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Which vaginal procedure is best for uterine prolapse?
More than one-third of women aged 45 years or older experience uterine prolapse, a condition that can impair physical, psychological, and sexual function. To compare vaginal vault suspension with hysterectomy, investigators at 4 large Dutch teaching hospitals from 2009 to 2012 randomly assigned women with uterine prolapse to sacrospinous hysteropexy (SSLF) or vaginal hysterectomy with uterosacral ligament suspension (ULS). The primary outcome was recurrent stage 2 or greater prolapse (within 1 cm or more of the hymenal ring) with bothersome bulge symptoms or repeat surgery for prolapse by 12 months follow-up.
Details of the trialOne hundred two women assigned to SSLF (median age, 62.7 years) and 100 assigned to hysterectomy with ULS (median age, 61.9 years) were analyzed for the primary outcome. The patients ranged in age from 33 to 85 years.
Surgical failure rates and adverse events were similarMean hospital stay was 3 days in both groups and the occurrence of urinary retention was likewise similar (15% for SSLF and 11% for hysterectomy with ULS). At 12 months, 0 and 4 women in the SSLF and hysterectomy with ULS groups, respectively, met the primary outcome. Study participants were considered a “surgical failure” if any type of prolapse with bothersome symptoms or repeat surgery or pessary use occurred. Failures occurred in approximately one-half of the women in both groups.
Rates of serious adverse events were low, and none were related to type of surgery. Nine women experienced buttock pain following SSLF hysteropexy, a known complication of this surgery. This pain resolved within 6 weeks in 8 of these women. In the remaining woman, persistent pain led to release of the hysteropexy suture and vaginal hysterectomy 4 months after her initial procedure.
What this evidence means for practice
Advantages of hysterectomy at the time of vaginal vault suspension include prevention of endometrial and cervical cancers as well as elimination of uterine bleeding. However, data from published surveys indicate that many US women with prolapse prefer to avoid hysterectomy if effective alternate surgeries are available.1
In the previously published 2014 Barber and colleagues’ OPTIMAL trial,1,2 the efficacy of vaginal hysterectomy with either SSLF or USL was equivalent (63.1% versus 64.5%, respectively). The success rates are lower for both procedures in this trial by Detollenaere and colleagues.
Both SSLF and ULS may result in life-altering buttock or leg pain, necessitating removal of the offending sutures; however, the ULS procedure offers a more anatomically correct result. Although the short follow-up interval represents a limitation, these trial results suggest that sacrospinous fixation without hysterectomy represents a reasonable option for women with bothersome uterine prolapse who would like to avoid hysterectomy.
—Meadow M. Good, DO, and Andrew M. Kaunitz, MD
Share your thoughts on this article! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.
- Korbly N, Kassis N, Good MM, et al. Patient preference for uterine preservation in women with pelvic organ prolapse: a fellow’s pelvic network research study. Am J Obstet Gynecol. 2013;209(5):470.e1−e6.
- Barber MD, Brubaker L, Burgio KL, et al. Comparison of 2 transvaginal surgical approaches and perioperative behavioral therapy for apical vaginal prolapse. The OPTIMAL randomized trial. JAMA. 2014;311(10):1023–1034.
More than one-third of women aged 45 years or older experience uterine prolapse, a condition that can impair physical, psychological, and sexual function. To compare vaginal vault suspension with hysterectomy, investigators at 4 large Dutch teaching hospitals from 2009 to 2012 randomly assigned women with uterine prolapse to sacrospinous hysteropexy (SSLF) or vaginal hysterectomy with uterosacral ligament suspension (ULS). The primary outcome was recurrent stage 2 or greater prolapse (within 1 cm or more of the hymenal ring) with bothersome bulge symptoms or repeat surgery for prolapse by 12 months follow-up.
Details of the trialOne hundred two women assigned to SSLF (median age, 62.7 years) and 100 assigned to hysterectomy with ULS (median age, 61.9 years) were analyzed for the primary outcome. The patients ranged in age from 33 to 85 years.
Surgical failure rates and adverse events were similarMean hospital stay was 3 days in both groups and the occurrence of urinary retention was likewise similar (15% for SSLF and 11% for hysterectomy with ULS). At 12 months, 0 and 4 women in the SSLF and hysterectomy with ULS groups, respectively, met the primary outcome. Study participants were considered a “surgical failure” if any type of prolapse with bothersome symptoms or repeat surgery or pessary use occurred. Failures occurred in approximately one-half of the women in both groups.
Rates of serious adverse events were low, and none were related to type of surgery. Nine women experienced buttock pain following SSLF hysteropexy, a known complication of this surgery. This pain resolved within 6 weeks in 8 of these women. In the remaining woman, persistent pain led to release of the hysteropexy suture and vaginal hysterectomy 4 months after her initial procedure.
What this evidence means for practice
Advantages of hysterectomy at the time of vaginal vault suspension include prevention of endometrial and cervical cancers as well as elimination of uterine bleeding. However, data from published surveys indicate that many US women with prolapse prefer to avoid hysterectomy if effective alternate surgeries are available.1
In the previously published 2014 Barber and colleagues’ OPTIMAL trial,1,2 the efficacy of vaginal hysterectomy with either SSLF or USL was equivalent (63.1% versus 64.5%, respectively). The success rates are lower for both procedures in this trial by Detollenaere and colleagues.
Both SSLF and ULS may result in life-altering buttock or leg pain, necessitating removal of the offending sutures; however, the ULS procedure offers a more anatomically correct result. Although the short follow-up interval represents a limitation, these trial results suggest that sacrospinous fixation without hysterectomy represents a reasonable option for women with bothersome uterine prolapse who would like to avoid hysterectomy.
—Meadow M. Good, DO, and Andrew M. Kaunitz, MD
Share your thoughts on this article! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.
More than one-third of women aged 45 years or older experience uterine prolapse, a condition that can impair physical, psychological, and sexual function. To compare vaginal vault suspension with hysterectomy, investigators at 4 large Dutch teaching hospitals from 2009 to 2012 randomly assigned women with uterine prolapse to sacrospinous hysteropexy (SSLF) or vaginal hysterectomy with uterosacral ligament suspension (ULS). The primary outcome was recurrent stage 2 or greater prolapse (within 1 cm or more of the hymenal ring) with bothersome bulge symptoms or repeat surgery for prolapse by 12 months follow-up.
Details of the trialOne hundred two women assigned to SSLF (median age, 62.7 years) and 100 assigned to hysterectomy with ULS (median age, 61.9 years) were analyzed for the primary outcome. The patients ranged in age from 33 to 85 years.
Surgical failure rates and adverse events were similarMean hospital stay was 3 days in both groups and the occurrence of urinary retention was likewise similar (15% for SSLF and 11% for hysterectomy with ULS). At 12 months, 0 and 4 women in the SSLF and hysterectomy with ULS groups, respectively, met the primary outcome. Study participants were considered a “surgical failure” if any type of prolapse with bothersome symptoms or repeat surgery or pessary use occurred. Failures occurred in approximately one-half of the women in both groups.
Rates of serious adverse events were low, and none were related to type of surgery. Nine women experienced buttock pain following SSLF hysteropexy, a known complication of this surgery. This pain resolved within 6 weeks in 8 of these women. In the remaining woman, persistent pain led to release of the hysteropexy suture and vaginal hysterectomy 4 months after her initial procedure.
What this evidence means for practice
Advantages of hysterectomy at the time of vaginal vault suspension include prevention of endometrial and cervical cancers as well as elimination of uterine bleeding. However, data from published surveys indicate that many US women with prolapse prefer to avoid hysterectomy if effective alternate surgeries are available.1
In the previously published 2014 Barber and colleagues’ OPTIMAL trial,1,2 the efficacy of vaginal hysterectomy with either SSLF or USL was equivalent (63.1% versus 64.5%, respectively). The success rates are lower for both procedures in this trial by Detollenaere and colleagues.
Both SSLF and ULS may result in life-altering buttock or leg pain, necessitating removal of the offending sutures; however, the ULS procedure offers a more anatomically correct result. Although the short follow-up interval represents a limitation, these trial results suggest that sacrospinous fixation without hysterectomy represents a reasonable option for women with bothersome uterine prolapse who would like to avoid hysterectomy.
—Meadow M. Good, DO, and Andrew M. Kaunitz, MD
Share your thoughts on this article! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.
- Korbly N, Kassis N, Good MM, et al. Patient preference for uterine preservation in women with pelvic organ prolapse: a fellow’s pelvic network research study. Am J Obstet Gynecol. 2013;209(5):470.e1−e6.
- Barber MD, Brubaker L, Burgio KL, et al. Comparison of 2 transvaginal surgical approaches and perioperative behavioral therapy for apical vaginal prolapse. The OPTIMAL randomized trial. JAMA. 2014;311(10):1023–1034.
- Korbly N, Kassis N, Good MM, et al. Patient preference for uterine preservation in women with pelvic organ prolapse: a fellow’s pelvic network research study. Am J Obstet Gynecol. 2013;209(5):470.e1−e6.
- Barber MD, Brubaker L, Burgio KL, et al. Comparison of 2 transvaginal surgical approaches and perioperative behavioral therapy for apical vaginal prolapse. The OPTIMAL randomized trial. JAMA. 2014;311(10):1023–1034.
Does the injection of ketorolac prior to IUD placement reduce pain?
Although the use of intrauterine devices (IUDs) is increasing, these highly effective contraceptives remain underutilized in the United States, compared with other developed countries. Concerns about pain with insertion represent one barrier to use.
In a double-blind trial, Ngo and colleagues randomly assigned women presenting for first-time IUD placement from 2012 to 2014 to either:
- ketorolac, a potent nonsteroidal anti-inflammatory drug (NSAID) (1-mL gluteal intramuscular injection of 30 mg of ketorolac) or
- saline (1-mL saline intramuscular injection).
The injection was given 30 minutes prior to IUD placement.
Pain associated with injection of the study drug, speculum and tenaculum placement, uterine sounding, IUD placement, and postinsertion pain were measured using a visual analog scale from 0 cm (no pain) to 10 cm (worst pain possible).
Of 67 participants (mean age, approximately 27 years; white race, 33%; African-American race, 33%; median parity, 1), pain was similar between ketorolac and placebo arms for all parameters except postinsertion pain, which was 0 cm and 1.3 cm for ketorolac and placebo, respectively, 15 minutes after placement (P<.001).
Although approximately 75% of participants reported that pain from the injection was “not as bad” as the pain from IUD placement, about 1 in 5 indicated that injection pain was equivalent to pain from IUD placement. Regardless of study group allocation, more than 90% of participants reported being satisfied or very satisfied with IUD placement overall, and more than 75% said they would recommend IUD placement to a friend.
More than 90% of women were satisfied with IUD placement, regardless of study allocation
As Ngo and colleagues observe, the analgesic effect of ketorolac peaks 1 to 2 hours after injection. This observation may explain why pain reduction was noted only after IUD insertion. Although ketorolac is not expensive, logistic considerations may make its routine use prior to IUD placement unrealistic in many ambulatory settings. Further, the great majority of participants (>90%) reported being satisfied with their IUD placement experience overall, regardless of study allocation.
Earlier studies suggesting that preplacement oral NSAIDs are ineffective in reducing placement pain involved the administration of analgesia in the clinic less than 1 hour before IUD insertion. I agree with Ngo and colleagues that future trials of oral NSAIDs should focus on administration of the medication prior to arrival at the clinic.
What this evidence means for practice
Findings from this randomized controlled trial provide only limited support for injection of an NSAID prior to IUD placement.
--Andrew M. Kaunitz, MD
Although the use of intrauterine devices (IUDs) is increasing, these highly effective contraceptives remain underutilized in the United States, compared with other developed countries. Concerns about pain with insertion represent one barrier to use.
In a double-blind trial, Ngo and colleagues randomly assigned women presenting for first-time IUD placement from 2012 to 2014 to either:
- ketorolac, a potent nonsteroidal anti-inflammatory drug (NSAID) (1-mL gluteal intramuscular injection of 30 mg of ketorolac) or
- saline (1-mL saline intramuscular injection).
The injection was given 30 minutes prior to IUD placement.
Pain associated with injection of the study drug, speculum and tenaculum placement, uterine sounding, IUD placement, and postinsertion pain were measured using a visual analog scale from 0 cm (no pain) to 10 cm (worst pain possible).
Of 67 participants (mean age, approximately 27 years; white race, 33%; African-American race, 33%; median parity, 1), pain was similar between ketorolac and placebo arms for all parameters except postinsertion pain, which was 0 cm and 1.3 cm for ketorolac and placebo, respectively, 15 minutes after placement (P<.001).
Although approximately 75% of participants reported that pain from the injection was “not as bad” as the pain from IUD placement, about 1 in 5 indicated that injection pain was equivalent to pain from IUD placement. Regardless of study group allocation, more than 90% of participants reported being satisfied or very satisfied with IUD placement overall, and more than 75% said they would recommend IUD placement to a friend.
More than 90% of women were satisfied with IUD placement, regardless of study allocation
As Ngo and colleagues observe, the analgesic effect of ketorolac peaks 1 to 2 hours after injection. This observation may explain why pain reduction was noted only after IUD insertion. Although ketorolac is not expensive, logistic considerations may make its routine use prior to IUD placement unrealistic in many ambulatory settings. Further, the great majority of participants (>90%) reported being satisfied with their IUD placement experience overall, regardless of study allocation.
Earlier studies suggesting that preplacement oral NSAIDs are ineffective in reducing placement pain involved the administration of analgesia in the clinic less than 1 hour before IUD insertion. I agree with Ngo and colleagues that future trials of oral NSAIDs should focus on administration of the medication prior to arrival at the clinic.
What this evidence means for practice
Findings from this randomized controlled trial provide only limited support for injection of an NSAID prior to IUD placement.
--Andrew M. Kaunitz, MD
Although the use of intrauterine devices (IUDs) is increasing, these highly effective contraceptives remain underutilized in the United States, compared with other developed countries. Concerns about pain with insertion represent one barrier to use.
In a double-blind trial, Ngo and colleagues randomly assigned women presenting for first-time IUD placement from 2012 to 2014 to either:
- ketorolac, a potent nonsteroidal anti-inflammatory drug (NSAID) (1-mL gluteal intramuscular injection of 30 mg of ketorolac) or
- saline (1-mL saline intramuscular injection).
The injection was given 30 minutes prior to IUD placement.
Pain associated with injection of the study drug, speculum and tenaculum placement, uterine sounding, IUD placement, and postinsertion pain were measured using a visual analog scale from 0 cm (no pain) to 10 cm (worst pain possible).
Of 67 participants (mean age, approximately 27 years; white race, 33%; African-American race, 33%; median parity, 1), pain was similar between ketorolac and placebo arms for all parameters except postinsertion pain, which was 0 cm and 1.3 cm for ketorolac and placebo, respectively, 15 minutes after placement (P<.001).
Although approximately 75% of participants reported that pain from the injection was “not as bad” as the pain from IUD placement, about 1 in 5 indicated that injection pain was equivalent to pain from IUD placement. Regardless of study group allocation, more than 90% of participants reported being satisfied or very satisfied with IUD placement overall, and more than 75% said they would recommend IUD placement to a friend.
More than 90% of women were satisfied with IUD placement, regardless of study allocation
As Ngo and colleagues observe, the analgesic effect of ketorolac peaks 1 to 2 hours after injection. This observation may explain why pain reduction was noted only after IUD insertion. Although ketorolac is not expensive, logistic considerations may make its routine use prior to IUD placement unrealistic in many ambulatory settings. Further, the great majority of participants (>90%) reported being satisfied with their IUD placement experience overall, regardless of study allocation.
Earlier studies suggesting that preplacement oral NSAIDs are ineffective in reducing placement pain involved the administration of analgesia in the clinic less than 1 hour before IUD insertion. I agree with Ngo and colleagues that future trials of oral NSAIDs should focus on administration of the medication prior to arrival at the clinic.
What this evidence means for practice
Findings from this randomized controlled trial provide only limited support for injection of an NSAID prior to IUD placement.
--Andrew M. Kaunitz, MD
Surgical bolt cutters quickly cut titanium ring
Clinicians can use a pair of large surgical bolt cutters to safely and quickly cut a titanium ring from a patient’s swollen finger, and then can pull apart the edges with two paper clips, according to a letter published online in Emergency Medicine Journal.
“Our method used simple equipment that is readily available in most hospitals at all times, took less than 30 seconds to perform, and could be performed by a sole operator without damage to the underlying finger,” wrote Dr. Andrej Salibi and Dr. Andrew Morritt at Sheffield (England) Teaching Hospital NHS Foundation (2015 Aug 13; doi: 10.1136/emermed-2015-204962).
Ring constriction is a fairly common problem that can cause necrosis and loss of the digit if the ring is not removed. Basic ring cutters can sever gold and silver, but not titanium, which has become popular for rings because it is hypoallergenic, durable, lightweight, and strong – so strong that diamond-tipped saws or drills can take up to 15 minutes to cut these rings, the surgeons noted. Many facilities also lack access to such equipment, and it generates enough heat that an assistant must irrigate the surrounding skin to prevent burns, they said.
Their case report described a patient who bathed in warm water at a spa and developed a painful, swollen finger that was constricted by a titanium wedding band. Elevation and lubrication at the emergency department failed to remove the ring, as did finger binding and use of a manual ring cutter.
“The fire service was called and attempted removal using specialized cutting equipment, which also failed,” the surgeons wrote. “The patient was then admitted under the plastic surgery service for hand elevation, and further attempts 8 hours later blunted two manual ring cutters.” At this point, they borrowed a large pair of bolt cutters from the operating room, which quickly severed the ring without harming the finger. Then they applied lateral traction with a pair of paper clips and removed it, they said.
The authors declared no funding sources or conflicts of interest.
Clinicians can use a pair of large surgical bolt cutters to safely and quickly cut a titanium ring from a patient’s swollen finger, and then can pull apart the edges with two paper clips, according to a letter published online in Emergency Medicine Journal.
“Our method used simple equipment that is readily available in most hospitals at all times, took less than 30 seconds to perform, and could be performed by a sole operator without damage to the underlying finger,” wrote Dr. Andrej Salibi and Dr. Andrew Morritt at Sheffield (England) Teaching Hospital NHS Foundation (2015 Aug 13; doi: 10.1136/emermed-2015-204962).
Ring constriction is a fairly common problem that can cause necrosis and loss of the digit if the ring is not removed. Basic ring cutters can sever gold and silver, but not titanium, which has become popular for rings because it is hypoallergenic, durable, lightweight, and strong – so strong that diamond-tipped saws or drills can take up to 15 minutes to cut these rings, the surgeons noted. Many facilities also lack access to such equipment, and it generates enough heat that an assistant must irrigate the surrounding skin to prevent burns, they said.
Their case report described a patient who bathed in warm water at a spa and developed a painful, swollen finger that was constricted by a titanium wedding band. Elevation and lubrication at the emergency department failed to remove the ring, as did finger binding and use of a manual ring cutter.
“The fire service was called and attempted removal using specialized cutting equipment, which also failed,” the surgeons wrote. “The patient was then admitted under the plastic surgery service for hand elevation, and further attempts 8 hours later blunted two manual ring cutters.” At this point, they borrowed a large pair of bolt cutters from the operating room, which quickly severed the ring without harming the finger. Then they applied lateral traction with a pair of paper clips and removed it, they said.
The authors declared no funding sources or conflicts of interest.
Clinicians can use a pair of large surgical bolt cutters to safely and quickly cut a titanium ring from a patient’s swollen finger, and then can pull apart the edges with two paper clips, according to a letter published online in Emergency Medicine Journal.
“Our method used simple equipment that is readily available in most hospitals at all times, took less than 30 seconds to perform, and could be performed by a sole operator without damage to the underlying finger,” wrote Dr. Andrej Salibi and Dr. Andrew Morritt at Sheffield (England) Teaching Hospital NHS Foundation (2015 Aug 13; doi: 10.1136/emermed-2015-204962).
Ring constriction is a fairly common problem that can cause necrosis and loss of the digit if the ring is not removed. Basic ring cutters can sever gold and silver, but not titanium, which has become popular for rings because it is hypoallergenic, durable, lightweight, and strong – so strong that diamond-tipped saws or drills can take up to 15 minutes to cut these rings, the surgeons noted. Many facilities also lack access to such equipment, and it generates enough heat that an assistant must irrigate the surrounding skin to prevent burns, they said.
Their case report described a patient who bathed in warm water at a spa and developed a painful, swollen finger that was constricted by a titanium wedding band. Elevation and lubrication at the emergency department failed to remove the ring, as did finger binding and use of a manual ring cutter.
“The fire service was called and attempted removal using specialized cutting equipment, which also failed,” the surgeons wrote. “The patient was then admitted under the plastic surgery service for hand elevation, and further attempts 8 hours later blunted two manual ring cutters.” At this point, they borrowed a large pair of bolt cutters from the operating room, which quickly severed the ring without harming the finger. Then they applied lateral traction with a pair of paper clips and removed it, they said.
The authors declared no funding sources or conflicts of interest.
FROM EMERGENCY MEDICINE JOURNAL
WCD: Watch for these emerging infections
VANCOUVER – Two serious emerging skin and soft tissue infections whose progress physicians will want to chart are melioidosis and Acinetobacter baumannii infection, Dr. Dirk M. Elston advised at the World Congress of Dermatology.
Both Burkholderia pseudomallei – the cause of melioidosis – and Acinetobacter baumannii are gram-negative organisms that laboratory staff sometimes mistakenly dismiss as culture contaminants. But melioidosis has a case fatality rate of up to 40%, and A. baumannii is an increasingly multidrug-resistant cause of community-acquired cellulitis, according to Dr. Elston, chair of the department of dermatology and dermatologic surgery at the Medical University of South Carolina, Charleston.
Dr. Elston, also managing director of the Ackerman Academy of Dermatopathology in New York, offered his views on these two emerging infections.
Melioidosis
“We know melioidosis from the rice paddies of Vietnam as a plaguelike ulceroglandular syndrome. It has reemerged in the Caribbean,” Dr. Elston reported.
Indeed, investigators at the Centers for Disease Control and Prevention reported earlier this year that melioidosis is now endemic in Puerto Rico based upon its findings of high seropositivity rates among patient contacts plus isolation of the causative organism from soil samples (Clin Infect Dis. 2015 Jan 15;60(2):243-250). The infection, which is believed to be underdiagnosed, also has been reported at numerous other sites in the Caribbean basin and in Latin America and Africa, as well as in Southeast Asia.
Although skin and soft tissue abscesses are common manifestations of this acute febrile illness, the most common clinical presentation of melioidosis is acute pneumonia with or without septicemia, which can be fulminant.
According to the CDC investigators, up to 80% of patients with melioidosis have diabetes, chronic lung disease, and/or excessive alcohol use as risk factors for the infection. In the Puerto Rican study, a history of injection drug use was for the first time identified as another risk factor. When in endemic areas such as Puerto Rico, individuals with diabetes or other risk factors should protect themselves from direct exposure to soil and water to reduce their risk of what is believed to be a transcutaneously acquired infection. The investigators advised that individuals with skin wounds or sores do the same.
The recommended treatment for melioidosis is intravenous ceftazidime, imipenem, or meropenem (N Engl J Med. 2012 Sep 13;367(11):1035-1044).
A. baumannii infection
In a recent report, Dr. Adam J. Friedman and his colleagues at the Albert Einstein College of Medicine in New York said that A. baumannii’s pattern of evolution to date is strikingly similar to that of methicillin-resistant Staphylococcus aureus. A. baumannii has displayed increasing pathogenicity and antibiotic resistance. The investigators warned that there is a real danger that, like MRSA, extensively drug-resistant A. baumannii will become a common community-acquired infection arising in previously healthy patients (JAMA Dermatol. 2014 Aug;150(8):905-906).
“There are some strains of gonococcus and some strains of Acinetobacter baumannii that appear to be resistant to all known antibiotics,” Dr. Elston said.
He reported having no relevant financial conflicts of interest.
VANCOUVER – Two serious emerging skin and soft tissue infections whose progress physicians will want to chart are melioidosis and Acinetobacter baumannii infection, Dr. Dirk M. Elston advised at the World Congress of Dermatology.
Both Burkholderia pseudomallei – the cause of melioidosis – and Acinetobacter baumannii are gram-negative organisms that laboratory staff sometimes mistakenly dismiss as culture contaminants. But melioidosis has a case fatality rate of up to 40%, and A. baumannii is an increasingly multidrug-resistant cause of community-acquired cellulitis, according to Dr. Elston, chair of the department of dermatology and dermatologic surgery at the Medical University of South Carolina, Charleston.
Dr. Elston, also managing director of the Ackerman Academy of Dermatopathology in New York, offered his views on these two emerging infections.
Melioidosis
“We know melioidosis from the rice paddies of Vietnam as a plaguelike ulceroglandular syndrome. It has reemerged in the Caribbean,” Dr. Elston reported.
Indeed, investigators at the Centers for Disease Control and Prevention reported earlier this year that melioidosis is now endemic in Puerto Rico based upon its findings of high seropositivity rates among patient contacts plus isolation of the causative organism from soil samples (Clin Infect Dis. 2015 Jan 15;60(2):243-250). The infection, which is believed to be underdiagnosed, also has been reported at numerous other sites in the Caribbean basin and in Latin America and Africa, as well as in Southeast Asia.
Although skin and soft tissue abscesses are common manifestations of this acute febrile illness, the most common clinical presentation of melioidosis is acute pneumonia with or without septicemia, which can be fulminant.
According to the CDC investigators, up to 80% of patients with melioidosis have diabetes, chronic lung disease, and/or excessive alcohol use as risk factors for the infection. In the Puerto Rican study, a history of injection drug use was for the first time identified as another risk factor. When in endemic areas such as Puerto Rico, individuals with diabetes or other risk factors should protect themselves from direct exposure to soil and water to reduce their risk of what is believed to be a transcutaneously acquired infection. The investigators advised that individuals with skin wounds or sores do the same.
The recommended treatment for melioidosis is intravenous ceftazidime, imipenem, or meropenem (N Engl J Med. 2012 Sep 13;367(11):1035-1044).
A. baumannii infection
In a recent report, Dr. Adam J. Friedman and his colleagues at the Albert Einstein College of Medicine in New York said that A. baumannii’s pattern of evolution to date is strikingly similar to that of methicillin-resistant Staphylococcus aureus. A. baumannii has displayed increasing pathogenicity and antibiotic resistance. The investigators warned that there is a real danger that, like MRSA, extensively drug-resistant A. baumannii will become a common community-acquired infection arising in previously healthy patients (JAMA Dermatol. 2014 Aug;150(8):905-906).
“There are some strains of gonococcus and some strains of Acinetobacter baumannii that appear to be resistant to all known antibiotics,” Dr. Elston said.
He reported having no relevant financial conflicts of interest.
VANCOUVER – Two serious emerging skin and soft tissue infections whose progress physicians will want to chart are melioidosis and Acinetobacter baumannii infection, Dr. Dirk M. Elston advised at the World Congress of Dermatology.
Both Burkholderia pseudomallei – the cause of melioidosis – and Acinetobacter baumannii are gram-negative organisms that laboratory staff sometimes mistakenly dismiss as culture contaminants. But melioidosis has a case fatality rate of up to 40%, and A. baumannii is an increasingly multidrug-resistant cause of community-acquired cellulitis, according to Dr. Elston, chair of the department of dermatology and dermatologic surgery at the Medical University of South Carolina, Charleston.
Dr. Elston, also managing director of the Ackerman Academy of Dermatopathology in New York, offered his views on these two emerging infections.
Melioidosis
“We know melioidosis from the rice paddies of Vietnam as a plaguelike ulceroglandular syndrome. It has reemerged in the Caribbean,” Dr. Elston reported.
Indeed, investigators at the Centers for Disease Control and Prevention reported earlier this year that melioidosis is now endemic in Puerto Rico based upon its findings of high seropositivity rates among patient contacts plus isolation of the causative organism from soil samples (Clin Infect Dis. 2015 Jan 15;60(2):243-250). The infection, which is believed to be underdiagnosed, also has been reported at numerous other sites in the Caribbean basin and in Latin America and Africa, as well as in Southeast Asia.
Although skin and soft tissue abscesses are common manifestations of this acute febrile illness, the most common clinical presentation of melioidosis is acute pneumonia with or without septicemia, which can be fulminant.
According to the CDC investigators, up to 80% of patients with melioidosis have diabetes, chronic lung disease, and/or excessive alcohol use as risk factors for the infection. In the Puerto Rican study, a history of injection drug use was for the first time identified as another risk factor. When in endemic areas such as Puerto Rico, individuals with diabetes or other risk factors should protect themselves from direct exposure to soil and water to reduce their risk of what is believed to be a transcutaneously acquired infection. The investigators advised that individuals with skin wounds or sores do the same.
The recommended treatment for melioidosis is intravenous ceftazidime, imipenem, or meropenem (N Engl J Med. 2012 Sep 13;367(11):1035-1044).
A. baumannii infection
In a recent report, Dr. Adam J. Friedman and his colleagues at the Albert Einstein College of Medicine in New York said that A. baumannii’s pattern of evolution to date is strikingly similar to that of methicillin-resistant Staphylococcus aureus. A. baumannii has displayed increasing pathogenicity and antibiotic resistance. The investigators warned that there is a real danger that, like MRSA, extensively drug-resistant A. baumannii will become a common community-acquired infection arising in previously healthy patients (JAMA Dermatol. 2014 Aug;150(8):905-906).
“There are some strains of gonococcus and some strains of Acinetobacter baumannii that appear to be resistant to all known antibiotics,” Dr. Elston said.
He reported having no relevant financial conflicts of interest.
EXPERT ANALYSIS FROM WCD 2015
Does preoperative urodynamics improve outcomes for women undergoing surgery for stress urinary incontinence?
In their review, Rachaneni and Latthe included randomized controlled trials (RCTs) comparing surgical outcomes in women investigated by urodynamics and women who had office evaluation only. Three RCTs met their a priori criteria of women with pure stress incontinence or stress-predominant mixed urinary incontinence, with outcomes describing cure or improvement of stress urinary incontinence (SUI). There were no statistical differences in the risk ratios of subjective cure, objective cure, voiding dysfunction, or urinary urgency between the 2 groups. Rachaneni and Latthe appropriately concluded that: “In women undergoing primary surgery for SUI or stress-predominant mixed urinary incontinence without voiding difficulties, urodynamics does not improve outcomes—as long as the women undergo careful office evaluation.”
Thorough evaluation is critical
It cannot be emphasized strongly enough that the mere presence of symptoms of SUI is insufficient justification for surgery. Providers should demonstrate SUI during office evaluation before operating on someone without urodynamics. The addition of a full-bladder standing stress test usually is sufficient to demonstrate incontinence in women with bothersome SUI.
National professional societies agree on what is involved in office evaluation. In June 2014, the American College of Obstetricians and Gynecologists and the American Urogynecologic Society published a joint committee opinion on evaluation of uncomplicated SUI in women before surgical treatment.1 The committee opinion states1:
Although the most recent Cochrane review found no evidence about urodynamic use in men, children, and people with neurologic disease and noted that large definitive trials are needed in which people are randomly allocated to urodynamics or not,2 most experts believe, and this review confirms, that the issue has been settled for preoperative urodynamics in women with uncomplicated SUI before surgery.
What this evidence means for practic
It is safe to proceed to surgery for SUI without urodynamic testing in women who meet all the following criteria: no previous surgery, no prolapse beyond the introitus, presence of predominant SUI complaints, demonstration of stress incontinence on cough stress testing, normal postvoid residual, mobile urethra, and normal urinalysis.
— Charles W. Nager, MD
Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.
1. Committee Opinion No. 603: Evaluation of uncomplicated stress urinary incontinence in women before surgical treatment. American College of Obstetricians and Gynecologists. Obstet Gynecol. 2014;123(6):1403–1407.
2. Clement K, Lapitan M, Omar M, Glazener CM. Urodynamic studies for management of urinary incontinence in children and adults: a short version Cochrane systematic review and meta-analysis. Neurourol Urodyn. 2015;34(5):407–412.
In their review, Rachaneni and Latthe included randomized controlled trials (RCTs) comparing surgical outcomes in women investigated by urodynamics and women who had office evaluation only. Three RCTs met their a priori criteria of women with pure stress incontinence or stress-predominant mixed urinary incontinence, with outcomes describing cure or improvement of stress urinary incontinence (SUI). There were no statistical differences in the risk ratios of subjective cure, objective cure, voiding dysfunction, or urinary urgency between the 2 groups. Rachaneni and Latthe appropriately concluded that: “In women undergoing primary surgery for SUI or stress-predominant mixed urinary incontinence without voiding difficulties, urodynamics does not improve outcomes—as long as the women undergo careful office evaluation.”
Thorough evaluation is critical
It cannot be emphasized strongly enough that the mere presence of symptoms of SUI is insufficient justification for surgery. Providers should demonstrate SUI during office evaluation before operating on someone without urodynamics. The addition of a full-bladder standing stress test usually is sufficient to demonstrate incontinence in women with bothersome SUI.
National professional societies agree on what is involved in office evaluation. In June 2014, the American College of Obstetricians and Gynecologists and the American Urogynecologic Society published a joint committee opinion on evaluation of uncomplicated SUI in women before surgical treatment.1 The committee opinion states1:
Although the most recent Cochrane review found no evidence about urodynamic use in men, children, and people with neurologic disease and noted that large definitive trials are needed in which people are randomly allocated to urodynamics or not,2 most experts believe, and this review confirms, that the issue has been settled for preoperative urodynamics in women with uncomplicated SUI before surgery.
What this evidence means for practic
It is safe to proceed to surgery for SUI without urodynamic testing in women who meet all the following criteria: no previous surgery, no prolapse beyond the introitus, presence of predominant SUI complaints, demonstration of stress incontinence on cough stress testing, normal postvoid residual, mobile urethra, and normal urinalysis.
— Charles W. Nager, MD
Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.
In their review, Rachaneni and Latthe included randomized controlled trials (RCTs) comparing surgical outcomes in women investigated by urodynamics and women who had office evaluation only. Three RCTs met their a priori criteria of women with pure stress incontinence or stress-predominant mixed urinary incontinence, with outcomes describing cure or improvement of stress urinary incontinence (SUI). There were no statistical differences in the risk ratios of subjective cure, objective cure, voiding dysfunction, or urinary urgency between the 2 groups. Rachaneni and Latthe appropriately concluded that: “In women undergoing primary surgery for SUI or stress-predominant mixed urinary incontinence without voiding difficulties, urodynamics does not improve outcomes—as long as the women undergo careful office evaluation.”
Thorough evaluation is critical
It cannot be emphasized strongly enough that the mere presence of symptoms of SUI is insufficient justification for surgery. Providers should demonstrate SUI during office evaluation before operating on someone without urodynamics. The addition of a full-bladder standing stress test usually is sufficient to demonstrate incontinence in women with bothersome SUI.
National professional societies agree on what is involved in office evaluation. In June 2014, the American College of Obstetricians and Gynecologists and the American Urogynecologic Society published a joint committee opinion on evaluation of uncomplicated SUI in women before surgical treatment.1 The committee opinion states1:
Although the most recent Cochrane review found no evidence about urodynamic use in men, children, and people with neurologic disease and noted that large definitive trials are needed in which people are randomly allocated to urodynamics or not,2 most experts believe, and this review confirms, that the issue has been settled for preoperative urodynamics in women with uncomplicated SUI before surgery.
What this evidence means for practic
It is safe to proceed to surgery for SUI without urodynamic testing in women who meet all the following criteria: no previous surgery, no prolapse beyond the introitus, presence of predominant SUI complaints, demonstration of stress incontinence on cough stress testing, normal postvoid residual, mobile urethra, and normal urinalysis.
— Charles W. Nager, MD
Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.
1. Committee Opinion No. 603: Evaluation of uncomplicated stress urinary incontinence in women before surgical treatment. American College of Obstetricians and Gynecologists. Obstet Gynecol. 2014;123(6):1403–1407.
2. Clement K, Lapitan M, Omar M, Glazener CM. Urodynamic studies for management of urinary incontinence in children and adults: a short version Cochrane systematic review and meta-analysis. Neurourol Urodyn. 2015;34(5):407–412.
1. Committee Opinion No. 603: Evaluation of uncomplicated stress urinary incontinence in women before surgical treatment. American College of Obstetricians and Gynecologists. Obstet Gynecol. 2014;123(6):1403–1407.
2. Clement K, Lapitan M, Omar M, Glazener CM. Urodynamic studies for management of urinary incontinence in children and adults: a short version Cochrane systematic review and meta-analysis. Neurourol Urodyn. 2015;34(5):407–412.
Does labor induction (vs expectant management) increase the risk of failed TOLAC?
Past research into outcomes for induction of labor for women attempting trial of labor after cesarean (TOLAC) has compared labor induction with spontaneous labor. This comparison may be biased against induction, say Lappen and colleagues, who conducted this recent study with the goal of characterizing the likelihood of failed TOLAC with induction and assessing maternal and neonatal outcomes of induction, compared with expectant management, by week of gestation (between 37 and 40 completed weeks).
Details of the study
The researchers analyzed data from the Consortium on Safe Labor,1 excluding women who had:
- no or more than 1 prior cesarean delivery
- multiple gestations
- fetal anomalies
- preterm delivery
- unknown labor type
- repeat cesarean delivery without a trial of labor (including those for whom TOLAC was contraindicated).
Their final, primary cohort included 6,033 women undergoing TOLAC (1,626 underwent induction of labor; 4,407 did not). For this group, induction of labor was defined to include all medically indicated and elective inductions.
They also analyzed a secondary cohort, for which they redefined the induction group to only include those inductions that were nonmedically indicated. This was a “low risk” cohort (n = 500) that excluded women with chronic conditions (hypertension, gestational diabetes, etc) that could result in medically indicated induction.
Induction of labor still associated with failed TOLAC
Comparing induction of labor with expectant management, the frequency of failed TOLAC was higher at each week of gestation, but not at 40 weeks. The adjusted odds ratios were:
- 37 weeks: 1.53 (95% confidence interval [CI], 1.02−2.28)
- 38 weeks: 1.74 (95% CI, 1.29−2.34)
- 39 weeks: 2.16 (95% CI, 1.76−2.67)
- 40 weeks: 1.21 (95% CI, 0.9−1.66).
Induction was associated with an increased risk of composite maternal morbidity at 39 weeks’ gestation. The authors attributed this to a statistically significant increase in the risk of transfusion. Induction was not associated with increased neonatal morbidity.
The authors point out that, since their data set collection, ACOG recommended against nonmedically indicated inductions before 39 weeks’ gestation, but argue that their results remain generalizable and clinically pertinent because medically indicated early-term inductions remain common.
What this evidence means for practice
The authors identified a significant increase in risk of failed TOLAC with induction of labor. These findings are consistent with prior work describing the favorable relationship between TOLAC success and spontaneous labor and thus should not alter current obstetric practice. The study authors used a large, reliable database for the analysis and controlled for maternal age, body mass index, and history of any prior vaginal birth. However, as the authors point out, the study was limited by a lack of data on obstetric factors that have been identified in prior studies to be pertinent to the likelihood of success of TOLAC, such as Bishop score, indication for prior cesarean delivery, and history of any successful vaginal birth after cesarean. Clinicians should consider each patient’s predictors for successful TOLAC individually and provide appropriate counseling. An induction of labor remains appropriate in well-selected patients attempting TOLAC.
— Janine S. Rhoades, MD, and Alison G. Cahill, MD
Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.
Reference
1. Zhang J, Landy HJ, Branch DW, et al. Contemporary patterns of spontaneous labor with normal neonatal outcomes. Obstet Gynecol. 2010;116(6):1281–1287.
Past research into outcomes for induction of labor for women attempting trial of labor after cesarean (TOLAC) has compared labor induction with spontaneous labor. This comparison may be biased against induction, say Lappen and colleagues, who conducted this recent study with the goal of characterizing the likelihood of failed TOLAC with induction and assessing maternal and neonatal outcomes of induction, compared with expectant management, by week of gestation (between 37 and 40 completed weeks).
Details of the study
The researchers analyzed data from the Consortium on Safe Labor,1 excluding women who had:
- no or more than 1 prior cesarean delivery
- multiple gestations
- fetal anomalies
- preterm delivery
- unknown labor type
- repeat cesarean delivery without a trial of labor (including those for whom TOLAC was contraindicated).
Their final, primary cohort included 6,033 women undergoing TOLAC (1,626 underwent induction of labor; 4,407 did not). For this group, induction of labor was defined to include all medically indicated and elective inductions.
They also analyzed a secondary cohort, for which they redefined the induction group to only include those inductions that were nonmedically indicated. This was a “low risk” cohort (n = 500) that excluded women with chronic conditions (hypertension, gestational diabetes, etc) that could result in medically indicated induction.
Induction of labor still associated with failed TOLAC
Comparing induction of labor with expectant management, the frequency of failed TOLAC was higher at each week of gestation, but not at 40 weeks. The adjusted odds ratios were:
- 37 weeks: 1.53 (95% confidence interval [CI], 1.02−2.28)
- 38 weeks: 1.74 (95% CI, 1.29−2.34)
- 39 weeks: 2.16 (95% CI, 1.76−2.67)
- 40 weeks: 1.21 (95% CI, 0.9−1.66).
Induction was associated with an increased risk of composite maternal morbidity at 39 weeks’ gestation. The authors attributed this to a statistically significant increase in the risk of transfusion. Induction was not associated with increased neonatal morbidity.
The authors point out that, since their data set collection, ACOG recommended against nonmedically indicated inductions before 39 weeks’ gestation, but argue that their results remain generalizable and clinically pertinent because medically indicated early-term inductions remain common.
What this evidence means for practice
The authors identified a significant increase in risk of failed TOLAC with induction of labor. These findings are consistent with prior work describing the favorable relationship between TOLAC success and spontaneous labor and thus should not alter current obstetric practice. The study authors used a large, reliable database for the analysis and controlled for maternal age, body mass index, and history of any prior vaginal birth. However, as the authors point out, the study was limited by a lack of data on obstetric factors that have been identified in prior studies to be pertinent to the likelihood of success of TOLAC, such as Bishop score, indication for prior cesarean delivery, and history of any successful vaginal birth after cesarean. Clinicians should consider each patient’s predictors for successful TOLAC individually and provide appropriate counseling. An induction of labor remains appropriate in well-selected patients attempting TOLAC.
— Janine S. Rhoades, MD, and Alison G. Cahill, MD
Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.
Past research into outcomes for induction of labor for women attempting trial of labor after cesarean (TOLAC) has compared labor induction with spontaneous labor. This comparison may be biased against induction, say Lappen and colleagues, who conducted this recent study with the goal of characterizing the likelihood of failed TOLAC with induction and assessing maternal and neonatal outcomes of induction, compared with expectant management, by week of gestation (between 37 and 40 completed weeks).
Details of the study
The researchers analyzed data from the Consortium on Safe Labor,1 excluding women who had:
- no or more than 1 prior cesarean delivery
- multiple gestations
- fetal anomalies
- preterm delivery
- unknown labor type
- repeat cesarean delivery without a trial of labor (including those for whom TOLAC was contraindicated).
Their final, primary cohort included 6,033 women undergoing TOLAC (1,626 underwent induction of labor; 4,407 did not). For this group, induction of labor was defined to include all medically indicated and elective inductions.
They also analyzed a secondary cohort, for which they redefined the induction group to only include those inductions that were nonmedically indicated. This was a “low risk” cohort (n = 500) that excluded women with chronic conditions (hypertension, gestational diabetes, etc) that could result in medically indicated induction.
Induction of labor still associated with failed TOLAC
Comparing induction of labor with expectant management, the frequency of failed TOLAC was higher at each week of gestation, but not at 40 weeks. The adjusted odds ratios were:
- 37 weeks: 1.53 (95% confidence interval [CI], 1.02−2.28)
- 38 weeks: 1.74 (95% CI, 1.29−2.34)
- 39 weeks: 2.16 (95% CI, 1.76−2.67)
- 40 weeks: 1.21 (95% CI, 0.9−1.66).
Induction was associated with an increased risk of composite maternal morbidity at 39 weeks’ gestation. The authors attributed this to a statistically significant increase in the risk of transfusion. Induction was not associated with increased neonatal morbidity.
The authors point out that, since their data set collection, ACOG recommended against nonmedically indicated inductions before 39 weeks’ gestation, but argue that their results remain generalizable and clinically pertinent because medically indicated early-term inductions remain common.
What this evidence means for practice
The authors identified a significant increase in risk of failed TOLAC with induction of labor. These findings are consistent with prior work describing the favorable relationship between TOLAC success and spontaneous labor and thus should not alter current obstetric practice. The study authors used a large, reliable database for the analysis and controlled for maternal age, body mass index, and history of any prior vaginal birth. However, as the authors point out, the study was limited by a lack of data on obstetric factors that have been identified in prior studies to be pertinent to the likelihood of success of TOLAC, such as Bishop score, indication for prior cesarean delivery, and history of any successful vaginal birth after cesarean. Clinicians should consider each patient’s predictors for successful TOLAC individually and provide appropriate counseling. An induction of labor remains appropriate in well-selected patients attempting TOLAC.
— Janine S. Rhoades, MD, and Alison G. Cahill, MD
Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.
Reference
1. Zhang J, Landy HJ, Branch DW, et al. Contemporary patterns of spontaneous labor with normal neonatal outcomes. Obstet Gynecol. 2010;116(6):1281–1287.
Reference
1. Zhang J, Landy HJ, Branch DW, et al. Contemporary patterns of spontaneous labor with normal neonatal outcomes. Obstet Gynecol. 2010;116(6):1281–1287.
The Three-Year Plan
Although 2019 may seem like a long way away, it isn’t too soon to start thinking about and preparing for the Merit-based Incentive Payment System (MIPS) or its (seemingly preferable) alternative, participation in an alternative payment model (APM) such as an ACO, a medical home, or a bundled payment program.
In April, Congress permanently repealed Medicare’s sustainable growth rate (SGR) formula for controlling physician payment. In yet another sign that we are in the midst of the biggest healthcare transformation in a generation, the 18-year-old SGR formula will be replaced by a far-reaching package of payment reforms. Here we will focus on the MIPS and its alternative, an APM, which involves assuming risk for financial loss or gain and measuring and reporting on quality.
The MIPS replaces three existing quality measurement programs that, to greater and lesser degrees, physicians have struggled with:
- Physician Quality Reporting System (PQRS);
- Value-based payment modifier; and
- Meaningful use of electronic health records.
MIPS will not totally eliminate these programs but will instead incorporate yet-to-be-defined elements of them and, presumably, though it is yet unclear, add new elements. For 2015-2018, the current payment system will remain intact. For 2019, physicians will have a choice. Either they must participate in MIPS, which will likely be complex and involve some administrative burden, or derive at least 25% of their practice revenue from an APM.
For those participating in MIPS, physician payment rates will be subject to an up or down adjustment based on performance in four categories: quality, meaningful use of EHRs, resource use, and clinical practice improvement.
There is an opportunity to avoid MIPS altogether, however. One of the most notable elements of the SGR fix is its push for physicians to participate in APMs such as ACOs, medical homes, bundled payment arrangements, and other payment models now being evaluated by the CMS Innovation Center. Physicians who gain a substantial portion—this means 25% in 2019 and 2020, and likely more thereafter—of their revenue through APMs like these will have the dual benefit of being exempt from MIPS participation and receiving a 5% annual bonus through 2024. After that, physicians in APMs will receive annual fee increases of 0.75%, while all other physicians will receive only a 0.25% increase.1
Strategic Thinking for Hospitalists: Enter an APM
If you’re asking yourself where you want your hospitalist practice to be in three years, I would suggest the answer is “in an alternative payment model of one kind or another.”
If you are an employed practice, strategic planning will involve assessing the APMs your hospital or health system is participating in and planning how your hospitalist practice can become a formal member of the arrangement.
If you are a freestanding practice, you should become a student of the APM policy coming from the CMS Innovation Center, and determine the best “insertion point” for your practice, such that you gain at least a quarter of your revenue through an APM within three years.
Reference
- Steinbrook R. The repeal of Medicare’s sustainable growth rate for physician payment. JAMA. 2015;313(20):2025-2026.
Obituary
Remembering Frank Michota, 1967-2015
Frank founded the “Update in Hospital Medicine” series at SHM annual meetings and in the Annals of Internal Medicine. He was a prolific speaker, writer, and teacher. More than that, Frank was an original kind of persona, one who collaborated often and led frequently, but rarely followed. Yet he had the humility to engage and contribute whenever he was asked.
I had the good fortune of working with him on a number of speaking and writing projects in the early days. I recall his charisma, irreverence, and larger-than-life presence whenever he addressed an audience.
Frank’s signature is etched forever on hospital medicine; our patients and hospitalists everywhere are the lucky beneficiaries of his work.
Although 2019 may seem like a long way away, it isn’t too soon to start thinking about and preparing for the Merit-based Incentive Payment System (MIPS) or its (seemingly preferable) alternative, participation in an alternative payment model (APM) such as an ACO, a medical home, or a bundled payment program.
In April, Congress permanently repealed Medicare’s sustainable growth rate (SGR) formula for controlling physician payment. In yet another sign that we are in the midst of the biggest healthcare transformation in a generation, the 18-year-old SGR formula will be replaced by a far-reaching package of payment reforms. Here we will focus on the MIPS and its alternative, an APM, which involves assuming risk for financial loss or gain and measuring and reporting on quality.
The MIPS replaces three existing quality measurement programs that, to greater and lesser degrees, physicians have struggled with:
- Physician Quality Reporting System (PQRS);
- Value-based payment modifier; and
- Meaningful use of electronic health records.
MIPS will not totally eliminate these programs but will instead incorporate yet-to-be-defined elements of them and, presumably, though it is yet unclear, add new elements. For 2015-2018, the current payment system will remain intact. For 2019, physicians will have a choice. Either they must participate in MIPS, which will likely be complex and involve some administrative burden, or derive at least 25% of their practice revenue from an APM.
For those participating in MIPS, physician payment rates will be subject to an up or down adjustment based on performance in four categories: quality, meaningful use of EHRs, resource use, and clinical practice improvement.
There is an opportunity to avoid MIPS altogether, however. One of the most notable elements of the SGR fix is its push for physicians to participate in APMs such as ACOs, medical homes, bundled payment arrangements, and other payment models now being evaluated by the CMS Innovation Center. Physicians who gain a substantial portion—this means 25% in 2019 and 2020, and likely more thereafter—of their revenue through APMs like these will have the dual benefit of being exempt from MIPS participation and receiving a 5% annual bonus through 2024. After that, physicians in APMs will receive annual fee increases of 0.75%, while all other physicians will receive only a 0.25% increase.1
Strategic Thinking for Hospitalists: Enter an APM
If you’re asking yourself where you want your hospitalist practice to be in three years, I would suggest the answer is “in an alternative payment model of one kind or another.”
If you are an employed practice, strategic planning will involve assessing the APMs your hospital or health system is participating in and planning how your hospitalist practice can become a formal member of the arrangement.
If you are a freestanding practice, you should become a student of the APM policy coming from the CMS Innovation Center, and determine the best “insertion point” for your practice, such that you gain at least a quarter of your revenue through an APM within three years.
Reference
- Steinbrook R. The repeal of Medicare’s sustainable growth rate for physician payment. JAMA. 2015;313(20):2025-2026.
Obituary
Remembering Frank Michota, 1967-2015
Frank founded the “Update in Hospital Medicine” series at SHM annual meetings and in the Annals of Internal Medicine. He was a prolific speaker, writer, and teacher. More than that, Frank was an original kind of persona, one who collaborated often and led frequently, but rarely followed. Yet he had the humility to engage and contribute whenever he was asked.
I had the good fortune of working with him on a number of speaking and writing projects in the early days. I recall his charisma, irreverence, and larger-than-life presence whenever he addressed an audience.
Frank’s signature is etched forever on hospital medicine; our patients and hospitalists everywhere are the lucky beneficiaries of his work.
Although 2019 may seem like a long way away, it isn’t too soon to start thinking about and preparing for the Merit-based Incentive Payment System (MIPS) or its (seemingly preferable) alternative, participation in an alternative payment model (APM) such as an ACO, a medical home, or a bundled payment program.
In April, Congress permanently repealed Medicare’s sustainable growth rate (SGR) formula for controlling physician payment. In yet another sign that we are in the midst of the biggest healthcare transformation in a generation, the 18-year-old SGR formula will be replaced by a far-reaching package of payment reforms. Here we will focus on the MIPS and its alternative, an APM, which involves assuming risk for financial loss or gain and measuring and reporting on quality.
The MIPS replaces three existing quality measurement programs that, to greater and lesser degrees, physicians have struggled with:
- Physician Quality Reporting System (PQRS);
- Value-based payment modifier; and
- Meaningful use of electronic health records.
MIPS will not totally eliminate these programs but will instead incorporate yet-to-be-defined elements of them and, presumably, though it is yet unclear, add new elements. For 2015-2018, the current payment system will remain intact. For 2019, physicians will have a choice. Either they must participate in MIPS, which will likely be complex and involve some administrative burden, or derive at least 25% of their practice revenue from an APM.
For those participating in MIPS, physician payment rates will be subject to an up or down adjustment based on performance in four categories: quality, meaningful use of EHRs, resource use, and clinical practice improvement.
There is an opportunity to avoid MIPS altogether, however. One of the most notable elements of the SGR fix is its push for physicians to participate in APMs such as ACOs, medical homes, bundled payment arrangements, and other payment models now being evaluated by the CMS Innovation Center. Physicians who gain a substantial portion—this means 25% in 2019 and 2020, and likely more thereafter—of their revenue through APMs like these will have the dual benefit of being exempt from MIPS participation and receiving a 5% annual bonus through 2024. After that, physicians in APMs will receive annual fee increases of 0.75%, while all other physicians will receive only a 0.25% increase.1
Strategic Thinking for Hospitalists: Enter an APM
If you’re asking yourself where you want your hospitalist practice to be in three years, I would suggest the answer is “in an alternative payment model of one kind or another.”
If you are an employed practice, strategic planning will involve assessing the APMs your hospital or health system is participating in and planning how your hospitalist practice can become a formal member of the arrangement.
If you are a freestanding practice, you should become a student of the APM policy coming from the CMS Innovation Center, and determine the best “insertion point” for your practice, such that you gain at least a quarter of your revenue through an APM within three years.
Reference
- Steinbrook R. The repeal of Medicare’s sustainable growth rate for physician payment. JAMA. 2015;313(20):2025-2026.
Obituary
Remembering Frank Michota, 1967-2015
Frank founded the “Update in Hospital Medicine” series at SHM annual meetings and in the Annals of Internal Medicine. He was a prolific speaker, writer, and teacher. More than that, Frank was an original kind of persona, one who collaborated often and led frequently, but rarely followed. Yet he had the humility to engage and contribute whenever he was asked.
I had the good fortune of working with him on a number of speaking and writing projects in the early days. I recall his charisma, irreverence, and larger-than-life presence whenever he addressed an audience.
Frank’s signature is etched forever on hospital medicine; our patients and hospitalists everywhere are the lucky beneficiaries of his work.
Tips for Hospitalists on Spending More of Their Time at the Top of Their License
Hospitalists spend too little time working at the top of their license. Put differently, I think a hospitalist often spends only about 1.5 to two hours in a 10- or 12-hour workday making use of the knowledge base and skills developed in training. (I wrote about this and referenced some hospitalist time-motion studies in my December 2010 column.)
The remaining hours are typically spent in activities such as figuring out which surgeon is on call and tracking her down, managing patient lists, filling out paper or electronic forms, explaining observation status to patients, and so on.
When I first became a hospitalist in the 1980s, there was already a lot of talk about the paperwork burden faced by doctors across all specialties. I recall the gnashing of teeth that ensued—lots of articles and seminars, and it seems to me even a few legislative proposals, focused on the topic. It appears that nearly every recruitment ad at the time mentioned something like “Let us take care of running the business, so you can focus solely on patient care.” Clearly, doctors were seeking relief from the burden of nonclinical work even back then.
I can’t recall reading or hearing anyone talk about the “paperwork” burden of physician practice in the past few years. This isn’t because things have gotten better; in fact, I think the burden of “non-doctoring activities” has steadily increased. We hear less about the problem of excessive paperwork simply because, more recently, it has been framed differently—it is now typically referred to as the problem of too little time spent practicing at the top of license.
Search the Internet for “top of license” and a number of interesting things turn up. Most are healthcare related—maybe other professions don’t use the term—and there are just as many links referring to nurses as physicians. Much is written about the need for primary care physicians to spend more time working at the top of their license, but I couldn’t find anything addressing this issue specifically for hospitalists.
What Can Be Done?
Moving your work as a hospitalist more to the top of your license isn’t a simple thing, and our whole field will need to work on this over time. The most effective interventions will vary some from place to place, but here are some ideas that may be relevant for many hospitalist groups.
Medication reconciliation. I fully support the idea of careful medication reconciliation, but, given that such a large portion of hospitalist patients are on so many medications, this is a time-consuming task. And, in many or most hospitals, the task suffers from diffusion of responsibility; for example, the ED nurse makes only a half-hearted attempt to get an accurate list, and the hospitalist believes that whatever the ED nurse entered into the record regarding patient medications is probably the best obtainable list.
A pharmacy technician stationed in the ED and charged with recording the best obtainable list of medicines on patient arrival can address both of these problems (for more information, the American Society of Health-System Pharmacists offers webinars and other resources on this topic). This would include calling family members, pharmacies, and physician offices for clarification in some cases. Hospitalists working in such an environment nearly always say it is extremely valuable in reducing inaccuracies in the pre-hospital medication list, as well as saving hospitalists time when they are admitting patients.
Unfortunately, hospitals may resist adding pharmacy technicians because of the expense or, in some cases, because of concerns that such work may exceed the legal scope of work for technicians.
Post-hospital appointments. I think arranging post-hospital appointments should be no more difficult for the hospitalist than ordering a complete blood count (CBC). It shouldn’t matter whether I want the patient to follow up with the PCP he has been seeing for years, or see a neurologist or diabetes educator as a new patient consult. Any treating doctor in the hospital should be able to arrange such post-hospital visits with just a click or two in the EHR, or a stroke of the pen. And the patient should leave the hospital with a written date and time of the appointment that has been made for them.
Few hospitals can reliably provide this, however, so, all too often, hospitalists spend their time calling clerical staff at outpatient clinics to arrange appointments, writing them down, and delivering them to patients. This is far from what anyone would consider top of license work. (I wrote a little more about this in last month’s column.)
Medicare benefits specialist. Many hospitalists end up spending significant time explaining to patients and families the reason a patient is on observation status and trying to defuse the resulting frustration and anger. As I stated in my November 2014 column, I think observation status is so frustrating to patients that it is often the root cause of complaints about care and, potentially, the source of malpractice suits.
Physicians have an unavoidable role in determining observation versus inpatient status, but I think hospitals should work hard to ensure that someone other than the doctor is available to explain to patients and families the reason for observation status, along with its implications, and to provide sympathy for their frustrations. This allows the doctor to stay focused on clinical care.
Limit reliance on a “triage hospitalist.” Hospitalist groups larger than about 20 providers often have one provider devoted through much of a daytime shift to triaging and assigning new referrals across all providers working that day. For larger practices, this triage work may consume all of the provider’s shift, so that person has no time left for clinical care. It is hard for me to see this as top of license work that only a physician or advanced practice clinician can do. In my December 2010 column, I provided some potential alternatives to dedicating a physician or other provider to a triage role.
Your list of important changes that are needed to move hospitalists toward more time spent working at the top of their license will likely differ a lot from the issues above. But every group could benefit from deliberately thinking about what would be most valuable for them and trying to make that a reality.
Hospitalists spend too little time working at the top of their license. Put differently, I think a hospitalist often spends only about 1.5 to two hours in a 10- or 12-hour workday making use of the knowledge base and skills developed in training. (I wrote about this and referenced some hospitalist time-motion studies in my December 2010 column.)
The remaining hours are typically spent in activities such as figuring out which surgeon is on call and tracking her down, managing patient lists, filling out paper or electronic forms, explaining observation status to patients, and so on.
When I first became a hospitalist in the 1980s, there was already a lot of talk about the paperwork burden faced by doctors across all specialties. I recall the gnashing of teeth that ensued—lots of articles and seminars, and it seems to me even a few legislative proposals, focused on the topic. It appears that nearly every recruitment ad at the time mentioned something like “Let us take care of running the business, so you can focus solely on patient care.” Clearly, doctors were seeking relief from the burden of nonclinical work even back then.
I can’t recall reading or hearing anyone talk about the “paperwork” burden of physician practice in the past few years. This isn’t because things have gotten better; in fact, I think the burden of “non-doctoring activities” has steadily increased. We hear less about the problem of excessive paperwork simply because, more recently, it has been framed differently—it is now typically referred to as the problem of too little time spent practicing at the top of license.
Search the Internet for “top of license” and a number of interesting things turn up. Most are healthcare related—maybe other professions don’t use the term—and there are just as many links referring to nurses as physicians. Much is written about the need for primary care physicians to spend more time working at the top of their license, but I couldn’t find anything addressing this issue specifically for hospitalists.
What Can Be Done?
Moving your work as a hospitalist more to the top of your license isn’t a simple thing, and our whole field will need to work on this over time. The most effective interventions will vary some from place to place, but here are some ideas that may be relevant for many hospitalist groups.
Medication reconciliation. I fully support the idea of careful medication reconciliation, but, given that such a large portion of hospitalist patients are on so many medications, this is a time-consuming task. And, in many or most hospitals, the task suffers from diffusion of responsibility; for example, the ED nurse makes only a half-hearted attempt to get an accurate list, and the hospitalist believes that whatever the ED nurse entered into the record regarding patient medications is probably the best obtainable list.
A pharmacy technician stationed in the ED and charged with recording the best obtainable list of medicines on patient arrival can address both of these problems (for more information, the American Society of Health-System Pharmacists offers webinars and other resources on this topic). This would include calling family members, pharmacies, and physician offices for clarification in some cases. Hospitalists working in such an environment nearly always say it is extremely valuable in reducing inaccuracies in the pre-hospital medication list, as well as saving hospitalists time when they are admitting patients.
Unfortunately, hospitals may resist adding pharmacy technicians because of the expense or, in some cases, because of concerns that such work may exceed the legal scope of work for technicians.
Post-hospital appointments. I think arranging post-hospital appointments should be no more difficult for the hospitalist than ordering a complete blood count (CBC). It shouldn’t matter whether I want the patient to follow up with the PCP he has been seeing for years, or see a neurologist or diabetes educator as a new patient consult. Any treating doctor in the hospital should be able to arrange such post-hospital visits with just a click or two in the EHR, or a stroke of the pen. And the patient should leave the hospital with a written date and time of the appointment that has been made for them.
Few hospitals can reliably provide this, however, so, all too often, hospitalists spend their time calling clerical staff at outpatient clinics to arrange appointments, writing them down, and delivering them to patients. This is far from what anyone would consider top of license work. (I wrote a little more about this in last month’s column.)
Medicare benefits specialist. Many hospitalists end up spending significant time explaining to patients and families the reason a patient is on observation status and trying to defuse the resulting frustration and anger. As I stated in my November 2014 column, I think observation status is so frustrating to patients that it is often the root cause of complaints about care and, potentially, the source of malpractice suits.
Physicians have an unavoidable role in determining observation versus inpatient status, but I think hospitals should work hard to ensure that someone other than the doctor is available to explain to patients and families the reason for observation status, along with its implications, and to provide sympathy for their frustrations. This allows the doctor to stay focused on clinical care.
Limit reliance on a “triage hospitalist.” Hospitalist groups larger than about 20 providers often have one provider devoted through much of a daytime shift to triaging and assigning new referrals across all providers working that day. For larger practices, this triage work may consume all of the provider’s shift, so that person has no time left for clinical care. It is hard for me to see this as top of license work that only a physician or advanced practice clinician can do. In my December 2010 column, I provided some potential alternatives to dedicating a physician or other provider to a triage role.
Your list of important changes that are needed to move hospitalists toward more time spent working at the top of their license will likely differ a lot from the issues above. But every group could benefit from deliberately thinking about what would be most valuable for them and trying to make that a reality.
Hospitalists spend too little time working at the top of their license. Put differently, I think a hospitalist often spends only about 1.5 to two hours in a 10- or 12-hour workday making use of the knowledge base and skills developed in training. (I wrote about this and referenced some hospitalist time-motion studies in my December 2010 column.)
The remaining hours are typically spent in activities such as figuring out which surgeon is on call and tracking her down, managing patient lists, filling out paper or electronic forms, explaining observation status to patients, and so on.
When I first became a hospitalist in the 1980s, there was already a lot of talk about the paperwork burden faced by doctors across all specialties. I recall the gnashing of teeth that ensued—lots of articles and seminars, and it seems to me even a few legislative proposals, focused on the topic. It appears that nearly every recruitment ad at the time mentioned something like “Let us take care of running the business, so you can focus solely on patient care.” Clearly, doctors were seeking relief from the burden of nonclinical work even back then.
I can’t recall reading or hearing anyone talk about the “paperwork” burden of physician practice in the past few years. This isn’t because things have gotten better; in fact, I think the burden of “non-doctoring activities” has steadily increased. We hear less about the problem of excessive paperwork simply because, more recently, it has been framed differently—it is now typically referred to as the problem of too little time spent practicing at the top of license.
Search the Internet for “top of license” and a number of interesting things turn up. Most are healthcare related—maybe other professions don’t use the term—and there are just as many links referring to nurses as physicians. Much is written about the need for primary care physicians to spend more time working at the top of their license, but I couldn’t find anything addressing this issue specifically for hospitalists.
What Can Be Done?
Moving your work as a hospitalist more to the top of your license isn’t a simple thing, and our whole field will need to work on this over time. The most effective interventions will vary some from place to place, but here are some ideas that may be relevant for many hospitalist groups.
Medication reconciliation. I fully support the idea of careful medication reconciliation, but, given that such a large portion of hospitalist patients are on so many medications, this is a time-consuming task. And, in many or most hospitals, the task suffers from diffusion of responsibility; for example, the ED nurse makes only a half-hearted attempt to get an accurate list, and the hospitalist believes that whatever the ED nurse entered into the record regarding patient medications is probably the best obtainable list.
A pharmacy technician stationed in the ED and charged with recording the best obtainable list of medicines on patient arrival can address both of these problems (for more information, the American Society of Health-System Pharmacists offers webinars and other resources on this topic). This would include calling family members, pharmacies, and physician offices for clarification in some cases. Hospitalists working in such an environment nearly always say it is extremely valuable in reducing inaccuracies in the pre-hospital medication list, as well as saving hospitalists time when they are admitting patients.
Unfortunately, hospitals may resist adding pharmacy technicians because of the expense or, in some cases, because of concerns that such work may exceed the legal scope of work for technicians.
Post-hospital appointments. I think arranging post-hospital appointments should be no more difficult for the hospitalist than ordering a complete blood count (CBC). It shouldn’t matter whether I want the patient to follow up with the PCP he has been seeing for years, or see a neurologist or diabetes educator as a new patient consult. Any treating doctor in the hospital should be able to arrange such post-hospital visits with just a click or two in the EHR, or a stroke of the pen. And the patient should leave the hospital with a written date and time of the appointment that has been made for them.
Few hospitals can reliably provide this, however, so, all too often, hospitalists spend their time calling clerical staff at outpatient clinics to arrange appointments, writing them down, and delivering them to patients. This is far from what anyone would consider top of license work. (I wrote a little more about this in last month’s column.)
Medicare benefits specialist. Many hospitalists end up spending significant time explaining to patients and families the reason a patient is on observation status and trying to defuse the resulting frustration and anger. As I stated in my November 2014 column, I think observation status is so frustrating to patients that it is often the root cause of complaints about care and, potentially, the source of malpractice suits.
Physicians have an unavoidable role in determining observation versus inpatient status, but I think hospitals should work hard to ensure that someone other than the doctor is available to explain to patients and families the reason for observation status, along with its implications, and to provide sympathy for their frustrations. This allows the doctor to stay focused on clinical care.
Limit reliance on a “triage hospitalist.” Hospitalist groups larger than about 20 providers often have one provider devoted through much of a daytime shift to triaging and assigning new referrals across all providers working that day. For larger practices, this triage work may consume all of the provider’s shift, so that person has no time left for clinical care. It is hard for me to see this as top of license work that only a physician or advanced practice clinician can do. In my December 2010 column, I provided some potential alternatives to dedicating a physician or other provider to a triage role.
Your list of important changes that are needed to move hospitalists toward more time spent working at the top of their license will likely differ a lot from the issues above. But every group could benefit from deliberately thinking about what would be most valuable for them and trying to make that a reality.
Does a high-dose influenza vaccine protect older adults to a greater extent than the standard-dose vaccine?
The objective of this investigation was to compare a standard-dose trivalent influenza vaccine with a high-dose vaccine in adults older than 65 years. The standard dose of the vaccine contained 15 µg of hemagglutinin per strain, and the high dose contained 60 µg hemagglutinin per strain. The study was conducted during the 2011–2012 and 2012–2013 flu seasons. Key outcome measures were efficacy, as assessed by the occurrence of laboratory-confirmed influenza at least 14 days after vaccination; immunogenicity of the vaccines; and frequency of adverse events.
Details of the study
The study involved 15,991 patients in the high-dose group and 15,998 patients in the standard-dose group. Two hundred twenty-eight participants (1.4%) in the high-dose group developed influenza, compared with 301 participants (1.9%) in the standard-dose group.
The overall efficacy of the high-dose vaccine was 24.2% (95% confidence interval [CI], 9.7–36.5), meaning that approximately 24% of influenza cases could have been prevented if the high-dose vaccine had been administered to all patients.
In the high-dose group, 8.3% of patients had at least 1 adverse event, compared with 9% in the standard-dose group (relative risk, 0.92; 95% CI, 0.85–0.99).
After vaccination, the hemagglutination inhibition titers were significantly higher in the high-dose group.
Fewer adverse events with the higher dose, but some events were graver
Influenza is a serious viral illness, and it can be associated with mortality in certain populations, such as very young children, pregnant women, and people older than 65 years.
As a general rule, older patients do not respond as well to the vaccine as younger patients do. The standard dose of vaccine provides about 50% protection against influenza in older patients, compared with approximately 60% to 65% in younger individuals. With the added protection of the high-dose vaccine (overall efficacy, 24.2%), approximately 62% of adults older than age 65 would be protected—a figure similar to that reported for younger patients.
The increase in effectiveness was achieved with no increase in the overall frequency of adverse effects. In fact, the frequency of adverse effects was actually slightly lower in the recipients of the higher dose. However, in 3 recipients of the high-dose vaccine the adverse effects were notable. One had a transient sixth cranial nerve palsy that started 1 day after vaccination. One had hypovolemic shock due to diarrhea that started 1 day after vaccination. One had acute disseminated encephalomyelitis that started 117 days after vaccination. All 3 patients recovered fully. No such serious events occurred in the standard-dose group.
Several barriers prevent widespread vaccination
The Centers for Disease Control and Prevention Advisory Committee on Immunization Practices strongly recommends influenza vaccination for everyone over the age of 6 months. Barriers to widespread vaccination include reluctance on the part of the patient, failure on the part of the physician to advocate for vaccination, and cost of the vaccine for patients who have suboptimal insurance or no insurance.
WHAT THIS EVIDENCE MEANS FOR PRACTICE
We should strongly advise older women in our practice to receive the high-dose influenza vaccine. We should caution them that the overall risk of adverse effects is actually lower than with the standard-dose vaccine but that serious effects can occur in rare instances.
—Patrick Duff, MD
Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.
The objective of this investigation was to compare a standard-dose trivalent influenza vaccine with a high-dose vaccine in adults older than 65 years. The standard dose of the vaccine contained 15 µg of hemagglutinin per strain, and the high dose contained 60 µg hemagglutinin per strain. The study was conducted during the 2011–2012 and 2012–2013 flu seasons. Key outcome measures were efficacy, as assessed by the occurrence of laboratory-confirmed influenza at least 14 days after vaccination; immunogenicity of the vaccines; and frequency of adverse events.
Details of the study
The study involved 15,991 patients in the high-dose group and 15,998 patients in the standard-dose group. Two hundred twenty-eight participants (1.4%) in the high-dose group developed influenza, compared with 301 participants (1.9%) in the standard-dose group.
The overall efficacy of the high-dose vaccine was 24.2% (95% confidence interval [CI], 9.7–36.5), meaning that approximately 24% of influenza cases could have been prevented if the high-dose vaccine had been administered to all patients.
In the high-dose group, 8.3% of patients had at least 1 adverse event, compared with 9% in the standard-dose group (relative risk, 0.92; 95% CI, 0.85–0.99).
After vaccination, the hemagglutination inhibition titers were significantly higher in the high-dose group.
Fewer adverse events with the higher dose, but some events were graver
Influenza is a serious viral illness, and it can be associated with mortality in certain populations, such as very young children, pregnant women, and people older than 65 years.
As a general rule, older patients do not respond as well to the vaccine as younger patients do. The standard dose of vaccine provides about 50% protection against influenza in older patients, compared with approximately 60% to 65% in younger individuals. With the added protection of the high-dose vaccine (overall efficacy, 24.2%), approximately 62% of adults older than age 65 would be protected—a figure similar to that reported for younger patients.
The increase in effectiveness was achieved with no increase in the overall frequency of adverse effects. In fact, the frequency of adverse effects was actually slightly lower in the recipients of the higher dose. However, in 3 recipients of the high-dose vaccine the adverse effects were notable. One had a transient sixth cranial nerve palsy that started 1 day after vaccination. One had hypovolemic shock due to diarrhea that started 1 day after vaccination. One had acute disseminated encephalomyelitis that started 117 days after vaccination. All 3 patients recovered fully. No such serious events occurred in the standard-dose group.
Several barriers prevent widespread vaccination
The Centers for Disease Control and Prevention Advisory Committee on Immunization Practices strongly recommends influenza vaccination for everyone over the age of 6 months. Barriers to widespread vaccination include reluctance on the part of the patient, failure on the part of the physician to advocate for vaccination, and cost of the vaccine for patients who have suboptimal insurance or no insurance.
WHAT THIS EVIDENCE MEANS FOR PRACTICE
We should strongly advise older women in our practice to receive the high-dose influenza vaccine. We should caution them that the overall risk of adverse effects is actually lower than with the standard-dose vaccine but that serious effects can occur in rare instances.
—Patrick Duff, MD
Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.
The objective of this investigation was to compare a standard-dose trivalent influenza vaccine with a high-dose vaccine in adults older than 65 years. The standard dose of the vaccine contained 15 µg of hemagglutinin per strain, and the high dose contained 60 µg hemagglutinin per strain. The study was conducted during the 2011–2012 and 2012–2013 flu seasons. Key outcome measures were efficacy, as assessed by the occurrence of laboratory-confirmed influenza at least 14 days after vaccination; immunogenicity of the vaccines; and frequency of adverse events.
Details of the study
The study involved 15,991 patients in the high-dose group and 15,998 patients in the standard-dose group. Two hundred twenty-eight participants (1.4%) in the high-dose group developed influenza, compared with 301 participants (1.9%) in the standard-dose group.
The overall efficacy of the high-dose vaccine was 24.2% (95% confidence interval [CI], 9.7–36.5), meaning that approximately 24% of influenza cases could have been prevented if the high-dose vaccine had been administered to all patients.
In the high-dose group, 8.3% of patients had at least 1 adverse event, compared with 9% in the standard-dose group (relative risk, 0.92; 95% CI, 0.85–0.99).
After vaccination, the hemagglutination inhibition titers were significantly higher in the high-dose group.
Fewer adverse events with the higher dose, but some events were graver
Influenza is a serious viral illness, and it can be associated with mortality in certain populations, such as very young children, pregnant women, and people older than 65 years.
As a general rule, older patients do not respond as well to the vaccine as younger patients do. The standard dose of vaccine provides about 50% protection against influenza in older patients, compared with approximately 60% to 65% in younger individuals. With the added protection of the high-dose vaccine (overall efficacy, 24.2%), approximately 62% of adults older than age 65 would be protected—a figure similar to that reported for younger patients.
The increase in effectiveness was achieved with no increase in the overall frequency of adverse effects. In fact, the frequency of adverse effects was actually slightly lower in the recipients of the higher dose. However, in 3 recipients of the high-dose vaccine the adverse effects were notable. One had a transient sixth cranial nerve palsy that started 1 day after vaccination. One had hypovolemic shock due to diarrhea that started 1 day after vaccination. One had acute disseminated encephalomyelitis that started 117 days after vaccination. All 3 patients recovered fully. No such serious events occurred in the standard-dose group.
Several barriers prevent widespread vaccination
The Centers for Disease Control and Prevention Advisory Committee on Immunization Practices strongly recommends influenza vaccination for everyone over the age of 6 months. Barriers to widespread vaccination include reluctance on the part of the patient, failure on the part of the physician to advocate for vaccination, and cost of the vaccine for patients who have suboptimal insurance or no insurance.
WHAT THIS EVIDENCE MEANS FOR PRACTICE
We should strongly advise older women in our practice to receive the high-dose influenza vaccine. We should caution them that the overall risk of adverse effects is actually lower than with the standard-dose vaccine but that serious effects can occur in rare instances.
—Patrick Duff, MD
Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.
Hospital Medicine's Old Practices Become New Again
The musty collections of National Geographic magazines once found in so many basements are largely gone. Replacing them are dusty sets of the Advisory Board binders and booklets found in hospital administration offices around the country. I think the same principle drives the impulse to collect both publications—the idea that they contain worthwhile information that one day will be reviewed. But I think it’s more likely they will be ignored until it is time to move and someone has to decide what to do with the painfully heavy pile of paper.
Lots of old and largely forgotten things are making a comeback in healthcare. I suppose this is always happening, but I sense we’re now experiencing more of this than usual. It’s a renaissance of sorts.
I first heard about fecal transplant for Clostridium difficile infection (instilling a “better” microbiome in the hope of realizing many benefits) about six or eight years ago. Although I was sure this was a new idea, my retired internist father told me this had been around when he was in training. Wikipedia says that four Colorado surgeons published a paper about it in 1958 and that the Chinese were doing this 1,600 years ago.
PCPs Visit Hospitalized Patients
Writing in the NEJM earlier this year, Goroll and Hunt proposed that primary care physicians visit their hospitalized patients in the role of consultant while the hospitalist remains attending. As they note, this idea surfaced as soon as the hospitalist model began taking hold. Back then, we usually referred to it as a “social visit” by the PCP. Anecdotal experience from my work with hundreds of hospitalist groups tells me that such visits have all but disappeared. But nearly every such PCP visit on a patient I’ve cared for has seemed worthwhile; in many cases, these hospital calls simply reassure a nervous patient or family member, and occasionally they ensure that the PCP and I arrive at a more effective plan of care than we might otherwise.
Perhaps new forms of healthcare reimbursement, accountable care, and population health may make “continuity visits” economically viable for PCPs. Wouldn’t it be interesting if PCP visits to hospitalized patients and hospitalist visits to outpatients, such as those occurring in a pre-op clinic or a skilled nursing facility, become commonplace? The trick in all of this will be to ensure the right amount of overlap, or shared visits, between PCP and hospitalist without expensive duplication of effort or errors stemming from too many cooks in the kitchen.
Post-Hospital Follow-Up Schedules
When I began practicing as a hospitalist in the 1980s, doctors routinely wrote orders similar to this one: “Have patient follow up with Dr. Smith (PCP or specialist) in 1-2 weeks.” The unit secretary or other hospital clerical staff would contact the physician’s office to schedule the appointment, and the patient would leave the hospital with a written reminder in hand. My sense is that nearly all hospitals had been doing this for decades; somehow this practice has nearly disappeared over the last 10-20 years, however, and I sometimes hear this old practice discussed as a new idea.
I think making sure the patient has a follow-up appointment in hand when leaving the hospital is likely good for clinical outcomes, readmissions, and patient satisfaction. In my view, it is hardly worth lots of research to prove the benefit of what should be a relatively low-cost intervention. Why not just have providers write orders detailing follow-up with a specific doctor or clinic and a timeframe, and have unit secretaries communicate with outpatient clinics to schedule the appointments and ensure that the details are provided to the patient, maybe via an EHR-generated after visit summary? Seems pretty easy, right?
Turns out it isn’t easy at all for most hospitals. Lots of energetic hospitalists have taken on a project like this, only to run into so many brick walls. One hospitalist told me recently that the unit secretary’s labor union at her hospital refused to allow it. So some hospitals have turned to a single person, or a small group of people, who make appointments for all hospital patients. Some hospitalist groups have one of their own staff make appointments for hospitalist patients. This relieves the unit secretaries of the task but requires additional funding for the salaries of these people.
Maybe, at some time not so far off, EHRs will be so user-friendly and patients/families so accustomed to using them that it will be common for patients/families to arrange the appointments on their own. It could even be a required step—a hard stop—in the discharge process.
Whatever emerges as the most common method of making these appointments, I think it is safe to say this old practice will become “new” and common within the next few years.
Multidisciplinary Rounds
While working as an orderly in the 1970s, I would often visit with the nurses in their break room. When a doctor arrived to make rounds on the floor, the RN would jump up, stub out her cigarette, and round with the doctor. I sometimes tagged along as an observer. The nurse let the doctor know just how the patient had been doing and provided test results and any other relevant information the doctor might need. The doctor would provide orders, and sometimes the nurse wrote them into the chart (think of today’s medical scribes). Although their interaction was much less collaborative than is typical today, they did ask lots of questions of one another to clarify ambiguities.
I think these 1970s caregivers were doing effective multidisciplinary rounds. But by the late 1980s or so, as both doctor and nurse became busier, they stopped rounding together.
I smile when I hear descriptions of this “new” idea of doctor and nurse (and often other caregivers) rounding together. Today’s hospital culture is less hierarchical than the 1970s, though some would say it still has a ways to go, so teamwork and multidisciplinary rounds may yield more benefit than decades ago. But the idea of rounding together certainly isn’t new.
As we try to figure out the best way to thrive in a rapidly changing healthcare environment, we may find value in returning to the old ways of doing some things.
The musty collections of National Geographic magazines once found in so many basements are largely gone. Replacing them are dusty sets of the Advisory Board binders and booklets found in hospital administration offices around the country. I think the same principle drives the impulse to collect both publications—the idea that they contain worthwhile information that one day will be reviewed. But I think it’s more likely they will be ignored until it is time to move and someone has to decide what to do with the painfully heavy pile of paper.
Lots of old and largely forgotten things are making a comeback in healthcare. I suppose this is always happening, but I sense we’re now experiencing more of this than usual. It’s a renaissance of sorts.
I first heard about fecal transplant for Clostridium difficile infection (instilling a “better” microbiome in the hope of realizing many benefits) about six or eight years ago. Although I was sure this was a new idea, my retired internist father told me this had been around when he was in training. Wikipedia says that four Colorado surgeons published a paper about it in 1958 and that the Chinese were doing this 1,600 years ago.
PCPs Visit Hospitalized Patients
Writing in the NEJM earlier this year, Goroll and Hunt proposed that primary care physicians visit their hospitalized patients in the role of consultant while the hospitalist remains attending. As they note, this idea surfaced as soon as the hospitalist model began taking hold. Back then, we usually referred to it as a “social visit” by the PCP. Anecdotal experience from my work with hundreds of hospitalist groups tells me that such visits have all but disappeared. But nearly every such PCP visit on a patient I’ve cared for has seemed worthwhile; in many cases, these hospital calls simply reassure a nervous patient or family member, and occasionally they ensure that the PCP and I arrive at a more effective plan of care than we might otherwise.
Perhaps new forms of healthcare reimbursement, accountable care, and population health may make “continuity visits” economically viable for PCPs. Wouldn’t it be interesting if PCP visits to hospitalized patients and hospitalist visits to outpatients, such as those occurring in a pre-op clinic or a skilled nursing facility, become commonplace? The trick in all of this will be to ensure the right amount of overlap, or shared visits, between PCP and hospitalist without expensive duplication of effort or errors stemming from too many cooks in the kitchen.
Post-Hospital Follow-Up Schedules
When I began practicing as a hospitalist in the 1980s, doctors routinely wrote orders similar to this one: “Have patient follow up with Dr. Smith (PCP or specialist) in 1-2 weeks.” The unit secretary or other hospital clerical staff would contact the physician’s office to schedule the appointment, and the patient would leave the hospital with a written reminder in hand. My sense is that nearly all hospitals had been doing this for decades; somehow this practice has nearly disappeared over the last 10-20 years, however, and I sometimes hear this old practice discussed as a new idea.
I think making sure the patient has a follow-up appointment in hand when leaving the hospital is likely good for clinical outcomes, readmissions, and patient satisfaction. In my view, it is hardly worth lots of research to prove the benefit of what should be a relatively low-cost intervention. Why not just have providers write orders detailing follow-up with a specific doctor or clinic and a timeframe, and have unit secretaries communicate with outpatient clinics to schedule the appointments and ensure that the details are provided to the patient, maybe via an EHR-generated after visit summary? Seems pretty easy, right?
Turns out it isn’t easy at all for most hospitals. Lots of energetic hospitalists have taken on a project like this, only to run into so many brick walls. One hospitalist told me recently that the unit secretary’s labor union at her hospital refused to allow it. So some hospitals have turned to a single person, or a small group of people, who make appointments for all hospital patients. Some hospitalist groups have one of their own staff make appointments for hospitalist patients. This relieves the unit secretaries of the task but requires additional funding for the salaries of these people.
Maybe, at some time not so far off, EHRs will be so user-friendly and patients/families so accustomed to using them that it will be common for patients/families to arrange the appointments on their own. It could even be a required step—a hard stop—in the discharge process.
Whatever emerges as the most common method of making these appointments, I think it is safe to say this old practice will become “new” and common within the next few years.
Multidisciplinary Rounds
While working as an orderly in the 1970s, I would often visit with the nurses in their break room. When a doctor arrived to make rounds on the floor, the RN would jump up, stub out her cigarette, and round with the doctor. I sometimes tagged along as an observer. The nurse let the doctor know just how the patient had been doing and provided test results and any other relevant information the doctor might need. The doctor would provide orders, and sometimes the nurse wrote them into the chart (think of today’s medical scribes). Although their interaction was much less collaborative than is typical today, they did ask lots of questions of one another to clarify ambiguities.
I think these 1970s caregivers were doing effective multidisciplinary rounds. But by the late 1980s or so, as both doctor and nurse became busier, they stopped rounding together.
I smile when I hear descriptions of this “new” idea of doctor and nurse (and often other caregivers) rounding together. Today’s hospital culture is less hierarchical than the 1970s, though some would say it still has a ways to go, so teamwork and multidisciplinary rounds may yield more benefit than decades ago. But the idea of rounding together certainly isn’t new.
As we try to figure out the best way to thrive in a rapidly changing healthcare environment, we may find value in returning to the old ways of doing some things.
The musty collections of National Geographic magazines once found in so many basements are largely gone. Replacing them are dusty sets of the Advisory Board binders and booklets found in hospital administration offices around the country. I think the same principle drives the impulse to collect both publications—the idea that they contain worthwhile information that one day will be reviewed. But I think it’s more likely they will be ignored until it is time to move and someone has to decide what to do with the painfully heavy pile of paper.
Lots of old and largely forgotten things are making a comeback in healthcare. I suppose this is always happening, but I sense we’re now experiencing more of this than usual. It’s a renaissance of sorts.
I first heard about fecal transplant for Clostridium difficile infection (instilling a “better” microbiome in the hope of realizing many benefits) about six or eight years ago. Although I was sure this was a new idea, my retired internist father told me this had been around when he was in training. Wikipedia says that four Colorado surgeons published a paper about it in 1958 and that the Chinese were doing this 1,600 years ago.
PCPs Visit Hospitalized Patients
Writing in the NEJM earlier this year, Goroll and Hunt proposed that primary care physicians visit their hospitalized patients in the role of consultant while the hospitalist remains attending. As they note, this idea surfaced as soon as the hospitalist model began taking hold. Back then, we usually referred to it as a “social visit” by the PCP. Anecdotal experience from my work with hundreds of hospitalist groups tells me that such visits have all but disappeared. But nearly every such PCP visit on a patient I’ve cared for has seemed worthwhile; in many cases, these hospital calls simply reassure a nervous patient or family member, and occasionally they ensure that the PCP and I arrive at a more effective plan of care than we might otherwise.
Perhaps new forms of healthcare reimbursement, accountable care, and population health may make “continuity visits” economically viable for PCPs. Wouldn’t it be interesting if PCP visits to hospitalized patients and hospitalist visits to outpatients, such as those occurring in a pre-op clinic or a skilled nursing facility, become commonplace? The trick in all of this will be to ensure the right amount of overlap, or shared visits, between PCP and hospitalist without expensive duplication of effort or errors stemming from too many cooks in the kitchen.
Post-Hospital Follow-Up Schedules
When I began practicing as a hospitalist in the 1980s, doctors routinely wrote orders similar to this one: “Have patient follow up with Dr. Smith (PCP or specialist) in 1-2 weeks.” The unit secretary or other hospital clerical staff would contact the physician’s office to schedule the appointment, and the patient would leave the hospital with a written reminder in hand. My sense is that nearly all hospitals had been doing this for decades; somehow this practice has nearly disappeared over the last 10-20 years, however, and I sometimes hear this old practice discussed as a new idea.
I think making sure the patient has a follow-up appointment in hand when leaving the hospital is likely good for clinical outcomes, readmissions, and patient satisfaction. In my view, it is hardly worth lots of research to prove the benefit of what should be a relatively low-cost intervention. Why not just have providers write orders detailing follow-up with a specific doctor or clinic and a timeframe, and have unit secretaries communicate with outpatient clinics to schedule the appointments and ensure that the details are provided to the patient, maybe via an EHR-generated after visit summary? Seems pretty easy, right?
Turns out it isn’t easy at all for most hospitals. Lots of energetic hospitalists have taken on a project like this, only to run into so many brick walls. One hospitalist told me recently that the unit secretary’s labor union at her hospital refused to allow it. So some hospitals have turned to a single person, or a small group of people, who make appointments for all hospital patients. Some hospitalist groups have one of their own staff make appointments for hospitalist patients. This relieves the unit secretaries of the task but requires additional funding for the salaries of these people.
Maybe, at some time not so far off, EHRs will be so user-friendly and patients/families so accustomed to using them that it will be common for patients/families to arrange the appointments on their own. It could even be a required step—a hard stop—in the discharge process.
Whatever emerges as the most common method of making these appointments, I think it is safe to say this old practice will become “new” and common within the next few years.
Multidisciplinary Rounds
While working as an orderly in the 1970s, I would often visit with the nurses in their break room. When a doctor arrived to make rounds on the floor, the RN would jump up, stub out her cigarette, and round with the doctor. I sometimes tagged along as an observer. The nurse let the doctor know just how the patient had been doing and provided test results and any other relevant information the doctor might need. The doctor would provide orders, and sometimes the nurse wrote them into the chart (think of today’s medical scribes). Although their interaction was much less collaborative than is typical today, they did ask lots of questions of one another to clarify ambiguities.
I think these 1970s caregivers were doing effective multidisciplinary rounds. But by the late 1980s or so, as both doctor and nurse became busier, they stopped rounding together.
I smile when I hear descriptions of this “new” idea of doctor and nurse (and often other caregivers) rounding together. Today’s hospital culture is less hierarchical than the 1970s, though some would say it still has a ways to go, so teamwork and multidisciplinary rounds may yield more benefit than decades ago. But the idea of rounding together certainly isn’t new.
As we try to figure out the best way to thrive in a rapidly changing healthcare environment, we may find value in returning to the old ways of doing some things.