reyes, ACS Division of Research and Optimal Patient Care, 312/202-5000 or [email protected].
• Information on MBSAQIP: Rasa Krapikas, ACS Division of Research and Optimal Patient Care, 312/202-5000 or [email protected].
Until next month …
From the Washington Office: Who we are and what we do
Senior staff of the Division of Advocacy and Health Policy was recently approached and asked to consider contributing a monthly column for ACS Surgery News. Unanimously, we agreed that it was imperative to do so and with this inaugural column, we embark on such an endeavor.
As many Fellows may be unfamiliar with the College’s Washington, DC, office and the Division of Advocacy and Health Policy, we thought it might be instructive with our first contribution to provide an overview of the office. However, being mindful of the proximity to the November elections, I will also refer Fellows to Election 2014: Issue-based considerations from a surgeon’s perspective in the Sept. 30th edition of the ACS Advocate for a quick refresher on some of the cogent issues expected to impact surgeons and their patients in the 114th Congress.
The ACS offices in Washington, DC, are located at 20 F St., NW, on the “Senate side” of Capitol Hill. The Division of Advocacy and Health Policy consists of 20 staff members working in the following areas: Legislative and Political Affairs, Quality Affairs, and Regulatory Affairs and State Affairs.
The Legislative and Political Affairs section currently consists of a Deputy Director, John Hedstrom, JD; as well as Manager of Political Affairs, Sara Morse; and lobbyists Matt Coffron and Heather Smith. Obviously, their focus is upon working toward the passage of legislation that furthers the College’s objectives of assuring access to quality surgical care. In the course of doing so, ACS staff routinely interface and work with not only individual members of Congress but also with congressional staff representing those individual members as well as the committee staff of the major committees of jurisdiction for our issues: 1) House Committee on Energy and Commerce; 2) House Ways and Means Committee; and 3) Senate Finance Committee. This section supports the College’s Legislative Committee.
ACSPA-SurgeonsPAC and the ACSPA-SurgeonsVoice platform of the Health Policy Advisory Council are managed by this section as well. The access to legislators facilitated by SurgeonsPAC enables us to have an opportunity to frame the argument on the issues affecting surgical patients and the practice of surgery. SurgeonsVoice provides resources for Fellows to develop relationships with their individual senators and representatives such that they too can actively participate in advocacy both at home via in-district meetings and here on Capitol Hill.
Though legislation and its attendant politics frequently garner more attention, it is the sections of Quality Affairs and Regulatory Affairs that concentrate on the effects of that successful legislation that becomes law and thus impacts surgeons and their patients. Staffing these sections are Manager of Regulatory Affairs, Vinita Ollapaly, JD; Manager of Quality Affairs, Jill Sage, MPH; as well as Sana Gokak, MPH; Neha Agrawal and Sarah Kurusz. Specific activities of this section include support of the General Surgery Coding and Reimbursement Committee and the annual ACS response to the Medicare Physician Fee Schedule proposed rule. This year that rule included proposals to eliminate 10- and 90-day global codes and to eliminate an exemption in the Open Payments (“Sunshine Act”) for physicians who serve as speakers at accredited CME programs. These areas of the ACS also assist Fellows in understanding and maintaining compliance with the Physician Quality Reporting System (PQRS). An excellent example of their work product can be found in the September issue of the ACS Bulletin entitled, “The benefits of PQRS participation and what the College is doing on your behalf (p. 28).
The State Affairs section moved to the Washington, DC, office from Chicago just over a year ago. Jon Sutton, who has been with ACS for 16 years, heads up this section and is assisted by Justin Rosen and Tara Leystra, MPH. Current active projects on which Jon and his team are engaged include obtaining coverage for bariatric surgery in the essential benefit packages of the various state exchanges, passage of the Uniform Emergency Volunteer Health Practitioners Act, as well as supporting the legislative and regulatory advocacy efforts of state chapters. The State Affairs section also supports the ACS delegation to the AMA House of Delegates and administers the State Lobby Day grant program.
The Director of the Division of Advocacy and Health Policy is Christian Shalgian, who has been with ACS for more than 16 years. Frank Opelka, MD, FACS (Medical Director for Quality and Health Policy) and I (Medical Director for Advocacy) are extremely pleased to have joined him this past June and look forward to assisting our Fellows and the College with challenges facing healthcare in the near and long-term future. We also look forward to contributing to ACS Surgery News as a means by which to communicate with you about our efforts relative to same.
Until next month …..
Dr. Bailey is a Pediatric Surgeon and Medical Director, Advocacy for the Division of Advocacy and Health Policy in the ACS offices in Washington, DC.
Senior staff of the Division of Advocacy and Health Policy was recently approached and asked to consider contributing a monthly column for ACS Surgery News. Unanimously, we agreed that it was imperative to do so and with this inaugural column, we embark on such an endeavor.
As many Fellows may be unfamiliar with the College’s Washington, DC, office and the Division of Advocacy and Health Policy, we thought it might be instructive with our first contribution to provide an overview of the office. However, being mindful of the proximity to the November elections, I will also refer Fellows to Election 2014: Issue-based considerations from a surgeon’s perspective in the Sept. 30th edition of the ACS Advocate for a quick refresher on some of the cogent issues expected to impact surgeons and their patients in the 114th Congress.
The ACS offices in Washington, DC, are located at 20 F St., NW, on the “Senate side” of Capitol Hill. The Division of Advocacy and Health Policy consists of 20 staff members working in the following areas: Legislative and Political Affairs, Quality Affairs, and Regulatory Affairs and State Affairs.
The Legislative and Political Affairs section currently consists of a Deputy Director, John Hedstrom, JD; as well as Manager of Political Affairs, Sara Morse; and lobbyists Matt Coffron and Heather Smith. Obviously, their focus is upon working toward the passage of legislation that furthers the College’s objectives of assuring access to quality surgical care. In the course of doing so, ACS staff routinely interface and work with not only individual members of Congress but also with congressional staff representing those individual members as well as the committee staff of the major committees of jurisdiction for our issues: 1) House Committee on Energy and Commerce; 2) House Ways and Means Committee; and 3) Senate Finance Committee. This section supports the College’s Legislative Committee.
ACSPA-SurgeonsPAC and the ACSPA-SurgeonsVoice platform of the Health Policy Advisory Council are managed by this section as well. The access to legislators facilitated by SurgeonsPAC enables us to have an opportunity to frame the argument on the issues affecting surgical patients and the practice of surgery. SurgeonsVoice provides resources for Fellows to develop relationships with their individual senators and representatives such that they too can actively participate in advocacy both at home via in-district meetings and here on Capitol Hill.
Though legislation and its attendant politics frequently garner more attention, it is the sections of Quality Affairs and Regulatory Affairs that concentrate on the effects of that successful legislation that becomes law and thus impacts surgeons and their patients. Staffing these sections are Manager of Regulatory Affairs, Vinita Ollapaly, JD; Manager of Quality Affairs, Jill Sage, MPH; as well as Sana Gokak, MPH; Neha Agrawal and Sarah Kurusz. Specific activities of this section include support of the General Surgery Coding and Reimbursement Committee and the annual ACS response to the Medicare Physician Fee Schedule proposed rule. This year that rule included proposals to eliminate 10- and 90-day global codes and to eliminate an exemption in the Open Payments (“Sunshine Act”) for physicians who serve as speakers at accredited CME programs. These areas of the ACS also assist Fellows in understanding and maintaining compliance with the Physician Quality Reporting System (PQRS). An excellent example of their work product can be found in the September issue of the ACS Bulletin entitled, “The benefits of PQRS participation and what the College is doing on your behalf (p. 28).
The State Affairs section moved to the Washington, DC, office from Chicago just over a year ago. Jon Sutton, who has been with ACS for 16 years, heads up this section and is assisted by Justin Rosen and Tara Leystra, MPH. Current active projects on which Jon and his team are engaged include obtaining coverage for bariatric surgery in the essential benefit packages of the various state exchanges, passage of the Uniform Emergency Volunteer Health Practitioners Act, as well as supporting the legislative and regulatory advocacy efforts of state chapters. The State Affairs section also supports the ACS delegation to the AMA House of Delegates and administers the State Lobby Day grant program.
The Director of the Division of Advocacy and Health Policy is Christian Shalgian, who has been with ACS for more than 16 years. Frank Opelka, MD, FACS (Medical Director for Quality and Health Policy) and I (Medical Director for Advocacy) are extremely pleased to have joined him this past June and look forward to assisting our Fellows and the College with challenges facing healthcare in the near and long-term future. We also look forward to contributing to ACS Surgery News as a means by which to communicate with you about our efforts relative to same.
Until next month …..
Dr. Bailey is a Pediatric Surgeon and Medical Director, Advocacy for the Division of Advocacy and Health Policy in the ACS offices in Washington, DC.
Senior staff of the Division of Advocacy and Health Policy was recently approached and asked to consider contributing a monthly column for ACS Surgery News. Unanimously, we agreed that it was imperative to do so and with this inaugural column, we embark on such an endeavor.
As many Fellows may be unfamiliar with the College’s Washington, DC, office and the Division of Advocacy and Health Policy, we thought it might be instructive with our first contribution to provide an overview of the office. However, being mindful of the proximity to the November elections, I will also refer Fellows to Election 2014: Issue-based considerations from a surgeon’s perspective in the Sept. 30th edition of the ACS Advocate for a quick refresher on some of the cogent issues expected to impact surgeons and their patients in the 114th Congress.
The ACS offices in Washington, DC, are located at 20 F St., NW, on the “Senate side” of Capitol Hill. The Division of Advocacy and Health Policy consists of 20 staff members working in the following areas: Legislative and Political Affairs, Quality Affairs, and Regulatory Affairs and State Affairs.
The Legislative and Political Affairs section currently consists of a Deputy Director, John Hedstrom, JD; as well as Manager of Political Affairs, Sara Morse; and lobbyists Matt Coffron and Heather Smith. Obviously, their focus is upon working toward the passage of legislation that furthers the College’s objectives of assuring access to quality surgical care. In the course of doing so, ACS staff routinely interface and work with not only individual members of Congress but also with congressional staff representing those individual members as well as the committee staff of the major committees of jurisdiction for our issues: 1) House Committee on Energy and Commerce; 2) House Ways and Means Committee; and 3) Senate Finance Committee. This section supports the College’s Legislative Committee.
ACSPA-SurgeonsPAC and the ACSPA-SurgeonsVoice platform of the Health Policy Advisory Council are managed by this section as well. The access to legislators facilitated by SurgeonsPAC enables us to have an opportunity to frame the argument on the issues affecting surgical patients and the practice of surgery. SurgeonsVoice provides resources for Fellows to develop relationships with their individual senators and representatives such that they too can actively participate in advocacy both at home via in-district meetings and here on Capitol Hill.
Though legislation and its attendant politics frequently garner more attention, it is the sections of Quality Affairs and Regulatory Affairs that concentrate on the effects of that successful legislation that becomes law and thus impacts surgeons and their patients. Staffing these sections are Manager of Regulatory Affairs, Vinita Ollapaly, JD; Manager of Quality Affairs, Jill Sage, MPH; as well as Sana Gokak, MPH; Neha Agrawal and Sarah Kurusz. Specific activities of this section include support of the General Surgery Coding and Reimbursement Committee and the annual ACS response to the Medicare Physician Fee Schedule proposed rule. This year that rule included proposals to eliminate 10- and 90-day global codes and to eliminate an exemption in the Open Payments (“Sunshine Act”) for physicians who serve as speakers at accredited CME programs. These areas of the ACS also assist Fellows in understanding and maintaining compliance with the Physician Quality Reporting System (PQRS). An excellent example of their work product can be found in the September issue of the ACS Bulletin entitled, “The benefits of PQRS participation and what the College is doing on your behalf (p. 28).
The State Affairs section moved to the Washington, DC, office from Chicago just over a year ago. Jon Sutton, who has been with ACS for 16 years, heads up this section and is assisted by Justin Rosen and Tara Leystra, MPH. Current active projects on which Jon and his team are engaged include obtaining coverage for bariatric surgery in the essential benefit packages of the various state exchanges, passage of the Uniform Emergency Volunteer Health Practitioners Act, as well as supporting the legislative and regulatory advocacy efforts of state chapters. The State Affairs section also supports the ACS delegation to the AMA House of Delegates and administers the State Lobby Day grant program.
The Director of the Division of Advocacy and Health Policy is Christian Shalgian, who has been with ACS for more than 16 years. Frank Opelka, MD, FACS (Medical Director for Quality and Health Policy) and I (Medical Director for Advocacy) are extremely pleased to have joined him this past June and look forward to assisting our Fellows and the College with challenges facing healthcare in the near and long-term future. We also look forward to contributing to ACS Surgery News as a means by which to communicate with you about our efforts relative to same.
Until next month …..
Dr. Bailey is a Pediatric Surgeon and Medical Director, Advocacy for the Division of Advocacy and Health Policy in the ACS offices in Washington, DC.
The Rural Surgeon: Critical staff ‘wearing many hats’
In my recent travels to ACS state chapter gatherings and in my meeting with rural surgeons in a variety of settings, I have heard on many occasions a particular theme of concern: the lack of resources, in particular, personnel resources available in rural hospitals. A shortage of nurses, assistants, and support staff of all kinds has emerged as a serious, continuing challenge for surgeons who work in small communities.
Rural surgery still “gets it done” in spite of resource challenges. Actually, rural surgeons perform more procedures per year with more variety in procedure types than did their urban peers, in spite of limited resources (J. Am. Coll. Surg. 2005;201:732-6).
Resource shortage for rural practices is a common subject on the rural surgery Listserv. Rural surgeons might exclaim, “We have done so much with so little for so long that we are now expected to do everything with nothing forever!” Nursing and support personnel are key resources that can be in short supply.
The rural surgery Listserv has hosted a contest inviting rural surgeons to complete the following statement: “You know you are a rural surgeon if … (YKYAARSI).” At a recent rural surgery dinner at a scientific meeting, we had a little fun amidst all of the serious topics. The winner surgeon read his winning entry: “You know you are a rural surgeon if your first OR assistant is also the OR director, the director of nursing, the DRG coordinator, the director of QA for the ER, the coordinator of emergency preparedness, the committee coordinator for the annual hospital Christmas party, the chairwoman of the committee for quality measures, the best enema nurse, and the best interpreter of the local jargon, such as ‘casophagus’ (esophagus), ‘whistle’ (penis), ‘physic’ (enema), ‘hepmotoma’ (hematoma ), and ‘toodinitis’ (vaginal infection).” Laughter and cheers followed.
Is this hyperbole? The winning YKYAARSI entry is likely closer to reality for many rural surgeons than might be supposed by those who practice in institutions with abundant personnel resources. In small community hospitals, one dedicated staff nurse can have many roles and many jobs.
Early in my career, I practiced with a true team. Individuals had specific roles. My physician assistants assisted me during operations and on rounds. The OR head nurse “ran the board.” The director of surgical services coordinated all functions of the OR from an office. The emergency room was under the management of a veteran emergency nurse. Patients received outstanding bedside nursing care on the surgical floors and in the ICU. IV teams developed and provided valuable services. Skilled lab techs drew blood. An administrative assistant coordinated social events and fund raising. Clearly, trained individuals focused on their areas of expertise.
Gradually, this structure changed. Individuals had to assume many different roles and fill positions that were otherwise unfamiliar to them. The nursing and support personnel resources available for surgery started to diminish significantly.
Today, the concept of team is reduced to single individuals “wearing many hats.” They have all accepted the additional roles to support their hospitals and then made sincere efforts to perform well. The added responsibilities have stressed these well-intentioned nurses, technicians, and assistants both physically and emotionally. Frequently circumstances prevented them from being resources for surgery, straining surgical performance and patient care. I have experienced such situations firsthand, and I have no doubt many readers have as well.
The YKYAARSI winning entry came to life at my critical access hospital. The OR charge nurse became the director for surgical services, ob.gyn., and the emergency department. Previously, this capable nurse would either circulate my cases or be the first assistant. She also took call. She had the greatest skill starting IVs. With the additional duties outside of the OR, this “resource” nearly disappeared, depriving the practice of her abilities and experience. Providing overall quality care became even more challenging. The new “director of almost everything” also led efforts to raise funds for the hospital building campaign. In addition, she developed and coordinated a half-marathon to lift spirits and get pledges for the hospital. In spite of being encouraged to the contrary by hospital administration, even this smart, determined nurse fell behind, and was no longer a resource for surgery.
Like other rural surgeons in similar circumstances, I persisted and adapted to working with less, but I recognize that this situation is not ideal, and perhaps in the long run, not sustainable.
The root of the problem of limited personnel resources for rural surgery is multifactorial and the topic for another column. If you have experienced a personnel shortage or a situation of critical staff “wearing many hats” and would like to contribute to this discussion, please feel free to e-mail me.
Dr. Caropreso is a general surgeon at Keokuk (Iowa) Area Hospital and Clinical Professor of Surgery at the University of Iowa Carver College of Medicine. He has practiced surgery in the rural communities of Mason City, Iowa; Keokuk, Iowa; and Carthage, Ill., for 37 years.
In my recent travels to ACS state chapter gatherings and in my meeting with rural surgeons in a variety of settings, I have heard on many occasions a particular theme of concern: the lack of resources, in particular, personnel resources available in rural hospitals. A shortage of nurses, assistants, and support staff of all kinds has emerged as a serious, continuing challenge for surgeons who work in small communities.
Rural surgery still “gets it done” in spite of resource challenges. Actually, rural surgeons perform more procedures per year with more variety in procedure types than did their urban peers, in spite of limited resources (J. Am. Coll. Surg. 2005;201:732-6).
Resource shortage for rural practices is a common subject on the rural surgery Listserv. Rural surgeons might exclaim, “We have done so much with so little for so long that we are now expected to do everything with nothing forever!” Nursing and support personnel are key resources that can be in short supply.
The rural surgery Listserv has hosted a contest inviting rural surgeons to complete the following statement: “You know you are a rural surgeon if … (YKYAARSI).” At a recent rural surgery dinner at a scientific meeting, we had a little fun amidst all of the serious topics. The winner surgeon read his winning entry: “You know you are a rural surgeon if your first OR assistant is also the OR director, the director of nursing, the DRG coordinator, the director of QA for the ER, the coordinator of emergency preparedness, the committee coordinator for the annual hospital Christmas party, the chairwoman of the committee for quality measures, the best enema nurse, and the best interpreter of the local jargon, such as ‘casophagus’ (esophagus), ‘whistle’ (penis), ‘physic’ (enema), ‘hepmotoma’ (hematoma ), and ‘toodinitis’ (vaginal infection).” Laughter and cheers followed.
Is this hyperbole? The winning YKYAARSI entry is likely closer to reality for many rural surgeons than might be supposed by those who practice in institutions with abundant personnel resources. In small community hospitals, one dedicated staff nurse can have many roles and many jobs.
Early in my career, I practiced with a true team. Individuals had specific roles. My physician assistants assisted me during operations and on rounds. The OR head nurse “ran the board.” The director of surgical services coordinated all functions of the OR from an office. The emergency room was under the management of a veteran emergency nurse. Patients received outstanding bedside nursing care on the surgical floors and in the ICU. IV teams developed and provided valuable services. Skilled lab techs drew blood. An administrative assistant coordinated social events and fund raising. Clearly, trained individuals focused on their areas of expertise.
Gradually, this structure changed. Individuals had to assume many different roles and fill positions that were otherwise unfamiliar to them. The nursing and support personnel resources available for surgery started to diminish significantly.
Today, the concept of team is reduced to single individuals “wearing many hats.” They have all accepted the additional roles to support their hospitals and then made sincere efforts to perform well. The added responsibilities have stressed these well-intentioned nurses, technicians, and assistants both physically and emotionally. Frequently circumstances prevented them from being resources for surgery, straining surgical performance and patient care. I have experienced such situations firsthand, and I have no doubt many readers have as well.
The YKYAARSI winning entry came to life at my critical access hospital. The OR charge nurse became the director for surgical services, ob.gyn., and the emergency department. Previously, this capable nurse would either circulate my cases or be the first assistant. She also took call. She had the greatest skill starting IVs. With the additional duties outside of the OR, this “resource” nearly disappeared, depriving the practice of her abilities and experience. Providing overall quality care became even more challenging. The new “director of almost everything” also led efforts to raise funds for the hospital building campaign. In addition, she developed and coordinated a half-marathon to lift spirits and get pledges for the hospital. In spite of being encouraged to the contrary by hospital administration, even this smart, determined nurse fell behind, and was no longer a resource for surgery.
Like other rural surgeons in similar circumstances, I persisted and adapted to working with less, but I recognize that this situation is not ideal, and perhaps in the long run, not sustainable.
The root of the problem of limited personnel resources for rural surgery is multifactorial and the topic for another column. If you have experienced a personnel shortage or a situation of critical staff “wearing many hats” and would like to contribute to this discussion, please feel free to e-mail me.
Dr. Caropreso is a general surgeon at Keokuk (Iowa) Area Hospital and Clinical Professor of Surgery at the University of Iowa Carver College of Medicine. He has practiced surgery in the rural communities of Mason City, Iowa; Keokuk, Iowa; and Carthage, Ill., for 37 years.
In my recent travels to ACS state chapter gatherings and in my meeting with rural surgeons in a variety of settings, I have heard on many occasions a particular theme of concern: the lack of resources, in particular, personnel resources available in rural hospitals. A shortage of nurses, assistants, and support staff of all kinds has emerged as a serious, continuing challenge for surgeons who work in small communities.
Rural surgery still “gets it done” in spite of resource challenges. Actually, rural surgeons perform more procedures per year with more variety in procedure types than did their urban peers, in spite of limited resources (J. Am. Coll. Surg. 2005;201:732-6).
Resource shortage for rural practices is a common subject on the rural surgery Listserv. Rural surgeons might exclaim, “We have done so much with so little for so long that we are now expected to do everything with nothing forever!” Nursing and support personnel are key resources that can be in short supply.
The rural surgery Listserv has hosted a contest inviting rural surgeons to complete the following statement: “You know you are a rural surgeon if … (YKYAARSI).” At a recent rural surgery dinner at a scientific meeting, we had a little fun amidst all of the serious topics. The winner surgeon read his winning entry: “You know you are a rural surgeon if your first OR assistant is also the OR director, the director of nursing, the DRG coordinator, the director of QA for the ER, the coordinator of emergency preparedness, the committee coordinator for the annual hospital Christmas party, the chairwoman of the committee for quality measures, the best enema nurse, and the best interpreter of the local jargon, such as ‘casophagus’ (esophagus), ‘whistle’ (penis), ‘physic’ (enema), ‘hepmotoma’ (hematoma ), and ‘toodinitis’ (vaginal infection).” Laughter and cheers followed.
Is this hyperbole? The winning YKYAARSI entry is likely closer to reality for many rural surgeons than might be supposed by those who practice in institutions with abundant personnel resources. In small community hospitals, one dedicated staff nurse can have many roles and many jobs.
Early in my career, I practiced with a true team. Individuals had specific roles. My physician assistants assisted me during operations and on rounds. The OR head nurse “ran the board.” The director of surgical services coordinated all functions of the OR from an office. The emergency room was under the management of a veteran emergency nurse. Patients received outstanding bedside nursing care on the surgical floors and in the ICU. IV teams developed and provided valuable services. Skilled lab techs drew blood. An administrative assistant coordinated social events and fund raising. Clearly, trained individuals focused on their areas of expertise.
Gradually, this structure changed. Individuals had to assume many different roles and fill positions that were otherwise unfamiliar to them. The nursing and support personnel resources available for surgery started to diminish significantly.
Today, the concept of team is reduced to single individuals “wearing many hats.” They have all accepted the additional roles to support their hospitals and then made sincere efforts to perform well. The added responsibilities have stressed these well-intentioned nurses, technicians, and assistants both physically and emotionally. Frequently circumstances prevented them from being resources for surgery, straining surgical performance and patient care. I have experienced such situations firsthand, and I have no doubt many readers have as well.
The YKYAARSI winning entry came to life at my critical access hospital. The OR charge nurse became the director for surgical services, ob.gyn., and the emergency department. Previously, this capable nurse would either circulate my cases or be the first assistant. She also took call. She had the greatest skill starting IVs. With the additional duties outside of the OR, this “resource” nearly disappeared, depriving the practice of her abilities and experience. Providing overall quality care became even more challenging. The new “director of almost everything” also led efforts to raise funds for the hospital building campaign. In addition, she developed and coordinated a half-marathon to lift spirits and get pledges for the hospital. In spite of being encouraged to the contrary by hospital administration, even this smart, determined nurse fell behind, and was no longer a resource for surgery.
Like other rural surgeons in similar circumstances, I persisted and adapted to working with less, but I recognize that this situation is not ideal, and perhaps in the long run, not sustainable.
The root of the problem of limited personnel resources for rural surgery is multifactorial and the topic for another column. If you have experienced a personnel shortage or a situation of critical staff “wearing many hats” and would like to contribute to this discussion, please feel free to e-mail me.
Dr. Caropreso is a general surgeon at Keokuk (Iowa) Area Hospital and Clinical Professor of Surgery at the University of Iowa Carver College of Medicine. He has practiced surgery in the rural communities of Mason City, Iowa; Keokuk, Iowa; and Carthage, Ill., for 37 years.
The Rural Surgeon: Thanksgiving
Thanksgiving will soon be here and celebrated joyfully with food, friends, and family in many homes around the country. Football, as well, has become a big part of this tradition on the fourth Thursday of November, an official holiday proclaimed by Abraham Lincoln in 1863. The first Thanksgiving was at Plymouth Plantation in 1621. It is unknown if any rural surgeons were present then. During this holiday, many rural surgeons will be giving thanks for more than food, friends, family, and football.
Twenty-five percent of the population is rural and fewer than 10% of surgeons practice in rural locations. This fact is complicated by the advanced age of the surgeons (~55 y/o) with more than 60% of them planning to retire in less than 10 years. The changes to all aspects of health care today, such as the Affordable Care Act, ACOs, and EMRs, affect the rural health care environment more profoundly and actually promote the deterioration of rural surgical practices. In recent years, rural surgeons have had few reasons to give thanks for the trajectory of their professional situation and fewer yet for the degree of acknowledgment of their challenges by the profession as a whole.
In the past 2 years, thanks to the tireless efforts of a few activists and enlightened leadership in the College, the ACS is now reaching out to rural surgeons, to recognize and to represent them. An important first step was the establishment of the Advisory Council on Rural Surgery, with its pillars for member services, education, quality, advocacy, as well as communication. The Council is chaired by Dr. Tyler Hughes.
Some critics might conclude that this council is just another group of surgeons more concerned about appearances and prominent positions than making an impact on the professional lives of rural surgeons. But such a conclusion would be wrong. Since its inception, the ACRS has worked relentlessly to identify and address the needs of rural surgeons. Efforts of all the pillars have involved education, along with local and national engagement of rural surgeons with emphasis on training, recruitment, and retention. The ACRS has stressed and promoted the value and quality found in rural surgical practices. Members of the Council have generously given their time and enthusiasm to advance these goals.
One of the major roles played by ACRS members has been contributing articles on the realities of a rural practice for the ACS Bulletin’s regular column, “Dispatches from rural surgeons.” Member services chair Dr. Mike Sarap wrote the initial article “The value of chapter membership: The rural surgeon’s perspective,” detailing chapter membership benefits. It concluded that patient care would benefit from a united, networked surgical community. Local ACS chapters can be a foundation of community and professional support among rural surgeons.
Dr. Mark Savarise, advocacy chair, wrote the feature article, “CPT 2012 brings with it new codes and code changes,” that provided invaluable information to rural surgeons, who otherwise would have struggled to secure it. Recently, Dr. Savarise wrote “ACS intervenes to resolve questions about the 96-hour rule” on an issue of great concern to rural surgeons. These efforts to raise awareness, articulate concerns, advocate for change, and inform members about issues are among the most important tasks of the ACRS.
The ACRS also emphasizes continuing education for rural surgeons. Rural surgery symposiums and skills courses over the years attest to that fact and acknowledge the ACRS connection with the Mithoefer Center, Cooperstown, NY, and the Nora Institute in Chicago, IL. ACRS council member, Dr. David Borgstrom, “Rural surgical practice requires a new training model, offers great opportunities” in another Bulletin rural surgery dispatch. The article describes the existing and emerging training programs, ranging from rural surgery rotations and dedicated rural surgery tracks to immersion and fellowship opportunities. The ACS has hosted a series of regional meetings such as the ACS Surgical Healthcare Quality Forum Iowa in June 2014 to engage the surgical community to share ideas on training and workforce needs, maintenance of quality care, and staff retention. In addition, ACS has introduced the Transition to Practice Program in General Surgery, which has been established in several institutions to help residents move into rural surgical practice. This program offers clinical training but also practice management training tailored to rural surgery.
ACRS quality chair, Dr. Don Nakayama, professor and chair at West Virginia University, Morgantown, has collected standards criteria for rural surgery centers of excellence and is composing a verification document for rural surgical practices. This document will assist rural surgeons and be instrumental in maintaining resources and quality in their practices. Once implemented by the ACS, the verification process for rural surgery, like the well-established program for trauma, will enable the highest standards required for the inspiring quality and for better outcomes. This new verification process and its standards give the rural surgeon a basis for the best practice.
The College has stepped up its advocacy efforts to have an impact on policy and legislation to support all surgeons. The ACS Washington office is vital and Dr. Pat Bailey, ACS medical director of advocacy, has worked with the ACRS to make sure the concerns of rural surgeons are incorporated into the advocacy strategy.
One of the four pillars of the ACRS is communication. The rural surgeons listserv was developed in by the ACRS in 2012 and has been a great success. With more than 1,000 members, and several million emails exchanged, the listserv has become meeting place for the community of rural surgeons. During the numerous rural listserv discussions and threads, many of the emails expressed thanks and appreciation. One rural surgeon volunteered, “This is the most tangible, personally applicable arm of the College I have been exposed to in nearly 40 years as a Fellow.” The conversation continued with this sentiment, “I am terrifically gratified to find that the guilt I have suffered all these years (30+) is misplaced.” As the thread continued, the word thanks appeared multiple times. The communication mission of the ACRS will continue with the development of the ACS Communities platform.
The ACS support for rural surgeons came at an ideal time. And for many in the community, this support is a cause for thankfulness.
In participating in the listserv, rural surgeons identified many topics of interest and some actual concerns to them. Call and locum tenens coverage were the most prominent potential issues. The ACS leadership is aware of both subjects and is currently investigating each one. These matters are vital to rural surgeons, and this publication, ACS Surgery News, invites rural surgeons (or any reader) to respond with any additional information. A productive dialogue could follow and be useful to the ACS. Regardless, the ACS will continue without interruption the process of support rural surgeons.
By its actions, the ACS gives living proof to its motto – “inspiring quality, highest standards, better outcomes” – which now have improved chances for surgeons to continue their work in rural communities. Rural surgeons have experienced the true meaning of ACS Fellowship. Indeed, during this Thanksgiving, rural surgeons will be giving thanks for food, friends, family, and the calling to the surgical profession. Rural surgeons will also be grateful for their College and its personal support of their profession and their practices. Thank you and Happy Thanksgiving to everyone.
Dr. Caropreso is a general surgeon at Keokuk (Iowa) Area Hospital and Clinical Professor of Surgery at the University of Iowa Carver College of Medicine. He has practiced surgery in the rural communities of Mason City, Iowa; Keokuk, Iowa; and Carthage, Ill., for 37 years.
Thanksgiving will soon be here and celebrated joyfully with food, friends, and family in many homes around the country. Football, as well, has become a big part of this tradition on the fourth Thursday of November, an official holiday proclaimed by Abraham Lincoln in 1863. The first Thanksgiving was at Plymouth Plantation in 1621. It is unknown if any rural surgeons were present then. During this holiday, many rural surgeons will be giving thanks for more than food, friends, family, and football.
Twenty-five percent of the population is rural and fewer than 10% of surgeons practice in rural locations. This fact is complicated by the advanced age of the surgeons (~55 y/o) with more than 60% of them planning to retire in less than 10 years. The changes to all aspects of health care today, such as the Affordable Care Act, ACOs, and EMRs, affect the rural health care environment more profoundly and actually promote the deterioration of rural surgical practices. In recent years, rural surgeons have had few reasons to give thanks for the trajectory of their professional situation and fewer yet for the degree of acknowledgment of their challenges by the profession as a whole.
In the past 2 years, thanks to the tireless efforts of a few activists and enlightened leadership in the College, the ACS is now reaching out to rural surgeons, to recognize and to represent them. An important first step was the establishment of the Advisory Council on Rural Surgery, with its pillars for member services, education, quality, advocacy, as well as communication. The Council is chaired by Dr. Tyler Hughes.
Some critics might conclude that this council is just another group of surgeons more concerned about appearances and prominent positions than making an impact on the professional lives of rural surgeons. But such a conclusion would be wrong. Since its inception, the ACRS has worked relentlessly to identify and address the needs of rural surgeons. Efforts of all the pillars have involved education, along with local and national engagement of rural surgeons with emphasis on training, recruitment, and retention. The ACRS has stressed and promoted the value and quality found in rural surgical practices. Members of the Council have generously given their time and enthusiasm to advance these goals.
One of the major roles played by ACRS members has been contributing articles on the realities of a rural practice for the ACS Bulletin’s regular column, “Dispatches from rural surgeons.” Member services chair Dr. Mike Sarap wrote the initial article “The value of chapter membership: The rural surgeon’s perspective,” detailing chapter membership benefits. It concluded that patient care would benefit from a united, networked surgical community. Local ACS chapters can be a foundation of community and professional support among rural surgeons.
Dr. Mark Savarise, advocacy chair, wrote the feature article, “CPT 2012 brings with it new codes and code changes,” that provided invaluable information to rural surgeons, who otherwise would have struggled to secure it. Recently, Dr. Savarise wrote “ACS intervenes to resolve questions about the 96-hour rule” on an issue of great concern to rural surgeons. These efforts to raise awareness, articulate concerns, advocate for change, and inform members about issues are among the most important tasks of the ACRS.
The ACRS also emphasizes continuing education for rural surgeons. Rural surgery symposiums and skills courses over the years attest to that fact and acknowledge the ACRS connection with the Mithoefer Center, Cooperstown, NY, and the Nora Institute in Chicago, IL. ACRS council member, Dr. David Borgstrom, “Rural surgical practice requires a new training model, offers great opportunities” in another Bulletin rural surgery dispatch. The article describes the existing and emerging training programs, ranging from rural surgery rotations and dedicated rural surgery tracks to immersion and fellowship opportunities. The ACS has hosted a series of regional meetings such as the ACS Surgical Healthcare Quality Forum Iowa in June 2014 to engage the surgical community to share ideas on training and workforce needs, maintenance of quality care, and staff retention. In addition, ACS has introduced the Transition to Practice Program in General Surgery, which has been established in several institutions to help residents move into rural surgical practice. This program offers clinical training but also practice management training tailored to rural surgery.
ACRS quality chair, Dr. Don Nakayama, professor and chair at West Virginia University, Morgantown, has collected standards criteria for rural surgery centers of excellence and is composing a verification document for rural surgical practices. This document will assist rural surgeons and be instrumental in maintaining resources and quality in their practices. Once implemented by the ACS, the verification process for rural surgery, like the well-established program for trauma, will enable the highest standards required for the inspiring quality and for better outcomes. This new verification process and its standards give the rural surgeon a basis for the best practice.
The College has stepped up its advocacy efforts to have an impact on policy and legislation to support all surgeons. The ACS Washington office is vital and Dr. Pat Bailey, ACS medical director of advocacy, has worked with the ACRS to make sure the concerns of rural surgeons are incorporated into the advocacy strategy.
One of the four pillars of the ACRS is communication. The rural surgeons listserv was developed in by the ACRS in 2012 and has been a great success. With more than 1,000 members, and several million emails exchanged, the listserv has become meeting place for the community of rural surgeons. During the numerous rural listserv discussions and threads, many of the emails expressed thanks and appreciation. One rural surgeon volunteered, “This is the most tangible, personally applicable arm of the College I have been exposed to in nearly 40 years as a Fellow.” The conversation continued with this sentiment, “I am terrifically gratified to find that the guilt I have suffered all these years (30+) is misplaced.” As the thread continued, the word thanks appeared multiple times. The communication mission of the ACRS will continue with the development of the ACS Communities platform.
The ACS support for rural surgeons came at an ideal time. And for many in the community, this support is a cause for thankfulness.
In participating in the listserv, rural surgeons identified many topics of interest and some actual concerns to them. Call and locum tenens coverage were the most prominent potential issues. The ACS leadership is aware of both subjects and is currently investigating each one. These matters are vital to rural surgeons, and this publication, ACS Surgery News, invites rural surgeons (or any reader) to respond with any additional information. A productive dialogue could follow and be useful to the ACS. Regardless, the ACS will continue without interruption the process of support rural surgeons.
By its actions, the ACS gives living proof to its motto – “inspiring quality, highest standards, better outcomes” – which now have improved chances for surgeons to continue their work in rural communities. Rural surgeons have experienced the true meaning of ACS Fellowship. Indeed, during this Thanksgiving, rural surgeons will be giving thanks for food, friends, family, and the calling to the surgical profession. Rural surgeons will also be grateful for their College and its personal support of their profession and their practices. Thank you and Happy Thanksgiving to everyone.
Dr. Caropreso is a general surgeon at Keokuk (Iowa) Area Hospital and Clinical Professor of Surgery at the University of Iowa Carver College of Medicine. He has practiced surgery in the rural communities of Mason City, Iowa; Keokuk, Iowa; and Carthage, Ill., for 37 years.
Thanksgiving will soon be here and celebrated joyfully with food, friends, and family in many homes around the country. Football, as well, has become a big part of this tradition on the fourth Thursday of November, an official holiday proclaimed by Abraham Lincoln in 1863. The first Thanksgiving was at Plymouth Plantation in 1621. It is unknown if any rural surgeons were present then. During this holiday, many rural surgeons will be giving thanks for more than food, friends, family, and football.
Twenty-five percent of the population is rural and fewer than 10% of surgeons practice in rural locations. This fact is complicated by the advanced age of the surgeons (~55 y/o) with more than 60% of them planning to retire in less than 10 years. The changes to all aspects of health care today, such as the Affordable Care Act, ACOs, and EMRs, affect the rural health care environment more profoundly and actually promote the deterioration of rural surgical practices. In recent years, rural surgeons have had few reasons to give thanks for the trajectory of their professional situation and fewer yet for the degree of acknowledgment of their challenges by the profession as a whole.
In the past 2 years, thanks to the tireless efforts of a few activists and enlightened leadership in the College, the ACS is now reaching out to rural surgeons, to recognize and to represent them. An important first step was the establishment of the Advisory Council on Rural Surgery, with its pillars for member services, education, quality, advocacy, as well as communication. The Council is chaired by Dr. Tyler Hughes.
Some critics might conclude that this council is just another group of surgeons more concerned about appearances and prominent positions than making an impact on the professional lives of rural surgeons. But such a conclusion would be wrong. Since its inception, the ACRS has worked relentlessly to identify and address the needs of rural surgeons. Efforts of all the pillars have involved education, along with local and national engagement of rural surgeons with emphasis on training, recruitment, and retention. The ACRS has stressed and promoted the value and quality found in rural surgical practices. Members of the Council have generously given their time and enthusiasm to advance these goals.
One of the major roles played by ACRS members has been contributing articles on the realities of a rural practice for the ACS Bulletin’s regular column, “Dispatches from rural surgeons.” Member services chair Dr. Mike Sarap wrote the initial article “The value of chapter membership: The rural surgeon’s perspective,” detailing chapter membership benefits. It concluded that patient care would benefit from a united, networked surgical community. Local ACS chapters can be a foundation of community and professional support among rural surgeons.
Dr. Mark Savarise, advocacy chair, wrote the feature article, “CPT 2012 brings with it new codes and code changes,” that provided invaluable information to rural surgeons, who otherwise would have struggled to secure it. Recently, Dr. Savarise wrote “ACS intervenes to resolve questions about the 96-hour rule” on an issue of great concern to rural surgeons. These efforts to raise awareness, articulate concerns, advocate for change, and inform members about issues are among the most important tasks of the ACRS.
The ACRS also emphasizes continuing education for rural surgeons. Rural surgery symposiums and skills courses over the years attest to that fact and acknowledge the ACRS connection with the Mithoefer Center, Cooperstown, NY, and the Nora Institute in Chicago, IL. ACRS council member, Dr. David Borgstrom, “Rural surgical practice requires a new training model, offers great opportunities” in another Bulletin rural surgery dispatch. The article describes the existing and emerging training programs, ranging from rural surgery rotations and dedicated rural surgery tracks to immersion and fellowship opportunities. The ACS has hosted a series of regional meetings such as the ACS Surgical Healthcare Quality Forum Iowa in June 2014 to engage the surgical community to share ideas on training and workforce needs, maintenance of quality care, and staff retention. In addition, ACS has introduced the Transition to Practice Program in General Surgery, which has been established in several institutions to help residents move into rural surgical practice. This program offers clinical training but also practice management training tailored to rural surgery.
ACRS quality chair, Dr. Don Nakayama, professor and chair at West Virginia University, Morgantown, has collected standards criteria for rural surgery centers of excellence and is composing a verification document for rural surgical practices. This document will assist rural surgeons and be instrumental in maintaining resources and quality in their practices. Once implemented by the ACS, the verification process for rural surgery, like the well-established program for trauma, will enable the highest standards required for the inspiring quality and for better outcomes. This new verification process and its standards give the rural surgeon a basis for the best practice.
The College has stepped up its advocacy efforts to have an impact on policy and legislation to support all surgeons. The ACS Washington office is vital and Dr. Pat Bailey, ACS medical director of advocacy, has worked with the ACRS to make sure the concerns of rural surgeons are incorporated into the advocacy strategy.
One of the four pillars of the ACRS is communication. The rural surgeons listserv was developed in by the ACRS in 2012 and has been a great success. With more than 1,000 members, and several million emails exchanged, the listserv has become meeting place for the community of rural surgeons. During the numerous rural listserv discussions and threads, many of the emails expressed thanks and appreciation. One rural surgeon volunteered, “This is the most tangible, personally applicable arm of the College I have been exposed to in nearly 40 years as a Fellow.” The conversation continued with this sentiment, “I am terrifically gratified to find that the guilt I have suffered all these years (30+) is misplaced.” As the thread continued, the word thanks appeared multiple times. The communication mission of the ACRS will continue with the development of the ACS Communities platform.
The ACS support for rural surgeons came at an ideal time. And for many in the community, this support is a cause for thankfulness.
In participating in the listserv, rural surgeons identified many topics of interest and some actual concerns to them. Call and locum tenens coverage were the most prominent potential issues. The ACS leadership is aware of both subjects and is currently investigating each one. These matters are vital to rural surgeons, and this publication, ACS Surgery News, invites rural surgeons (or any reader) to respond with any additional information. A productive dialogue could follow and be useful to the ACS. Regardless, the ACS will continue without interruption the process of support rural surgeons.
By its actions, the ACS gives living proof to its motto – “inspiring quality, highest standards, better outcomes” – which now have improved chances for surgeons to continue their work in rural communities. Rural surgeons have experienced the true meaning of ACS Fellowship. Indeed, during this Thanksgiving, rural surgeons will be giving thanks for food, friends, family, and the calling to the surgical profession. Rural surgeons will also be grateful for their College and its personal support of their profession and their practices. Thank you and Happy Thanksgiving to everyone.
Dr. Caropreso is a general surgeon at Keokuk (Iowa) Area Hospital and Clinical Professor of Surgery at the University of Iowa Carver College of Medicine. He has practiced surgery in the rural communities of Mason City, Iowa; Keokuk, Iowa; and Carthage, Ill., for 37 years.
A post-Thanksgiving post
In the wake of the grand jury’s decision not to indict Officer Darren Wilson for the death of Michael Brown in Ferguson, Mo., an artist/comedian named Joe Veix made a brilliant fake mock-up of what the New York Times’ banner page would look like the following day. The fake headline says, “Everything’s ... Awful,” (expletive deleted) and it calls out the endlessly scatological nature of the opinion pages. It captured the bleakness of the moment. The world-on-fire sentiment is one that I often feel, particularly when calamities, man-made or otherwise, strike.
So the Thanksgiving holiday was a welcome break from the world. It was a time to retreat from the world.
Starting with the peaceful drive from Providence, R.I., to New York, we insulated ourselves briefly from the 24-hour news cycle, the bad news, the critics and thought pieces, and the criticisms of the thought pieces. We managed to tune out our phones, those instruments of endless mind-numbing connectivity, and enjoy each other’s company. We listened to music, told stories, spent time together in the kitchen making old family favorites. We talked about our anxieties and aspirations. We shared stories of our childhood and sibling rivalry, and the curious relationship of parents and children. We had dinner with friends of a friend, strangers who welcomed us into their home. We made new friends, got well fed, and drank plenty of hot apple cider and whiskey. We basked in love and affection, and went to bed that night content as pigs in a very warm blanket.
The holiday was enough, for the briefest of moments, to be at peace with the mess of the human condition.
This left me thinking of the ultimate big-level picture of the condition we are in. In 1990, the spacecraft Voyager 1 left our atmosphere, and when it was about 4 billion miles away, it took a snapshot of Earth, seen here.
It is this image that inspired Carl Sagan to write the following passage. Every reading of it leaves me with different measures but always the same combination of conflicting emotions: of sadness, and insignificance, of awe, and gratitude, and hope.
“From this distant vantage point, the Earth might not seem of any particular interest. But for us, it’s different. Consider again that dot. That’s here, that’s home, that’s us. On it everyone you love, everyone you know, everyone you ever heard of, every human being who ever was, lived out their lives. The aggregate of our joy and suffering, thousands of confident religions, ideologies, and economic doctrines, every hunter and forager, every hero and coward, every creator and destroyer of civilization, every king and peasant, every young couple in love, every mother and father, hopeful child, inventor and explorer, every teacher of morals, every corrupt politician, every “superstar,” every “supreme leader,” every saint and sinner in the history of our species lived there – on the mote of dust suspended in a sunbeam.”
Dr. Chan practices rheumatology in Pawtucket, R.I.
In the wake of the grand jury’s decision not to indict Officer Darren Wilson for the death of Michael Brown in Ferguson, Mo., an artist/comedian named Joe Veix made a brilliant fake mock-up of what the New York Times’ banner page would look like the following day. The fake headline says, “Everything’s ... Awful,” (expletive deleted) and it calls out the endlessly scatological nature of the opinion pages. It captured the bleakness of the moment. The world-on-fire sentiment is one that I often feel, particularly when calamities, man-made or otherwise, strike.
So the Thanksgiving holiday was a welcome break from the world. It was a time to retreat from the world.
Starting with the peaceful drive from Providence, R.I., to New York, we insulated ourselves briefly from the 24-hour news cycle, the bad news, the critics and thought pieces, and the criticisms of the thought pieces. We managed to tune out our phones, those instruments of endless mind-numbing connectivity, and enjoy each other’s company. We listened to music, told stories, spent time together in the kitchen making old family favorites. We talked about our anxieties and aspirations. We shared stories of our childhood and sibling rivalry, and the curious relationship of parents and children. We had dinner with friends of a friend, strangers who welcomed us into their home. We made new friends, got well fed, and drank plenty of hot apple cider and whiskey. We basked in love and affection, and went to bed that night content as pigs in a very warm blanket.
The holiday was enough, for the briefest of moments, to be at peace with the mess of the human condition.
This left me thinking of the ultimate big-level picture of the condition we are in. In 1990, the spacecraft Voyager 1 left our atmosphere, and when it was about 4 billion miles away, it took a snapshot of Earth, seen here.
It is this image that inspired Carl Sagan to write the following passage. Every reading of it leaves me with different measures but always the same combination of conflicting emotions: of sadness, and insignificance, of awe, and gratitude, and hope.
“From this distant vantage point, the Earth might not seem of any particular interest. But for us, it’s different. Consider again that dot. That’s here, that’s home, that’s us. On it everyone you love, everyone you know, everyone you ever heard of, every human being who ever was, lived out their lives. The aggregate of our joy and suffering, thousands of confident religions, ideologies, and economic doctrines, every hunter and forager, every hero and coward, every creator and destroyer of civilization, every king and peasant, every young couple in love, every mother and father, hopeful child, inventor and explorer, every teacher of morals, every corrupt politician, every “superstar,” every “supreme leader,” every saint and sinner in the history of our species lived there – on the mote of dust suspended in a sunbeam.”
Dr. Chan practices rheumatology in Pawtucket, R.I.
In the wake of the grand jury’s decision not to indict Officer Darren Wilson for the death of Michael Brown in Ferguson, Mo., an artist/comedian named Joe Veix made a brilliant fake mock-up of what the New York Times’ banner page would look like the following day. The fake headline says, “Everything’s ... Awful,” (expletive deleted) and it calls out the endlessly scatological nature of the opinion pages. It captured the bleakness of the moment. The world-on-fire sentiment is one that I often feel, particularly when calamities, man-made or otherwise, strike.
So the Thanksgiving holiday was a welcome break from the world. It was a time to retreat from the world.
Starting with the peaceful drive from Providence, R.I., to New York, we insulated ourselves briefly from the 24-hour news cycle, the bad news, the critics and thought pieces, and the criticisms of the thought pieces. We managed to tune out our phones, those instruments of endless mind-numbing connectivity, and enjoy each other’s company. We listened to music, told stories, spent time together in the kitchen making old family favorites. We talked about our anxieties and aspirations. We shared stories of our childhood and sibling rivalry, and the curious relationship of parents and children. We had dinner with friends of a friend, strangers who welcomed us into their home. We made new friends, got well fed, and drank plenty of hot apple cider and whiskey. We basked in love and affection, and went to bed that night content as pigs in a very warm blanket.
The holiday was enough, for the briefest of moments, to be at peace with the mess of the human condition.
This left me thinking of the ultimate big-level picture of the condition we are in. In 1990, the spacecraft Voyager 1 left our atmosphere, and when it was about 4 billion miles away, it took a snapshot of Earth, seen here.
It is this image that inspired Carl Sagan to write the following passage. Every reading of it leaves me with different measures but always the same combination of conflicting emotions: of sadness, and insignificance, of awe, and gratitude, and hope.
“From this distant vantage point, the Earth might not seem of any particular interest. But for us, it’s different. Consider again that dot. That’s here, that’s home, that’s us. On it everyone you love, everyone you know, everyone you ever heard of, every human being who ever was, lived out their lives. The aggregate of our joy and suffering, thousands of confident religions, ideologies, and economic doctrines, every hunter and forager, every hero and coward, every creator and destroyer of civilization, every king and peasant, every young couple in love, every mother and father, hopeful child, inventor and explorer, every teacher of morals, every corrupt politician, every “superstar,” every “supreme leader,” every saint and sinner in the history of our species lived there – on the mote of dust suspended in a sunbeam.”
Dr. Chan practices rheumatology in Pawtucket, R.I.
Predictions for 2015
Last year, there were five predictions made that appeared to be on the money – but there is more to the story!
1. The approach to diagnosis and treatment of influenza was essential knowledge for clinicians. Last year, we started seeing influenza activity early – with disease confirmed in mid-November, peaking during the week ending December 28, 2013 and trending downward in early January 2014. Hospitalizations were most common in young and middle aged adults and the 2009 H1N1 virus predominated.
This year, again we are seeing influenza early – with nearly all states reporting at least sporadic and local activity, and several states (Alaska, Florida, Louisiana, Massachusetts, and Texas) reporting regional activity as of the week ending November 24, 2014. At my institution, we’ve already tested over 500 children and over 100 were positive – influenza A (H3N2) strains are predominating. That may be important for the two reasons you’ll read below.
2. Invasive staphylococcal disease caused by methicillin-susceptible Staphylococcus aureus (MSSA) was more common than methicillin-resistant Staphylococcus aureus (MRSA), as the national burden of MRSA disease decreased (JAMA 2014;311:1438-9). The rates of clindamycin resistance continue to be pretty steady at approximately 15%-18%, but higher for MSSA than for MRSA – a point that is important to consider when empirically treating suspected invasive staphylococcal infection.
3. Multidrug resistant uropathogens took an increasingly prominent role in 2014, requiring careful approach to diagnosis (every child treated for urinary tract infection should have an appropriately obtained urine culture with an identified pathogen) and treatment (the drug used should be based on antibiotic susceptibility testing results). Particularly concerning is the emergence of carbapenem-resistant Enterobacteriaceae, which cause infection more commonly in hospitalized patients, those with indwelling devices, and those who have received long courses of antibiotics.
4. It was an outbreak year for parechovirus (HPeV), a viral pathogen causing meningitis in very young infants. Such infants present with signs and symptoms of meningitis but rarely show CSF pleocytosis. Diagnosis relies on the detection of the virus by polymerase chain reaction testing in CSF – a test which is not routinely available in many laboratories. At my institution this season, we saw nearly as many cases of parechovirus meningitis (n = 43) as we saw cases of enterovirus meningitis (n = 63). The parechovirus virus we detected was HPeV type 3, which can cause particularly severe disease in neonates.
5. Data confirmed that making human papillomavirus (HPV) vaccine a standard recommendation increased vaccine uptake and coverage. In February of 2014, a “Dear Colleague” letter that was endorsed by six leading medical organizations encouraged providers to promote HPV vaccination by giving a strong recommendation, citing data based on research conducted by the Centers for Disease Control and Prevention. We still have a long way to go as HPV vaccine coverage for teens remains at 35% for the three-dose series while meningococcal and Tdap vaccine (both vaccines that generally receive a standard recommendation by physicians) coverage is at nearly 90%.
So for 2015, I’ll start the discussion by saying there are five major developments I did not see coming for this past year, but that will remain relevant for the year 2015!
1. In June of 2014, live attenuated influenza vaccine (LAIV) was announced by the Advisory Committee on Immunization Practices to be the preferred vaccine in children aged 2-8 years. The American Academy of Pediatrics followed with a recommendation that either inactivated influenza vaccine (IIV) or LAIV be used for children, including children aged 2-8 years – the key being to give the vaccine as soon as one had it available. What was not known then and I did not predict was that newer data would confirm that in children aged 2-8 years who received LAIV last year when 2009 H1N1 strains predominated, there was essentially no coverage against 2009 H1N1 virus. This was in contrast to data from the prior 2 years and is as yet unexplained. The AAP continues to recommend that either vaccine be given and all children be immunized. That may be especially important this year as the influenza season started early. Disease will likely have been widespread by Christmas in many parts of the United States, and it looks like influenza A H3N2 strains will be most commonly noted. So the good news for young children who received LAIV is that 2009 H1N1 strains so far have not been seen this year. The bad news is that there are two H3N2 strains circulating, and potentially only one will be covered by the 2014-2015 seasonal vaccine. Staffing your office and hospital for a likely high census respiratory viral season is going to be essential.
2. The largest U.S. outbreak ever of enterovirus (EV) D-68 respiratory infection occurred between August and October of 2014. This virus – which had been identified in 1962 but was rarely described over the next 36 years except in small clusters of disease – was reported in nearly every state and characterized by unusually severe respiratory tract infection. Many, but not all children, had a history of asthma or prior wheezing, and the clinical presentation was that of severe bronchospasm that was generally resistant to standard bronchodilator therapy. The spectrum of infection likely ranged from mild upper respiratory infection to severe bronchospasm with respiratory failure, and the burden of disease resulting in hospitalization was substantial at many children’s hospitals. The big question now is what will enterovirus season 2015 bring us? The good news here is that we now have a test to rapidly diagnose EV D-68, which will allow us to more clearly understand the burden of disease – and potentially to define antiviral treatment (none of the current antivirals is effective) and prevention (there is no vaccine against EV D-68).
3. The etiology of the neurologic illness, which appeared to mimic polio and presented during the same time frame during which EV D-68 was circulating, is as yet unknown. As of Nov. 26, 2014, the CDC has received reports of 90 children in 32 states who meet a case definition consistent with acute flaccid myelitis. While certain viruses – including West Nile virus, herpes virus, adenovirus, and certain enterovirus types (for example, enterovirus 71, and the classic being polio) – may cause acute flaccid paralysis and can be confirmed by detecting the virus in cerebrospinal fluid and stool, to date virus testing for all viruses, including EV D-68, has been negative in all of the patients reported. Hopefully, 2015 will be the year that will allow us to more clearly understand this neurologic illness – and this is important because so far most children have shown minimal recovery of function.
4. If you see a child (or adult) who recently traveled to the Caribbean and returns with fever, rash, and joint pain, especially with severe pain of the hands and feet, think chikungunya virus infection. As of the end of October 2014, local transmission had been identified in 37 countries or territories in the Caribbean (including Puerto Rico and the U.S. Virgin Islands), with a total of 780,206 suspected cases and over 15,000 confirmed cases reported from these areas. Consider this in contrast to the numbers from 2006 through 2011, when 117 cases of chikungunya fever were reported in returning travelers. As of Dec. 2, a total of 1,911 chikungunya virus disease cases have been reported to ArboNET from U.S. states. The mosquito that transmits chikungunya virus can bite in day and night, and prevention relies on appropriate use of mosquito repellents. Physicians should be prepared to discuss the risks of this virus with travelers who plan a trip to the Caribbean, especially those at high risk, including those with underlying medical conditions, preexisting arthritis diagnoses, and pregnant women (because of the potential risk to newborns whose mothers develop intrapartum infection).
5. And lastly, Ebola. While there were reports that Ebola virus disease had emerged in West Africa as early as December of 2013, the scope of the outbreak and extent of loss of human life has been unbelievably huge. Dr. Carrie Byington, who is the current chair of the AAP Committee on Infectious Diseases, wrote an article in AAP News in October 2014 describing the needs of children who have been impacted by Ebola virus disease (EVD). She noted that UNICEF estimated there were at that time, over 4,000 Ebola orphans in the countries most affected by EVD, including Sierra Leone, Liberia, and Guinea, and that these countries urgently needed medical infrastructure for treatment and prevention of this disease. It appears that at least two Ebola vaccines will be deployed in West Africa in 2015, and it is not a moment too soon. While cases in Liberia seemed to be decreasing, it looks like Sierra Leone cases continue to mount.
Dr. Jackson is chief of pediatric infectious diseases at Children’s Mercy Hospital, Kansas City, Mo., and professor of pediatrics at the University of Missouri–Kansas City. Dr. Jackson was a member of the AAP Committee on Infectious Diseases who wrote the AAP clinical report entitled “Guidance on Management of Asymptomatic Neonates Born to Women With Active Genital Herpes Lesions,” but said she had no other conflicts of interest to disclose. E-mail her at [email protected].
Last year, there were five predictions made that appeared to be on the money – but there is more to the story!
1. The approach to diagnosis and treatment of influenza was essential knowledge for clinicians. Last year, we started seeing influenza activity early – with disease confirmed in mid-November, peaking during the week ending December 28, 2013 and trending downward in early January 2014. Hospitalizations were most common in young and middle aged adults and the 2009 H1N1 virus predominated.
This year, again we are seeing influenza early – with nearly all states reporting at least sporadic and local activity, and several states (Alaska, Florida, Louisiana, Massachusetts, and Texas) reporting regional activity as of the week ending November 24, 2014. At my institution, we’ve already tested over 500 children and over 100 were positive – influenza A (H3N2) strains are predominating. That may be important for the two reasons you’ll read below.
2. Invasive staphylococcal disease caused by methicillin-susceptible Staphylococcus aureus (MSSA) was more common than methicillin-resistant Staphylococcus aureus (MRSA), as the national burden of MRSA disease decreased (JAMA 2014;311:1438-9). The rates of clindamycin resistance continue to be pretty steady at approximately 15%-18%, but higher for MSSA than for MRSA – a point that is important to consider when empirically treating suspected invasive staphylococcal infection.
3. Multidrug resistant uropathogens took an increasingly prominent role in 2014, requiring careful approach to diagnosis (every child treated for urinary tract infection should have an appropriately obtained urine culture with an identified pathogen) and treatment (the drug used should be based on antibiotic susceptibility testing results). Particularly concerning is the emergence of carbapenem-resistant Enterobacteriaceae, which cause infection more commonly in hospitalized patients, those with indwelling devices, and those who have received long courses of antibiotics.
4. It was an outbreak year for parechovirus (HPeV), a viral pathogen causing meningitis in very young infants. Such infants present with signs and symptoms of meningitis but rarely show CSF pleocytosis. Diagnosis relies on the detection of the virus by polymerase chain reaction testing in CSF – a test which is not routinely available in many laboratories. At my institution this season, we saw nearly as many cases of parechovirus meningitis (n = 43) as we saw cases of enterovirus meningitis (n = 63). The parechovirus virus we detected was HPeV type 3, which can cause particularly severe disease in neonates.
5. Data confirmed that making human papillomavirus (HPV) vaccine a standard recommendation increased vaccine uptake and coverage. In February of 2014, a “Dear Colleague” letter that was endorsed by six leading medical organizations encouraged providers to promote HPV vaccination by giving a strong recommendation, citing data based on research conducted by the Centers for Disease Control and Prevention. We still have a long way to go as HPV vaccine coverage for teens remains at 35% for the three-dose series while meningococcal and Tdap vaccine (both vaccines that generally receive a standard recommendation by physicians) coverage is at nearly 90%.
So for 2015, I’ll start the discussion by saying there are five major developments I did not see coming for this past year, but that will remain relevant for the year 2015!
1. In June of 2014, live attenuated influenza vaccine (LAIV) was announced by the Advisory Committee on Immunization Practices to be the preferred vaccine in children aged 2-8 years. The American Academy of Pediatrics followed with a recommendation that either inactivated influenza vaccine (IIV) or LAIV be used for children, including children aged 2-8 years – the key being to give the vaccine as soon as one had it available. What was not known then and I did not predict was that newer data would confirm that in children aged 2-8 years who received LAIV last year when 2009 H1N1 strains predominated, there was essentially no coverage against 2009 H1N1 virus. This was in contrast to data from the prior 2 years and is as yet unexplained. The AAP continues to recommend that either vaccine be given and all children be immunized. That may be especially important this year as the influenza season started early. Disease will likely have been widespread by Christmas in many parts of the United States, and it looks like influenza A H3N2 strains will be most commonly noted. So the good news for young children who received LAIV is that 2009 H1N1 strains so far have not been seen this year. The bad news is that there are two H3N2 strains circulating, and potentially only one will be covered by the 2014-2015 seasonal vaccine. Staffing your office and hospital for a likely high census respiratory viral season is going to be essential.
2. The largest U.S. outbreak ever of enterovirus (EV) D-68 respiratory infection occurred between August and October of 2014. This virus – which had been identified in 1962 but was rarely described over the next 36 years except in small clusters of disease – was reported in nearly every state and characterized by unusually severe respiratory tract infection. Many, but not all children, had a history of asthma or prior wheezing, and the clinical presentation was that of severe bronchospasm that was generally resistant to standard bronchodilator therapy. The spectrum of infection likely ranged from mild upper respiratory infection to severe bronchospasm with respiratory failure, and the burden of disease resulting in hospitalization was substantial at many children’s hospitals. The big question now is what will enterovirus season 2015 bring us? The good news here is that we now have a test to rapidly diagnose EV D-68, which will allow us to more clearly understand the burden of disease – and potentially to define antiviral treatment (none of the current antivirals is effective) and prevention (there is no vaccine against EV D-68).
3. The etiology of the neurologic illness, which appeared to mimic polio and presented during the same time frame during which EV D-68 was circulating, is as yet unknown. As of Nov. 26, 2014, the CDC has received reports of 90 children in 32 states who meet a case definition consistent with acute flaccid myelitis. While certain viruses – including West Nile virus, herpes virus, adenovirus, and certain enterovirus types (for example, enterovirus 71, and the classic being polio) – may cause acute flaccid paralysis and can be confirmed by detecting the virus in cerebrospinal fluid and stool, to date virus testing for all viruses, including EV D-68, has been negative in all of the patients reported. Hopefully, 2015 will be the year that will allow us to more clearly understand this neurologic illness – and this is important because so far most children have shown minimal recovery of function.
4. If you see a child (or adult) who recently traveled to the Caribbean and returns with fever, rash, and joint pain, especially with severe pain of the hands and feet, think chikungunya virus infection. As of the end of October 2014, local transmission had been identified in 37 countries or territories in the Caribbean (including Puerto Rico and the U.S. Virgin Islands), with a total of 780,206 suspected cases and over 15,000 confirmed cases reported from these areas. Consider this in contrast to the numbers from 2006 through 2011, when 117 cases of chikungunya fever were reported in returning travelers. As of Dec. 2, a total of 1,911 chikungunya virus disease cases have been reported to ArboNET from U.S. states. The mosquito that transmits chikungunya virus can bite in day and night, and prevention relies on appropriate use of mosquito repellents. Physicians should be prepared to discuss the risks of this virus with travelers who plan a trip to the Caribbean, especially those at high risk, including those with underlying medical conditions, preexisting arthritis diagnoses, and pregnant women (because of the potential risk to newborns whose mothers develop intrapartum infection).
5. And lastly, Ebola. While there were reports that Ebola virus disease had emerged in West Africa as early as December of 2013, the scope of the outbreak and extent of loss of human life has been unbelievably huge. Dr. Carrie Byington, who is the current chair of the AAP Committee on Infectious Diseases, wrote an article in AAP News in October 2014 describing the needs of children who have been impacted by Ebola virus disease (EVD). She noted that UNICEF estimated there were at that time, over 4,000 Ebola orphans in the countries most affected by EVD, including Sierra Leone, Liberia, and Guinea, and that these countries urgently needed medical infrastructure for treatment and prevention of this disease. It appears that at least two Ebola vaccines will be deployed in West Africa in 2015, and it is not a moment too soon. While cases in Liberia seemed to be decreasing, it looks like Sierra Leone cases continue to mount.
Dr. Jackson is chief of pediatric infectious diseases at Children’s Mercy Hospital, Kansas City, Mo., and professor of pediatrics at the University of Missouri–Kansas City. Dr. Jackson was a member of the AAP Committee on Infectious Diseases who wrote the AAP clinical report entitled “Guidance on Management of Asymptomatic Neonates Born to Women With Active Genital Herpes Lesions,” but said she had no other conflicts of interest to disclose. E-mail her at [email protected].
Last year, there were five predictions made that appeared to be on the money – but there is more to the story!
1. The approach to diagnosis and treatment of influenza was essential knowledge for clinicians. Last year, we started seeing influenza activity early – with disease confirmed in mid-November, peaking during the week ending December 28, 2013 and trending downward in early January 2014. Hospitalizations were most common in young and middle aged adults and the 2009 H1N1 virus predominated.
This year, again we are seeing influenza early – with nearly all states reporting at least sporadic and local activity, and several states (Alaska, Florida, Louisiana, Massachusetts, and Texas) reporting regional activity as of the week ending November 24, 2014. At my institution, we’ve already tested over 500 children and over 100 were positive – influenza A (H3N2) strains are predominating. That may be important for the two reasons you’ll read below.
2. Invasive staphylococcal disease caused by methicillin-susceptible Staphylococcus aureus (MSSA) was more common than methicillin-resistant Staphylococcus aureus (MRSA), as the national burden of MRSA disease decreased (JAMA 2014;311:1438-9). The rates of clindamycin resistance continue to be pretty steady at approximately 15%-18%, but higher for MSSA than for MRSA – a point that is important to consider when empirically treating suspected invasive staphylococcal infection.
3. Multidrug resistant uropathogens took an increasingly prominent role in 2014, requiring careful approach to diagnosis (every child treated for urinary tract infection should have an appropriately obtained urine culture with an identified pathogen) and treatment (the drug used should be based on antibiotic susceptibility testing results). Particularly concerning is the emergence of carbapenem-resistant Enterobacteriaceae, which cause infection more commonly in hospitalized patients, those with indwelling devices, and those who have received long courses of antibiotics.
4. It was an outbreak year for parechovirus (HPeV), a viral pathogen causing meningitis in very young infants. Such infants present with signs and symptoms of meningitis but rarely show CSF pleocytosis. Diagnosis relies on the detection of the virus by polymerase chain reaction testing in CSF – a test which is not routinely available in many laboratories. At my institution this season, we saw nearly as many cases of parechovirus meningitis (n = 43) as we saw cases of enterovirus meningitis (n = 63). The parechovirus virus we detected was HPeV type 3, which can cause particularly severe disease in neonates.
5. Data confirmed that making human papillomavirus (HPV) vaccine a standard recommendation increased vaccine uptake and coverage. In February of 2014, a “Dear Colleague” letter that was endorsed by six leading medical organizations encouraged providers to promote HPV vaccination by giving a strong recommendation, citing data based on research conducted by the Centers for Disease Control and Prevention. We still have a long way to go as HPV vaccine coverage for teens remains at 35% for the three-dose series while meningococcal and Tdap vaccine (both vaccines that generally receive a standard recommendation by physicians) coverage is at nearly 90%.
So for 2015, I’ll start the discussion by saying there are five major developments I did not see coming for this past year, but that will remain relevant for the year 2015!
1. In June of 2014, live attenuated influenza vaccine (LAIV) was announced by the Advisory Committee on Immunization Practices to be the preferred vaccine in children aged 2-8 years. The American Academy of Pediatrics followed with a recommendation that either inactivated influenza vaccine (IIV) or LAIV be used for children, including children aged 2-8 years – the key being to give the vaccine as soon as one had it available. What was not known then and I did not predict was that newer data would confirm that in children aged 2-8 years who received LAIV last year when 2009 H1N1 strains predominated, there was essentially no coverage against 2009 H1N1 virus. This was in contrast to data from the prior 2 years and is as yet unexplained. The AAP continues to recommend that either vaccine be given and all children be immunized. That may be especially important this year as the influenza season started early. Disease will likely have been widespread by Christmas in many parts of the United States, and it looks like influenza A H3N2 strains will be most commonly noted. So the good news for young children who received LAIV is that 2009 H1N1 strains so far have not been seen this year. The bad news is that there are two H3N2 strains circulating, and potentially only one will be covered by the 2014-2015 seasonal vaccine. Staffing your office and hospital for a likely high census respiratory viral season is going to be essential.
2. The largest U.S. outbreak ever of enterovirus (EV) D-68 respiratory infection occurred between August and October of 2014. This virus – which had been identified in 1962 but was rarely described over the next 36 years except in small clusters of disease – was reported in nearly every state and characterized by unusually severe respiratory tract infection. Many, but not all children, had a history of asthma or prior wheezing, and the clinical presentation was that of severe bronchospasm that was generally resistant to standard bronchodilator therapy. The spectrum of infection likely ranged from mild upper respiratory infection to severe bronchospasm with respiratory failure, and the burden of disease resulting in hospitalization was substantial at many children’s hospitals. The big question now is what will enterovirus season 2015 bring us? The good news here is that we now have a test to rapidly diagnose EV D-68, which will allow us to more clearly understand the burden of disease – and potentially to define antiviral treatment (none of the current antivirals is effective) and prevention (there is no vaccine against EV D-68).
3. The etiology of the neurologic illness, which appeared to mimic polio and presented during the same time frame during which EV D-68 was circulating, is as yet unknown. As of Nov. 26, 2014, the CDC has received reports of 90 children in 32 states who meet a case definition consistent with acute flaccid myelitis. While certain viruses – including West Nile virus, herpes virus, adenovirus, and certain enterovirus types (for example, enterovirus 71, and the classic being polio) – may cause acute flaccid paralysis and can be confirmed by detecting the virus in cerebrospinal fluid and stool, to date virus testing for all viruses, including EV D-68, has been negative in all of the patients reported. Hopefully, 2015 will be the year that will allow us to more clearly understand this neurologic illness – and this is important because so far most children have shown minimal recovery of function.
4. If you see a child (or adult) who recently traveled to the Caribbean and returns with fever, rash, and joint pain, especially with severe pain of the hands and feet, think chikungunya virus infection. As of the end of October 2014, local transmission had been identified in 37 countries or territories in the Caribbean (including Puerto Rico and the U.S. Virgin Islands), with a total of 780,206 suspected cases and over 15,000 confirmed cases reported from these areas. Consider this in contrast to the numbers from 2006 through 2011, when 117 cases of chikungunya fever were reported in returning travelers. As of Dec. 2, a total of 1,911 chikungunya virus disease cases have been reported to ArboNET from U.S. states. The mosquito that transmits chikungunya virus can bite in day and night, and prevention relies on appropriate use of mosquito repellents. Physicians should be prepared to discuss the risks of this virus with travelers who plan a trip to the Caribbean, especially those at high risk, including those with underlying medical conditions, preexisting arthritis diagnoses, and pregnant women (because of the potential risk to newborns whose mothers develop intrapartum infection).
5. And lastly, Ebola. While there were reports that Ebola virus disease had emerged in West Africa as early as December of 2013, the scope of the outbreak and extent of loss of human life has been unbelievably huge. Dr. Carrie Byington, who is the current chair of the AAP Committee on Infectious Diseases, wrote an article in AAP News in October 2014 describing the needs of children who have been impacted by Ebola virus disease (EVD). She noted that UNICEF estimated there were at that time, over 4,000 Ebola orphans in the countries most affected by EVD, including Sierra Leone, Liberia, and Guinea, and that these countries urgently needed medical infrastructure for treatment and prevention of this disease. It appears that at least two Ebola vaccines will be deployed in West Africa in 2015, and it is not a moment too soon. While cases in Liberia seemed to be decreasing, it looks like Sierra Leone cases continue to mount.
Dr. Jackson is chief of pediatric infectious diseases at Children’s Mercy Hospital, Kansas City, Mo., and professor of pediatrics at the University of Missouri–Kansas City. Dr. Jackson was a member of the AAP Committee on Infectious Diseases who wrote the AAP clinical report entitled “Guidance on Management of Asymptomatic Neonates Born to Women With Active Genital Herpes Lesions,” but said she had no other conflicts of interest to disclose. E-mail her at [email protected].
