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VAM ’17 Will Be a ‘Spectacular Meeting’
Participants at the Vascular Annual Meeting (VAM) have lots more to look forward to than sunny skies, beaches and palm trees. A number of new program features are planned to add interest and value to the meeting, said Dr. Ron Dalman.
Dr. Dalman chairs the SVS Program Committee, which develops programming and content for VAM, the premiere meeting for vascular specialists.
The 2017 meeting will be May 31-June 3 in beautiful San Diego, with plenaries and exhibits set for June 1-3.
Changes for 2017 include:
• More and potentially longer sessions with collaborative specialty societies, such as the American Venous Forum, the Society for Vascular Ultrasound and the Society of Thoracic Surgeons. “These sessions provide a multi-disciplinary perspective on our common problems and showcase the SVS’ leadership role in vascular health and disease management,” said Dr. Dalman. Members provided positive feedback on last year’s partnership sessions, so this year, these program features will be significantly expanded.
• An educational review course highlighting some of the more frequently missed questions from the latest version of the Vascular Education Self-Assessment Program (VESAP3).
• Guideline summaries, organized by the SVS Document Oversight Committee and presented by the authorship group for each, on critical topics such as abdominal aortic aneurysms, aortic dissection, venous disease and more. These summaries will be incorporated into post-graduate programming. “It makes sense to cover current practice guidelines and consensus documents, as several high-profile efforts are being updated this year,” said Dr. Dalman. “We can give attendees an executive summary of current guidelines by their respective authors, and attendees will come away with unique insights into why the most impactful and significant changes were included in each respective document.”
• Sessions of potential interest to surgeons in community practice environments, marked in the schedule as such by the SVS Community Practice Committee.
“These improvements will increase the value of the Annual Meeting for all attendees,” Dr. Dalman said. “We’re emphasizing interactive education, not simply passive learning. It’s going to be very exciting – and different in both style and substance.”
A Californian himself, Dr. Dalman also is looking forward to showing off his state. “San Diego is a wonderful place to vacation and the meeting venue provides convenient access to the Gaslamp District, the waterfront and the world-famous beaches,” he said.
“We encourage our members to bring their families to San Diego and make a vacation out of it.”
With the programming additions, increased opportunities for participation, the educational activities planned plus the perfect location, he added, “This is going to be a spectacular meeting.”
Participants at the Vascular Annual Meeting (VAM) have lots more to look forward to than sunny skies, beaches and palm trees. A number of new program features are planned to add interest and value to the meeting, said Dr. Ron Dalman.
Dr. Dalman chairs the SVS Program Committee, which develops programming and content for VAM, the premiere meeting for vascular specialists.
The 2017 meeting will be May 31-June 3 in beautiful San Diego, with plenaries and exhibits set for June 1-3.
Changes for 2017 include:
• More and potentially longer sessions with collaborative specialty societies, such as the American Venous Forum, the Society for Vascular Ultrasound and the Society of Thoracic Surgeons. “These sessions provide a multi-disciplinary perspective on our common problems and showcase the SVS’ leadership role in vascular health and disease management,” said Dr. Dalman. Members provided positive feedback on last year’s partnership sessions, so this year, these program features will be significantly expanded.
• An educational review course highlighting some of the more frequently missed questions from the latest version of the Vascular Education Self-Assessment Program (VESAP3).
• Guideline summaries, organized by the SVS Document Oversight Committee and presented by the authorship group for each, on critical topics such as abdominal aortic aneurysms, aortic dissection, venous disease and more. These summaries will be incorporated into post-graduate programming. “It makes sense to cover current practice guidelines and consensus documents, as several high-profile efforts are being updated this year,” said Dr. Dalman. “We can give attendees an executive summary of current guidelines by their respective authors, and attendees will come away with unique insights into why the most impactful and significant changes were included in each respective document.”
• Sessions of potential interest to surgeons in community practice environments, marked in the schedule as such by the SVS Community Practice Committee.
“These improvements will increase the value of the Annual Meeting for all attendees,” Dr. Dalman said. “We’re emphasizing interactive education, not simply passive learning. It’s going to be very exciting – and different in both style and substance.”
A Californian himself, Dr. Dalman also is looking forward to showing off his state. “San Diego is a wonderful place to vacation and the meeting venue provides convenient access to the Gaslamp District, the waterfront and the world-famous beaches,” he said.
“We encourage our members to bring their families to San Diego and make a vacation out of it.”
With the programming additions, increased opportunities for participation, the educational activities planned plus the perfect location, he added, “This is going to be a spectacular meeting.”
Participants at the Vascular Annual Meeting (VAM) have lots more to look forward to than sunny skies, beaches and palm trees. A number of new program features are planned to add interest and value to the meeting, said Dr. Ron Dalman.
Dr. Dalman chairs the SVS Program Committee, which develops programming and content for VAM, the premiere meeting for vascular specialists.
The 2017 meeting will be May 31-June 3 in beautiful San Diego, with plenaries and exhibits set for June 1-3.
Changes for 2017 include:
• More and potentially longer sessions with collaborative specialty societies, such as the American Venous Forum, the Society for Vascular Ultrasound and the Society of Thoracic Surgeons. “These sessions provide a multi-disciplinary perspective on our common problems and showcase the SVS’ leadership role in vascular health and disease management,” said Dr. Dalman. Members provided positive feedback on last year’s partnership sessions, so this year, these program features will be significantly expanded.
• An educational review course highlighting some of the more frequently missed questions from the latest version of the Vascular Education Self-Assessment Program (VESAP3).
• Guideline summaries, organized by the SVS Document Oversight Committee and presented by the authorship group for each, on critical topics such as abdominal aortic aneurysms, aortic dissection, venous disease and more. These summaries will be incorporated into post-graduate programming. “It makes sense to cover current practice guidelines and consensus documents, as several high-profile efforts are being updated this year,” said Dr. Dalman. “We can give attendees an executive summary of current guidelines by their respective authors, and attendees will come away with unique insights into why the most impactful and significant changes were included in each respective document.”
• Sessions of potential interest to surgeons in community practice environments, marked in the schedule as such by the SVS Community Practice Committee.
“These improvements will increase the value of the Annual Meeting for all attendees,” Dr. Dalman said. “We’re emphasizing interactive education, not simply passive learning. It’s going to be very exciting – and different in both style and substance.”
A Californian himself, Dr. Dalman also is looking forward to showing off his state. “San Diego is a wonderful place to vacation and the meeting venue provides convenient access to the Gaslamp District, the waterfront and the world-famous beaches,” he said.
“We encourage our members to bring their families to San Diego and make a vacation out of it.”
With the programming additions, increased opportunities for participation, the educational activities planned plus the perfect location, he added, “This is going to be a spectacular meeting.”
Ready for post-acute care?
The definition of “hospitalist,” according to the SHM website, is a clinician “dedicated to delivering comprehensive medical care to hospitalized patients.” For years, the hospital setting was the specialties’ identifier. But as hospitalists’ scope has expanded, and post-acute care (PAC) in the United States has grown, more hospitalists are extending their roles into this space.
PAC today is more than the traditional nursing home, according to Manoj K. Mathew, MD, SFHM, national medical director of Agilon Health in Los Angeles.
Many of those expanded settings Dr. Mathew describes emerged as a result of the Affordable Care Act. Since its enactment in 2010, the ACA has heightened providers’ focus on the “Triple Aim” of improving the patient experience (including quality and satisfaction), improving the health of populations, and reducing the per capita cost of healthcare.1 Vishal Kuchaculla, MD, New England regional post-acute medical director of Knoxville,Tenn.-based TeamHealth, says new service lines also developed as Medicare clamped down on long-term inpatient hospital stays by giving financial impetus to discharge patients as soon as possible.
“Over the last few years, there’s been a major shift from fee-for-service to risk-based payment models,” Dr. Kuchaculla says. “The government’s financial incentives are driving outcomes to improve performance initiatives.”
“Today, LTACHs can be used as substitutes for short-term acute care,” says Sean R. Muldoon, MD, MPH, FCCP, chief medical officer of Kindred Healthcare in Louisville, Ky., and former chair of SHM’s Post-Acute Care Committee. “This means that a patient can be directly admitted from their home to an LTACH. In fact, many hospice and home-care patients are referred from physicians’ offices without a preceding hospitalization.”
Hospitalists can fill a need
More hospitalists are working in PACs for a number of reasons. Dr. Mathew says PAC facilities and services have “typically lacked the clinical structure and processes to obtain the results that patients and payors expect.
“These deficits needed to be quickly remedied as patients discharged from hospitals have increased acuity and higher disease burdens,” he adds. “Hospitalists were the natural choice to fill roles requiring their expertise and experience.”
Dr. Muldoon considers the expanded scope of practice into PACs an additional layer to hospital medicine’s value proposition to the healthcare system.
“As experts in the management of inpatient populations, it’s natural for hospitalists to expand to other facilities with inpatient-like populations,” he says, noting SNFs are the most popular choice, with IRFs and LTACHs also being common places to work. Few hospitalists work in home care or hospice.
PAC settings are designed to help patients who are transitioning from an inpatient setting back to their home or other setting.
“Many patients go home after a SNF stay, while others will move to a nursing home or other longer-term care setting for the first time,” says Tiffany Radcliff, PhD, a health economist in the department of health policy and management at Texas A&M University School of Public Health in College Station. “With this in mind, hospitalists working in PAC have the opportunity to address each patient’s ongoing care needs and prepare them for their next setting. Hospitalists can manage medication or other care regimen changes that resulted from an inpatient stay, reinforce discharge instructions to the patient and their caregivers, and identify any other issues with continuing care that need to be addressed before discharge to the next care setting.”
Transitioning Care
Even if a hospitalist is not employed at a PAC, it’s important that they know something about them.
“As patients are moved downstream earlier, hospitalists are being asked to help make a judgment regarding when and where an inpatient is transitioned,” Dr. Muldoon says. As organizations move toward becoming fully risk capable, it is necessary to develop referral networks of high-quality PAC providers to achieve the best clinical outcomes, reduce readmissions, and lower costs.2“Therefore, hospitalists should have a working knowledge of the different sites of service as well as some opinion on the suitability of available options in their community,” Dr. Muldoon says. “The hospitalist can also help to educate the hospitalized patient on what to expect at a PAC.”
If a patient is inappropriately prepared for the PAC setting, it could lead to incomplete management of their condition, which ultimately could lead to readmission.
“When hospitalists know how care is provided in a PAC setting, they are better able to ensure a smoother transition of care between settings,” says Tochi Iroku-Malize, MD, MPH, MBA, FAAFP, SFHM, chair of family medicine at Northwell Health in Long Island, N.Y. “This will ultimately prevent unnecessary readmissions.”
Further, the quality metrics that hospitals and thereby hospitalists are judged by no longer end at the hospital’s exit.
“The ownership of acute-care outcomes requires extending the accountability to outside of the institution’s four walls,” Dr. Mathew says. “The inpatient team needs to place great importance on the transition of care and the subsequent quality of that care when the patient is discharged.”
Robert W. Harrington Jr., MD, SFHM, chief medical officer of Plano, Texas–based Reliant Post-Acute Care Solutions and former SHM president, says the health system landscapes are pushing HM beyond the hospitals’ walls.
How PAC settings differ from hospitals
Practicing in PAC has some important nuances that hospitalists from short-term acute care need to get accustomed to, Dr. Muldoon says. Primarily, the diagnostic capabilities are much more limited, as is the presence of high-level staffing. Further, patients are less resilient to medication changes and interventions, so changes need to be done gradually.
“Hospitalists who try to practice acute-care medicine in a PAC setting may become frustrated by the length of time it takes to do a work-up, get a consultation, and respond to a patient’s change of condition,” Dr. Muldoon says. “Nonetheless, hospitalists can overcome this once recognizing this mind shift.”
According to Dr. Harrington, another challenge hospitalists may face is the inability of the hospital’s and PAC facility’s IT platforms to exchange electronic information.
“The major vendors on both sides need to figure out an interoperability strategy,” he says. “Currently, it often takes 1-3 days to receive a new patient’s discharge summary. The summary may consist of a stack of paper that takes significant time to sort through and requires the PAC facility to perform duplicate data entry. It’s a very highly inefficient process that opens up the doors to mistakes and errors of omission and commission that can result in bad patient outcomes.”
Arif Nazir, MD, CMD, FACP, AGSF, chief medical officer of Signature HealthCARE and president of SHC Medical Partners, both in Louisville, Ky., cites additional reasons the lack of seamless communication between a hospital and PAC facility is problematic. “I see physicians order laboratory tests and investigations that were already done in the hospital because they didn’t know they were already performed or never received the results,” he says. “Similarly, I see patients continue to take medications prescribed in the hospital long term even though they were only supposed to take them short term. I’ve also seen patients come to a PAC setting from a hospital without any formal understanding of their rehabilitative period and expectations for recovery.”
What’s ahead?
Looking to the future, Surafel Tsega, MD, clinical instructor at Mount Sinai Hospital in New York, says he thinks there will be a move toward greater collaboration among inpatient and PAC facilities, particularly in the discharge process, given that hospitals have an added incentive to ensure safe transitions because reimbursement from the Centers for Medicare & Medicaid Services is tied to readmissions and there are penalties for readmission. This involves more comprehensive planning regarding “warm handoffs” (e.g., real-time discussions with PAC providers about a patient’s hospital course and plan of care upon discharge), transferring of information, and so forth.
And while it can still be challenging to identify high-risk patients or determine the intensity and duration of their care, Dr. Mathew says risk-stratification tools and care pathways are continually being refined to maximize value with the limited resources available. In addition, with an increased emphasis on employing a team approach to care, there will be better integration of non-medical services to address the social determinants of health, which play significant roles in overall health and healing.
“Working with community-based organizations for this purpose will be a valuable tool for any of the population health–based initiatives,” he says.
Dr. Muldoon says he believes healthcare reform will increasingly view an inpatient admission as something to be avoided.
“If hospitalization can’t be avoided, then it should be shortened as much as possible,” he says. “This will shift inpatient care into LTACHs, SNFs, and IRFs. Hospitalists would be wise to follow patients into those settings as traditional inpatient census is reduced. This will take a few years, so hospitalists should start now in preparing for that downstream transition of individuals who were previously inpatients.”
The cost of care, and other PAC facts and figures
The amount of money that Medicare spends on post-acute care (PAC) has been increasing. In 2012, 12.6% of Medicare beneficiaries used some form of PAC, costing $62 billion.2 That amounts to the Centers for Medicare & Medicaid Services spending close to 25% of Medicare beneficiary expenses on PAC, a 133% increase from 2001 to 2012. Among the different types, $30.4 billion was spent on skilled nursing facilities (SNFs), $18.6 billion on home health, and $13.1 billion on long-term acute care (LTAC) and acute-care rehabilitation.2
It’s also been reported that after short-term acute-care hospitalization, about one in five Medicare beneficiaries requires continued specialized treatment in one of the three typical Medicare PAC settings: inpatient rehabilitation facilities (IRFs), LTAC hospitals, and SNFs.3
What’s more, hospital readmission nearly doubles the cost of an episode, so the financial implications for organizations operating in risk-bearing arrangements are significant. In 2013, 2,213 hospitals were charged $280 million in readmission penalties.2
References
1. The role of post-acute care in new care delivery models. American Hospital Association website. Available at: http://www.aha.org/research/reports/tw/15dec-tw-postacute.pdf. Accessed Nov. 7, 2016.
2. Post-acute care integration: Today and in the future. DHG Healthcare website. Available at: http://www2.dhgllp.com/res_pubs/HCG-Post-Acute-Care-Integration.pdf. Accessed Nov. 7, 2016.
3. Overview: Post-acute care transitions toolkit. Society for Hospital Medicine website. Available at: http://www.hospitalmedicine.org/Web/Quality___Innovation/Implementation_Toolkit/pact/Overview_PACT.aspx?hkey=dea3da3c-8620-46db-a00f-89f07f021958. Accessed Nov. 10, 2016.
The definition of “hospitalist,” according to the SHM website, is a clinician “dedicated to delivering comprehensive medical care to hospitalized patients.” For years, the hospital setting was the specialties’ identifier. But as hospitalists’ scope has expanded, and post-acute care (PAC) in the United States has grown, more hospitalists are extending their roles into this space.
PAC today is more than the traditional nursing home, according to Manoj K. Mathew, MD, SFHM, national medical director of Agilon Health in Los Angeles.
Many of those expanded settings Dr. Mathew describes emerged as a result of the Affordable Care Act. Since its enactment in 2010, the ACA has heightened providers’ focus on the “Triple Aim” of improving the patient experience (including quality and satisfaction), improving the health of populations, and reducing the per capita cost of healthcare.1 Vishal Kuchaculla, MD, New England regional post-acute medical director of Knoxville,Tenn.-based TeamHealth, says new service lines also developed as Medicare clamped down on long-term inpatient hospital stays by giving financial impetus to discharge patients as soon as possible.
“Over the last few years, there’s been a major shift from fee-for-service to risk-based payment models,” Dr. Kuchaculla says. “The government’s financial incentives are driving outcomes to improve performance initiatives.”
“Today, LTACHs can be used as substitutes for short-term acute care,” says Sean R. Muldoon, MD, MPH, FCCP, chief medical officer of Kindred Healthcare in Louisville, Ky., and former chair of SHM’s Post-Acute Care Committee. “This means that a patient can be directly admitted from their home to an LTACH. In fact, many hospice and home-care patients are referred from physicians’ offices without a preceding hospitalization.”
Hospitalists can fill a need
More hospitalists are working in PACs for a number of reasons. Dr. Mathew says PAC facilities and services have “typically lacked the clinical structure and processes to obtain the results that patients and payors expect.
“These deficits needed to be quickly remedied as patients discharged from hospitals have increased acuity and higher disease burdens,” he adds. “Hospitalists were the natural choice to fill roles requiring their expertise and experience.”
Dr. Muldoon considers the expanded scope of practice into PACs an additional layer to hospital medicine’s value proposition to the healthcare system.
“As experts in the management of inpatient populations, it’s natural for hospitalists to expand to other facilities with inpatient-like populations,” he says, noting SNFs are the most popular choice, with IRFs and LTACHs also being common places to work. Few hospitalists work in home care or hospice.
PAC settings are designed to help patients who are transitioning from an inpatient setting back to their home or other setting.
“Many patients go home after a SNF stay, while others will move to a nursing home or other longer-term care setting for the first time,” says Tiffany Radcliff, PhD, a health economist in the department of health policy and management at Texas A&M University School of Public Health in College Station. “With this in mind, hospitalists working in PAC have the opportunity to address each patient’s ongoing care needs and prepare them for their next setting. Hospitalists can manage medication or other care regimen changes that resulted from an inpatient stay, reinforce discharge instructions to the patient and their caregivers, and identify any other issues with continuing care that need to be addressed before discharge to the next care setting.”
Transitioning Care
Even if a hospitalist is not employed at a PAC, it’s important that they know something about them.
“As patients are moved downstream earlier, hospitalists are being asked to help make a judgment regarding when and where an inpatient is transitioned,” Dr. Muldoon says. As organizations move toward becoming fully risk capable, it is necessary to develop referral networks of high-quality PAC providers to achieve the best clinical outcomes, reduce readmissions, and lower costs.2“Therefore, hospitalists should have a working knowledge of the different sites of service as well as some opinion on the suitability of available options in their community,” Dr. Muldoon says. “The hospitalist can also help to educate the hospitalized patient on what to expect at a PAC.”
If a patient is inappropriately prepared for the PAC setting, it could lead to incomplete management of their condition, which ultimately could lead to readmission.
“When hospitalists know how care is provided in a PAC setting, they are better able to ensure a smoother transition of care between settings,” says Tochi Iroku-Malize, MD, MPH, MBA, FAAFP, SFHM, chair of family medicine at Northwell Health in Long Island, N.Y. “This will ultimately prevent unnecessary readmissions.”
Further, the quality metrics that hospitals and thereby hospitalists are judged by no longer end at the hospital’s exit.
“The ownership of acute-care outcomes requires extending the accountability to outside of the institution’s four walls,” Dr. Mathew says. “The inpatient team needs to place great importance on the transition of care and the subsequent quality of that care when the patient is discharged.”
Robert W. Harrington Jr., MD, SFHM, chief medical officer of Plano, Texas–based Reliant Post-Acute Care Solutions and former SHM president, says the health system landscapes are pushing HM beyond the hospitals’ walls.
How PAC settings differ from hospitals
Practicing in PAC has some important nuances that hospitalists from short-term acute care need to get accustomed to, Dr. Muldoon says. Primarily, the diagnostic capabilities are much more limited, as is the presence of high-level staffing. Further, patients are less resilient to medication changes and interventions, so changes need to be done gradually.
“Hospitalists who try to practice acute-care medicine in a PAC setting may become frustrated by the length of time it takes to do a work-up, get a consultation, and respond to a patient’s change of condition,” Dr. Muldoon says. “Nonetheless, hospitalists can overcome this once recognizing this mind shift.”
According to Dr. Harrington, another challenge hospitalists may face is the inability of the hospital’s and PAC facility’s IT platforms to exchange electronic information.
“The major vendors on both sides need to figure out an interoperability strategy,” he says. “Currently, it often takes 1-3 days to receive a new patient’s discharge summary. The summary may consist of a stack of paper that takes significant time to sort through and requires the PAC facility to perform duplicate data entry. It’s a very highly inefficient process that opens up the doors to mistakes and errors of omission and commission that can result in bad patient outcomes.”
Arif Nazir, MD, CMD, FACP, AGSF, chief medical officer of Signature HealthCARE and president of SHC Medical Partners, both in Louisville, Ky., cites additional reasons the lack of seamless communication between a hospital and PAC facility is problematic. “I see physicians order laboratory tests and investigations that were already done in the hospital because they didn’t know they were already performed or never received the results,” he says. “Similarly, I see patients continue to take medications prescribed in the hospital long term even though they were only supposed to take them short term. I’ve also seen patients come to a PAC setting from a hospital without any formal understanding of their rehabilitative period and expectations for recovery.”
What’s ahead?
Looking to the future, Surafel Tsega, MD, clinical instructor at Mount Sinai Hospital in New York, says he thinks there will be a move toward greater collaboration among inpatient and PAC facilities, particularly in the discharge process, given that hospitals have an added incentive to ensure safe transitions because reimbursement from the Centers for Medicare & Medicaid Services is tied to readmissions and there are penalties for readmission. This involves more comprehensive planning regarding “warm handoffs” (e.g., real-time discussions with PAC providers about a patient’s hospital course and plan of care upon discharge), transferring of information, and so forth.
And while it can still be challenging to identify high-risk patients or determine the intensity and duration of their care, Dr. Mathew says risk-stratification tools and care pathways are continually being refined to maximize value with the limited resources available. In addition, with an increased emphasis on employing a team approach to care, there will be better integration of non-medical services to address the social determinants of health, which play significant roles in overall health and healing.
“Working with community-based organizations for this purpose will be a valuable tool for any of the population health–based initiatives,” he says.
Dr. Muldoon says he believes healthcare reform will increasingly view an inpatient admission as something to be avoided.
“If hospitalization can’t be avoided, then it should be shortened as much as possible,” he says. “This will shift inpatient care into LTACHs, SNFs, and IRFs. Hospitalists would be wise to follow patients into those settings as traditional inpatient census is reduced. This will take a few years, so hospitalists should start now in preparing for that downstream transition of individuals who were previously inpatients.”
The cost of care, and other PAC facts and figures
The amount of money that Medicare spends on post-acute care (PAC) has been increasing. In 2012, 12.6% of Medicare beneficiaries used some form of PAC, costing $62 billion.2 That amounts to the Centers for Medicare & Medicaid Services spending close to 25% of Medicare beneficiary expenses on PAC, a 133% increase from 2001 to 2012. Among the different types, $30.4 billion was spent on skilled nursing facilities (SNFs), $18.6 billion on home health, and $13.1 billion on long-term acute care (LTAC) and acute-care rehabilitation.2
It’s also been reported that after short-term acute-care hospitalization, about one in five Medicare beneficiaries requires continued specialized treatment in one of the three typical Medicare PAC settings: inpatient rehabilitation facilities (IRFs), LTAC hospitals, and SNFs.3
What’s more, hospital readmission nearly doubles the cost of an episode, so the financial implications for organizations operating in risk-bearing arrangements are significant. In 2013, 2,213 hospitals were charged $280 million in readmission penalties.2
References
1. The role of post-acute care in new care delivery models. American Hospital Association website. Available at: http://www.aha.org/research/reports/tw/15dec-tw-postacute.pdf. Accessed Nov. 7, 2016.
2. Post-acute care integration: Today and in the future. DHG Healthcare website. Available at: http://www2.dhgllp.com/res_pubs/HCG-Post-Acute-Care-Integration.pdf. Accessed Nov. 7, 2016.
3. Overview: Post-acute care transitions toolkit. Society for Hospital Medicine website. Available at: http://www.hospitalmedicine.org/Web/Quality___Innovation/Implementation_Toolkit/pact/Overview_PACT.aspx?hkey=dea3da3c-8620-46db-a00f-89f07f021958. Accessed Nov. 10, 2016.
The definition of “hospitalist,” according to the SHM website, is a clinician “dedicated to delivering comprehensive medical care to hospitalized patients.” For years, the hospital setting was the specialties’ identifier. But as hospitalists’ scope has expanded, and post-acute care (PAC) in the United States has grown, more hospitalists are extending their roles into this space.
PAC today is more than the traditional nursing home, according to Manoj K. Mathew, MD, SFHM, national medical director of Agilon Health in Los Angeles.
Many of those expanded settings Dr. Mathew describes emerged as a result of the Affordable Care Act. Since its enactment in 2010, the ACA has heightened providers’ focus on the “Triple Aim” of improving the patient experience (including quality and satisfaction), improving the health of populations, and reducing the per capita cost of healthcare.1 Vishal Kuchaculla, MD, New England regional post-acute medical director of Knoxville,Tenn.-based TeamHealth, says new service lines also developed as Medicare clamped down on long-term inpatient hospital stays by giving financial impetus to discharge patients as soon as possible.
“Over the last few years, there’s been a major shift from fee-for-service to risk-based payment models,” Dr. Kuchaculla says. “The government’s financial incentives are driving outcomes to improve performance initiatives.”
“Today, LTACHs can be used as substitutes for short-term acute care,” says Sean R. Muldoon, MD, MPH, FCCP, chief medical officer of Kindred Healthcare in Louisville, Ky., and former chair of SHM’s Post-Acute Care Committee. “This means that a patient can be directly admitted from their home to an LTACH. In fact, many hospice and home-care patients are referred from physicians’ offices without a preceding hospitalization.”
Hospitalists can fill a need
More hospitalists are working in PACs for a number of reasons. Dr. Mathew says PAC facilities and services have “typically lacked the clinical structure and processes to obtain the results that patients and payors expect.
“These deficits needed to be quickly remedied as patients discharged from hospitals have increased acuity and higher disease burdens,” he adds. “Hospitalists were the natural choice to fill roles requiring their expertise and experience.”
Dr. Muldoon considers the expanded scope of practice into PACs an additional layer to hospital medicine’s value proposition to the healthcare system.
“As experts in the management of inpatient populations, it’s natural for hospitalists to expand to other facilities with inpatient-like populations,” he says, noting SNFs are the most popular choice, with IRFs and LTACHs also being common places to work. Few hospitalists work in home care or hospice.
PAC settings are designed to help patients who are transitioning from an inpatient setting back to their home or other setting.
“Many patients go home after a SNF stay, while others will move to a nursing home or other longer-term care setting for the first time,” says Tiffany Radcliff, PhD, a health economist in the department of health policy and management at Texas A&M University School of Public Health in College Station. “With this in mind, hospitalists working in PAC have the opportunity to address each patient’s ongoing care needs and prepare them for their next setting. Hospitalists can manage medication or other care regimen changes that resulted from an inpatient stay, reinforce discharge instructions to the patient and their caregivers, and identify any other issues with continuing care that need to be addressed before discharge to the next care setting.”
Transitioning Care
Even if a hospitalist is not employed at a PAC, it’s important that they know something about them.
“As patients are moved downstream earlier, hospitalists are being asked to help make a judgment regarding when and where an inpatient is transitioned,” Dr. Muldoon says. As organizations move toward becoming fully risk capable, it is necessary to develop referral networks of high-quality PAC providers to achieve the best clinical outcomes, reduce readmissions, and lower costs.2“Therefore, hospitalists should have a working knowledge of the different sites of service as well as some opinion on the suitability of available options in their community,” Dr. Muldoon says. “The hospitalist can also help to educate the hospitalized patient on what to expect at a PAC.”
If a patient is inappropriately prepared for the PAC setting, it could lead to incomplete management of their condition, which ultimately could lead to readmission.
“When hospitalists know how care is provided in a PAC setting, they are better able to ensure a smoother transition of care between settings,” says Tochi Iroku-Malize, MD, MPH, MBA, FAAFP, SFHM, chair of family medicine at Northwell Health in Long Island, N.Y. “This will ultimately prevent unnecessary readmissions.”
Further, the quality metrics that hospitals and thereby hospitalists are judged by no longer end at the hospital’s exit.
“The ownership of acute-care outcomes requires extending the accountability to outside of the institution’s four walls,” Dr. Mathew says. “The inpatient team needs to place great importance on the transition of care and the subsequent quality of that care when the patient is discharged.”
Robert W. Harrington Jr., MD, SFHM, chief medical officer of Plano, Texas–based Reliant Post-Acute Care Solutions and former SHM president, says the health system landscapes are pushing HM beyond the hospitals’ walls.
How PAC settings differ from hospitals
Practicing in PAC has some important nuances that hospitalists from short-term acute care need to get accustomed to, Dr. Muldoon says. Primarily, the diagnostic capabilities are much more limited, as is the presence of high-level staffing. Further, patients are less resilient to medication changes and interventions, so changes need to be done gradually.
“Hospitalists who try to practice acute-care medicine in a PAC setting may become frustrated by the length of time it takes to do a work-up, get a consultation, and respond to a patient’s change of condition,” Dr. Muldoon says. “Nonetheless, hospitalists can overcome this once recognizing this mind shift.”
According to Dr. Harrington, another challenge hospitalists may face is the inability of the hospital’s and PAC facility’s IT platforms to exchange electronic information.
“The major vendors on both sides need to figure out an interoperability strategy,” he says. “Currently, it often takes 1-3 days to receive a new patient’s discharge summary. The summary may consist of a stack of paper that takes significant time to sort through and requires the PAC facility to perform duplicate data entry. It’s a very highly inefficient process that opens up the doors to mistakes and errors of omission and commission that can result in bad patient outcomes.”
Arif Nazir, MD, CMD, FACP, AGSF, chief medical officer of Signature HealthCARE and president of SHC Medical Partners, both in Louisville, Ky., cites additional reasons the lack of seamless communication between a hospital and PAC facility is problematic. “I see physicians order laboratory tests and investigations that were already done in the hospital because they didn’t know they were already performed or never received the results,” he says. “Similarly, I see patients continue to take medications prescribed in the hospital long term even though they were only supposed to take them short term. I’ve also seen patients come to a PAC setting from a hospital without any formal understanding of their rehabilitative period and expectations for recovery.”
What’s ahead?
Looking to the future, Surafel Tsega, MD, clinical instructor at Mount Sinai Hospital in New York, says he thinks there will be a move toward greater collaboration among inpatient and PAC facilities, particularly in the discharge process, given that hospitals have an added incentive to ensure safe transitions because reimbursement from the Centers for Medicare & Medicaid Services is tied to readmissions and there are penalties for readmission. This involves more comprehensive planning regarding “warm handoffs” (e.g., real-time discussions with PAC providers about a patient’s hospital course and plan of care upon discharge), transferring of information, and so forth.
And while it can still be challenging to identify high-risk patients or determine the intensity and duration of their care, Dr. Mathew says risk-stratification tools and care pathways are continually being refined to maximize value with the limited resources available. In addition, with an increased emphasis on employing a team approach to care, there will be better integration of non-medical services to address the social determinants of health, which play significant roles in overall health and healing.
“Working with community-based organizations for this purpose will be a valuable tool for any of the population health–based initiatives,” he says.
Dr. Muldoon says he believes healthcare reform will increasingly view an inpatient admission as something to be avoided.
“If hospitalization can’t be avoided, then it should be shortened as much as possible,” he says. “This will shift inpatient care into LTACHs, SNFs, and IRFs. Hospitalists would be wise to follow patients into those settings as traditional inpatient census is reduced. This will take a few years, so hospitalists should start now in preparing for that downstream transition of individuals who were previously inpatients.”
The cost of care, and other PAC facts and figures
The amount of money that Medicare spends on post-acute care (PAC) has been increasing. In 2012, 12.6% of Medicare beneficiaries used some form of PAC, costing $62 billion.2 That amounts to the Centers for Medicare & Medicaid Services spending close to 25% of Medicare beneficiary expenses on PAC, a 133% increase from 2001 to 2012. Among the different types, $30.4 billion was spent on skilled nursing facilities (SNFs), $18.6 billion on home health, and $13.1 billion on long-term acute care (LTAC) and acute-care rehabilitation.2
It’s also been reported that after short-term acute-care hospitalization, about one in five Medicare beneficiaries requires continued specialized treatment in one of the three typical Medicare PAC settings: inpatient rehabilitation facilities (IRFs), LTAC hospitals, and SNFs.3
What’s more, hospital readmission nearly doubles the cost of an episode, so the financial implications for organizations operating in risk-bearing arrangements are significant. In 2013, 2,213 hospitals were charged $280 million in readmission penalties.2
References
1. The role of post-acute care in new care delivery models. American Hospital Association website. Available at: http://www.aha.org/research/reports/tw/15dec-tw-postacute.pdf. Accessed Nov. 7, 2016.
2. Post-acute care integration: Today and in the future. DHG Healthcare website. Available at: http://www2.dhgllp.com/res_pubs/HCG-Post-Acute-Care-Integration.pdf. Accessed Nov. 7, 2016.
3. Overview: Post-acute care transitions toolkit. Society for Hospital Medicine website. Available at: http://www.hospitalmedicine.org/Web/Quality___Innovation/Implementation_Toolkit/pact/Overview_PACT.aspx?hkey=dea3da3c-8620-46db-a00f-89f07f021958. Accessed Nov. 10, 2016.
Transplantation palliative care: The time is ripe
Over 10 years ago, a challenge was made in a surgical publication for increased collaboration between the fields of transplantation and palliative care.1
Since that time not much progress has been made bringing these fields together in a consistent way that would mutually benefit patients and the specialties. However, other progress has been made, particularly in the field of palliative care, which could brighten the prospects and broaden the opportunities to accomplish collaboration between palliative care and transplantation.
Growth of palliative services
During the past decade there has been a robust proliferation of hospital-based palliative care programs in the United States. In all, 67% of U.S. hospitals with 50 or more beds report palliative care teams, up from 63% in 2011 and 53% in 2008.
Only a decade ago, critical care and palliative care were generally considered mutually exclusive. Evidence is trickling in to suggest that this is no longer the case. Although palliative care was not an integral part of critical care at that time, patients, families, and even practitioners began to demand these services. Cook and Rocker have eloquently advocated the rightful place of palliative care in the ICU.2
Studies in recent years have shown that the integration of palliative care into critical care decreases in length of ICU and hospital stay, decreases costs, enhances patient/family satisfaction, and promotes a more rapid consensus about goals of care, without increasing mortality. The ICU experience to date could be considered a reassuring precedent for transplantation palliative care.
Integration of palliative care with transplantation
Early palliative care intervention has been shown to improve symptom burden and depression scores in end-stage liver disease patients awaiting transplant. In addition, early palliative care consultation in conjunction with cancer treatment has been associated with increased survival in non–small-cell lung cancer patients. It has been demonstrated that early integration of palliative care in the surgical ICU alongside disease-directed curative care can be accomplished without change in mortality, while improving end-of-life practice in liver transplant patients.3
What palliative care can do for transplant patients
What does palliative care mean for the person (and family) awaiting transplantation? For the cirrhotic patient with cachexia, ascites, and encephalopathy, it means access to the services of a team trained in the management of these symptoms. Palliative care teams can also provide psychosocial and spiritual support for patients and families who are intimidated by the complex navigation of the health care system and the existential threat that end-stage organ failure presents to them. Skilled palliative care and services can be the difference between failing and extended life with a higher quality of life for these very sick patients
Resuscitation of a patient, whether through restoration of organ function or interdicting the progression of disease, begins with resuscitation of hope. Nothing achieves this more quickly than amelioration of burdensome symptoms for the patient and family.
The barriers for transplant surgeons and teams referring and incorporating palliative care services in their practices are multiple and profound. The unique dilemma facing the transplant team is to balance the treatment of the failing organ, the treatment of the patient (and family and friends), and the best use of the graft, a precious gift of society.
Palliative surgery has been defined as any invasive procedure in which the main intention is to mitigate physical symptoms in patients with noncurable disease without causing premature death. The very success of transplantation over the past 3 decades has obscured our memory of transplantation as a type of palliative surgery. It is a well-known axiom of reconstructive surgery that the reconstructed site should be compared to what was there, not to “normal.” Even in the current era of improved immunosuppression and posttransplant support services, one could hardly describe even a successful transplant patient’s experience as “normal.” These patients’ lives may be extended and/or enhanced but they need palliative care before, during, and after transplantation. The growing availability of trained palliative care clinicians and teams, the increased familiarity of palliative and end-of-life care to surgical residents and fellows, and quality metrics measuring palliative care outcomes will provide reassurance and guidance to address reservations about the convergence of the two seemingly opposite realities.
A modest proposal
We propose that palliative care be presented to the entire spectrum of transplantation care: on the ward, in the ICU, and after transplantation. More specific “triggers” for palliative care for referral of transplant patients should be identified. Wentlandt et al.4 have described a promising model for an ambulatory clinic, which provides early, integrated palliative care to patients awaiting and receiving organ transplantation. In addition, we propose an application for grant funding for a conference and eventual formation of a work group of transplant surgeons and team members, palliative care clinicians, and patient/families who have experienced one of the aspects of the transplant spectrum. We await the subspecialty certification in hospice and palliative medicine of a transplant surgeon. Outside of transplantation, every other surgical specialty in the United States has diplomates certified in hospice and palliative medicine. We await the benefits that will accrue from research about the merging of these fields.
1. Molmenti EP, Dunn GP: Transplantation and palliative care: The convergence of two seemingly opposite realities. Surg Clin North Am. 2005;85:373-82.
2. Cook D, Rocker G. Dying with dignity in the intensive care unit. N Engl J Med. 2014;370:2506-14.
3. Lamba S, Murphy P, McVicker S, Smith JH, and Mosenthal AC. Changing end-of-life care practice for liver transplant patients: structured palliative care intervention in the surgical intensive care unit. J Pain Symptom Manage. 2012; 44(4):508-19.
4. Wentlandt, K., Dall’Osto, A., Freeman, N., Le, L. W., Kaya, E., Ross, H., Singer, L. G., Abbey, S., Clarke, H. and Zimmermann, C. (2016), The Transplant Palliative Care Clinic: An early palliative care model for patients in a transplant program. Clin Transplant. 2016 Nov 4; doi: 10.1111/ctr.12838.
Dr. Azoulay is a transplantation specialist of Assistance Publique – Hôpitaux de Paris, and the University of Paris. Dr. Dunn is medical director of the Palliative Care Consultation Service at the University of Pittsburgh Medical Center Hamot, and vice-chair of the ACS Committee on Surgical Palliative Care.
Over 10 years ago, a challenge was made in a surgical publication for increased collaboration between the fields of transplantation and palliative care.1
Since that time not much progress has been made bringing these fields together in a consistent way that would mutually benefit patients and the specialties. However, other progress has been made, particularly in the field of palliative care, which could brighten the prospects and broaden the opportunities to accomplish collaboration between palliative care and transplantation.
Growth of palliative services
During the past decade there has been a robust proliferation of hospital-based palliative care programs in the United States. In all, 67% of U.S. hospitals with 50 or more beds report palliative care teams, up from 63% in 2011 and 53% in 2008.
Only a decade ago, critical care and palliative care were generally considered mutually exclusive. Evidence is trickling in to suggest that this is no longer the case. Although palliative care was not an integral part of critical care at that time, patients, families, and even practitioners began to demand these services. Cook and Rocker have eloquently advocated the rightful place of palliative care in the ICU.2
Studies in recent years have shown that the integration of palliative care into critical care decreases in length of ICU and hospital stay, decreases costs, enhances patient/family satisfaction, and promotes a more rapid consensus about goals of care, without increasing mortality. The ICU experience to date could be considered a reassuring precedent for transplantation palliative care.
Integration of palliative care with transplantation
Early palliative care intervention has been shown to improve symptom burden and depression scores in end-stage liver disease patients awaiting transplant. In addition, early palliative care consultation in conjunction with cancer treatment has been associated with increased survival in non–small-cell lung cancer patients. It has been demonstrated that early integration of palliative care in the surgical ICU alongside disease-directed curative care can be accomplished without change in mortality, while improving end-of-life practice in liver transplant patients.3
What palliative care can do for transplant patients
What does palliative care mean for the person (and family) awaiting transplantation? For the cirrhotic patient with cachexia, ascites, and encephalopathy, it means access to the services of a team trained in the management of these symptoms. Palliative care teams can also provide psychosocial and spiritual support for patients and families who are intimidated by the complex navigation of the health care system and the existential threat that end-stage organ failure presents to them. Skilled palliative care and services can be the difference between failing and extended life with a higher quality of life for these very sick patients
Resuscitation of a patient, whether through restoration of organ function or interdicting the progression of disease, begins with resuscitation of hope. Nothing achieves this more quickly than amelioration of burdensome symptoms for the patient and family.
The barriers for transplant surgeons and teams referring and incorporating palliative care services in their practices are multiple and profound. The unique dilemma facing the transplant team is to balance the treatment of the failing organ, the treatment of the patient (and family and friends), and the best use of the graft, a precious gift of society.
Palliative surgery has been defined as any invasive procedure in which the main intention is to mitigate physical symptoms in patients with noncurable disease without causing premature death. The very success of transplantation over the past 3 decades has obscured our memory of transplantation as a type of palliative surgery. It is a well-known axiom of reconstructive surgery that the reconstructed site should be compared to what was there, not to “normal.” Even in the current era of improved immunosuppression and posttransplant support services, one could hardly describe even a successful transplant patient’s experience as “normal.” These patients’ lives may be extended and/or enhanced but they need palliative care before, during, and after transplantation. The growing availability of trained palliative care clinicians and teams, the increased familiarity of palliative and end-of-life care to surgical residents and fellows, and quality metrics measuring palliative care outcomes will provide reassurance and guidance to address reservations about the convergence of the two seemingly opposite realities.
A modest proposal
We propose that palliative care be presented to the entire spectrum of transplantation care: on the ward, in the ICU, and after transplantation. More specific “triggers” for palliative care for referral of transplant patients should be identified. Wentlandt et al.4 have described a promising model for an ambulatory clinic, which provides early, integrated palliative care to patients awaiting and receiving organ transplantation. In addition, we propose an application for grant funding for a conference and eventual formation of a work group of transplant surgeons and team members, palliative care clinicians, and patient/families who have experienced one of the aspects of the transplant spectrum. We await the subspecialty certification in hospice and palliative medicine of a transplant surgeon. Outside of transplantation, every other surgical specialty in the United States has diplomates certified in hospice and palliative medicine. We await the benefits that will accrue from research about the merging of these fields.
1. Molmenti EP, Dunn GP: Transplantation and palliative care: The convergence of two seemingly opposite realities. Surg Clin North Am. 2005;85:373-82.
2. Cook D, Rocker G. Dying with dignity in the intensive care unit. N Engl J Med. 2014;370:2506-14.
3. Lamba S, Murphy P, McVicker S, Smith JH, and Mosenthal AC. Changing end-of-life care practice for liver transplant patients: structured palliative care intervention in the surgical intensive care unit. J Pain Symptom Manage. 2012; 44(4):508-19.
4. Wentlandt, K., Dall’Osto, A., Freeman, N., Le, L. W., Kaya, E., Ross, H., Singer, L. G., Abbey, S., Clarke, H. and Zimmermann, C. (2016), The Transplant Palliative Care Clinic: An early palliative care model for patients in a transplant program. Clin Transplant. 2016 Nov 4; doi: 10.1111/ctr.12838.
Dr. Azoulay is a transplantation specialist of Assistance Publique – Hôpitaux de Paris, and the University of Paris. Dr. Dunn is medical director of the Palliative Care Consultation Service at the University of Pittsburgh Medical Center Hamot, and vice-chair of the ACS Committee on Surgical Palliative Care.
Over 10 years ago, a challenge was made in a surgical publication for increased collaboration between the fields of transplantation and palliative care.1
Since that time not much progress has been made bringing these fields together in a consistent way that would mutually benefit patients and the specialties. However, other progress has been made, particularly in the field of palliative care, which could brighten the prospects and broaden the opportunities to accomplish collaboration between palliative care and transplantation.
Growth of palliative services
During the past decade there has been a robust proliferation of hospital-based palliative care programs in the United States. In all, 67% of U.S. hospitals with 50 or more beds report palliative care teams, up from 63% in 2011 and 53% in 2008.
Only a decade ago, critical care and palliative care were generally considered mutually exclusive. Evidence is trickling in to suggest that this is no longer the case. Although palliative care was not an integral part of critical care at that time, patients, families, and even practitioners began to demand these services. Cook and Rocker have eloquently advocated the rightful place of palliative care in the ICU.2
Studies in recent years have shown that the integration of palliative care into critical care decreases in length of ICU and hospital stay, decreases costs, enhances patient/family satisfaction, and promotes a more rapid consensus about goals of care, without increasing mortality. The ICU experience to date could be considered a reassuring precedent for transplantation palliative care.
Integration of palliative care with transplantation
Early palliative care intervention has been shown to improve symptom burden and depression scores in end-stage liver disease patients awaiting transplant. In addition, early palliative care consultation in conjunction with cancer treatment has been associated with increased survival in non–small-cell lung cancer patients. It has been demonstrated that early integration of palliative care in the surgical ICU alongside disease-directed curative care can be accomplished without change in mortality, while improving end-of-life practice in liver transplant patients.3
What palliative care can do for transplant patients
What does palliative care mean for the person (and family) awaiting transplantation? For the cirrhotic patient with cachexia, ascites, and encephalopathy, it means access to the services of a team trained in the management of these symptoms. Palliative care teams can also provide psychosocial and spiritual support for patients and families who are intimidated by the complex navigation of the health care system and the existential threat that end-stage organ failure presents to them. Skilled palliative care and services can be the difference between failing and extended life with a higher quality of life for these very sick patients
Resuscitation of a patient, whether through restoration of organ function or interdicting the progression of disease, begins with resuscitation of hope. Nothing achieves this more quickly than amelioration of burdensome symptoms for the patient and family.
The barriers for transplant surgeons and teams referring and incorporating palliative care services in their practices are multiple and profound. The unique dilemma facing the transplant team is to balance the treatment of the failing organ, the treatment of the patient (and family and friends), and the best use of the graft, a precious gift of society.
Palliative surgery has been defined as any invasive procedure in which the main intention is to mitigate physical symptoms in patients with noncurable disease without causing premature death. The very success of transplantation over the past 3 decades has obscured our memory of transplantation as a type of palliative surgery. It is a well-known axiom of reconstructive surgery that the reconstructed site should be compared to what was there, not to “normal.” Even in the current era of improved immunosuppression and posttransplant support services, one could hardly describe even a successful transplant patient’s experience as “normal.” These patients’ lives may be extended and/or enhanced but they need palliative care before, during, and after transplantation. The growing availability of trained palliative care clinicians and teams, the increased familiarity of palliative and end-of-life care to surgical residents and fellows, and quality metrics measuring palliative care outcomes will provide reassurance and guidance to address reservations about the convergence of the two seemingly opposite realities.
A modest proposal
We propose that palliative care be presented to the entire spectrum of transplantation care: on the ward, in the ICU, and after transplantation. More specific “triggers” for palliative care for referral of transplant patients should be identified. Wentlandt et al.4 have described a promising model for an ambulatory clinic, which provides early, integrated palliative care to patients awaiting and receiving organ transplantation. In addition, we propose an application for grant funding for a conference and eventual formation of a work group of transplant surgeons and team members, palliative care clinicians, and patient/families who have experienced one of the aspects of the transplant spectrum. We await the subspecialty certification in hospice and palliative medicine of a transplant surgeon. Outside of transplantation, every other surgical specialty in the United States has diplomates certified in hospice and palliative medicine. We await the benefits that will accrue from research about the merging of these fields.
1. Molmenti EP, Dunn GP: Transplantation and palliative care: The convergence of two seemingly opposite realities. Surg Clin North Am. 2005;85:373-82.
2. Cook D, Rocker G. Dying with dignity in the intensive care unit. N Engl J Med. 2014;370:2506-14.
3. Lamba S, Murphy P, McVicker S, Smith JH, and Mosenthal AC. Changing end-of-life care practice for liver transplant patients: structured palliative care intervention in the surgical intensive care unit. J Pain Symptom Manage. 2012; 44(4):508-19.
4. Wentlandt, K., Dall’Osto, A., Freeman, N., Le, L. W., Kaya, E., Ross, H., Singer, L. G., Abbey, S., Clarke, H. and Zimmermann, C. (2016), The Transplant Palliative Care Clinic: An early palliative care model for patients in a transplant program. Clin Transplant. 2016 Nov 4; doi: 10.1111/ctr.12838.
Dr. Azoulay is a transplantation specialist of Assistance Publique – Hôpitaux de Paris, and the University of Paris. Dr. Dunn is medical director of the Palliative Care Consultation Service at the University of Pittsburgh Medical Center Hamot, and vice-chair of the ACS Committee on Surgical Palliative Care.
Best Practices: Protecting Dry Vulnerable Skin with CeraVe® Healing Ointment
A supplement to Dermatology News. This advertising supplement is sponsored by Valeant Pharmaceuticals.
- Reinforcing the Skin Barrier
- NEA Seal of Acceptance
- A Preventative Approach to Dry, Cracked Skin
- CeraVe Ointment in the Clinical Setting
Faculty/Faculty Disclosure
Sheila Fallon Friedlander, MD
Professor of Clinical Dermatology & Pediatrics
Director, Pediatric Dermatology Fellowship Training Program
University of California at San Diego School of Medicine
Rady Children’s Hospital,
San Diego, California
Dr. Friedlander was compensated for her participation in the development of this article.
CeraVe is a registered trademark of Valeant Pharmaceuticals International, Inc. or its affiliates.
A supplement to Dermatology News. This advertising supplement is sponsored by Valeant Pharmaceuticals.
- Reinforcing the Skin Barrier
- NEA Seal of Acceptance
- A Preventative Approach to Dry, Cracked Skin
- CeraVe Ointment in the Clinical Setting
Faculty/Faculty Disclosure
Sheila Fallon Friedlander, MD
Professor of Clinical Dermatology & Pediatrics
Director, Pediatric Dermatology Fellowship Training Program
University of California at San Diego School of Medicine
Rady Children’s Hospital,
San Diego, California
Dr. Friedlander was compensated for her participation in the development of this article.
CeraVe is a registered trademark of Valeant Pharmaceuticals International, Inc. or its affiliates.
A supplement to Dermatology News. This advertising supplement is sponsored by Valeant Pharmaceuticals.
- Reinforcing the Skin Barrier
- NEA Seal of Acceptance
- A Preventative Approach to Dry, Cracked Skin
- CeraVe Ointment in the Clinical Setting
Faculty/Faculty Disclosure
Sheila Fallon Friedlander, MD
Professor of Clinical Dermatology & Pediatrics
Director, Pediatric Dermatology Fellowship Training Program
University of California at San Diego School of Medicine
Rady Children’s Hospital,
San Diego, California
Dr. Friedlander was compensated for her participation in the development of this article.
CeraVe is a registered trademark of Valeant Pharmaceuticals International, Inc. or its affiliates.
Fluctuant Subcutaneous Nodule in the Axilla of an Adolescent Female
Fluctuant Subcutaneous Nodule in the Axilla of an Adolescent Female
The Diagnosis: Accessory Breast
A diagnosis of accessory breast was confirmed on histopathology, which demonstrated a slightly hyperplastic and hyperpigmented epidermis. The dermis contained an increased number of smooth muscle bundles with the presence of apocrine glands and mammary lobules (Figure). Tenderness of the mass fluctuated according to the patient’s menstrual cycle, which supported a diagnosis of accessory breast over lipoma. The patient had no signs of infection or other systemic symptoms that were suggestive of lymphadenopathy. Unlike an epidermoid inclusion cyst, our patient’s mass presented as poorly defined and boggy in texture. Biopsy results were not consistent with malignancy, ruling out soft tissue sarcoma.
B, Myoepithelial cells lined a stratified columnar epithelium, characteristic of breast tissue (H&E, original magnification x40).
Accessory breasts are characterized by the presence of breast tissue outside the breast and can be found anywhere along the milk line from the axillae to the vulva.1 The prevalence of accessory breasts is 2% to 6% of women, with an average age of presentation for treatment of 42 years.2 Ninety percent of accessory breasts are found in the thorax, 5% are found in the abdomen, and 5% are found in the axillae.3 Incidence is uncommon in adolescents; however, in addition to our patient, there are several cases in the literature of adolescents with accessory breasts in the axillae.4,5
Ectopic mammary tissue is divided into 8 classes based on the Kajava classification system (Table). In a retrospective study of adolescent females with accessory breasts, 91% (10/11) of patients were classified as class IV, and 1 was class II.6 Similarly, our patient was classified as class IV since her accessory breast was composed entirely of glandular tissue and did not include an areola and nipple.
Supernumerary breast structures such as areolas and nipples typically are diagnosed at birth, whereas supernumerary breast tissue is not diagnosed until after hormonal stimulation typically seen during puberty, pregnancy, or breastfeeding. Common symptoms include cyclic pain with menstruation, fluctuation in the size of the mass, and tenderness of the ectopic tissue. There also can be restricted range of motion and increased irritation from clothing. Ultrasonography generally shows a hypoechoic septate indicative of mammary tissue.6 Diagnosis is confirmed by histopathologic studies that show mammary lobules in the dermis with smooth muscle, mammary ducts connected to the nipple, and connective stroma.6
If bothersome, ectopic breast tissue can be surgically removed, either by direct excision or suction lipectomy depending on the size of the mass.2 Postoperative complications are low but can include seroma, bleeding, infection, remnant tissue, or undesired cosmetic results. As with normal breast tissue, ectopic breast tissue can manifest with benign and malignant pathologies.
In conclusion, accessory breast is a benign condition that can cause cyclical pain with menstruation, restricted range of motion, discomfort, anxiety, and cosmetic problems. It is important to keep this diagnosis on the differential when evaluating a soft tissue mass that appears in the axillary region.
- Loukas M, Clarke P, Tubbs RS. Accessory breasts: a historical and current perspective. Am Surg. 2007;73:525-528.
- Bartsich SA, Ofodile FA. Accessory breast tissue in the axilla: classification and treatment. Plast Reconstr Surg. 2011;128:35E-36E. doi:10.1097/PRS.0b013e3182173f95
- Mazine K, Bouassria A, Elbouhaddouti H. Bilateral supernumerary axillary breasts: a case report. Pan Afr Med J. 2020;36:282. doi:10.11604 /pamj.2020.36.282.20445
- Patel RV, Govani D, Patel R, et al. Adolescent right axillary accessory breast with galactorrhoea. BMJ Case Rep. 2014;2014:bcr2014204215. doi:10.1136/bcr-2014-204215
- Surd A, Mironescu A, Gocan H. Fibroadenoma in axillary supernumerary breast in a 17-year-old girl: case report. J Pediatr Adolesc Gynecol. 2016;29:E79-E81. doi:10.1016/j.jpag.2016.04.008
- De la Torre M, Lorca-García C, de Tomás E, et al. Axillary ectopic breast tissue in the adolescent. Pediatr Surg Int. 2022;38:1445-1451. doi:10.1007/s00383-022-05184-1
The Diagnosis: Accessory Breast
A diagnosis of accessory breast was confirmed on histopathology, which demonstrated a slightly hyperplastic and hyperpigmented epidermis. The dermis contained an increased number of smooth muscle bundles with the presence of apocrine glands and mammary lobules (Figure). Tenderness of the mass fluctuated according to the patient’s menstrual cycle, which supported a diagnosis of accessory breast over lipoma. The patient had no signs of infection or other systemic symptoms that were suggestive of lymphadenopathy. Unlike an epidermoid inclusion cyst, our patient’s mass presented as poorly defined and boggy in texture. Biopsy results were not consistent with malignancy, ruling out soft tissue sarcoma.
B, Myoepithelial cells lined a stratified columnar epithelium, characteristic of breast tissue (H&E, original magnification x40).
Accessory breasts are characterized by the presence of breast tissue outside the breast and can be found anywhere along the milk line from the axillae to the vulva.1 The prevalence of accessory breasts is 2% to 6% of women, with an average age of presentation for treatment of 42 years.2 Ninety percent of accessory breasts are found in the thorax, 5% are found in the abdomen, and 5% are found in the axillae.3 Incidence is uncommon in adolescents; however, in addition to our patient, there are several cases in the literature of adolescents with accessory breasts in the axillae.4,5
Ectopic mammary tissue is divided into 8 classes based on the Kajava classification system (Table). In a retrospective study of adolescent females with accessory breasts, 91% (10/11) of patients were classified as class IV, and 1 was class II.6 Similarly, our patient was classified as class IV since her accessory breast was composed entirely of glandular tissue and did not include an areola and nipple.
Supernumerary breast structures such as areolas and nipples typically are diagnosed at birth, whereas supernumerary breast tissue is not diagnosed until after hormonal stimulation typically seen during puberty, pregnancy, or breastfeeding. Common symptoms include cyclic pain with menstruation, fluctuation in the size of the mass, and tenderness of the ectopic tissue. There also can be restricted range of motion and increased irritation from clothing. Ultrasonography generally shows a hypoechoic septate indicative of mammary tissue.6 Diagnosis is confirmed by histopathologic studies that show mammary lobules in the dermis with smooth muscle, mammary ducts connected to the nipple, and connective stroma.6
If bothersome, ectopic breast tissue can be surgically removed, either by direct excision or suction lipectomy depending on the size of the mass.2 Postoperative complications are low but can include seroma, bleeding, infection, remnant tissue, or undesired cosmetic results. As with normal breast tissue, ectopic breast tissue can manifest with benign and malignant pathologies.
In conclusion, accessory breast is a benign condition that can cause cyclical pain with menstruation, restricted range of motion, discomfort, anxiety, and cosmetic problems. It is important to keep this diagnosis on the differential when evaluating a soft tissue mass that appears in the axillary region.
The Diagnosis: Accessory Breast
A diagnosis of accessory breast was confirmed on histopathology, which demonstrated a slightly hyperplastic and hyperpigmented epidermis. The dermis contained an increased number of smooth muscle bundles with the presence of apocrine glands and mammary lobules (Figure). Tenderness of the mass fluctuated according to the patient’s menstrual cycle, which supported a diagnosis of accessory breast over lipoma. The patient had no signs of infection or other systemic symptoms that were suggestive of lymphadenopathy. Unlike an epidermoid inclusion cyst, our patient’s mass presented as poorly defined and boggy in texture. Biopsy results were not consistent with malignancy, ruling out soft tissue sarcoma.
B, Myoepithelial cells lined a stratified columnar epithelium, characteristic of breast tissue (H&E, original magnification x40).
Accessory breasts are characterized by the presence of breast tissue outside the breast and can be found anywhere along the milk line from the axillae to the vulva.1 The prevalence of accessory breasts is 2% to 6% of women, with an average age of presentation for treatment of 42 years.2 Ninety percent of accessory breasts are found in the thorax, 5% are found in the abdomen, and 5% are found in the axillae.3 Incidence is uncommon in adolescents; however, in addition to our patient, there are several cases in the literature of adolescents with accessory breasts in the axillae.4,5
Ectopic mammary tissue is divided into 8 classes based on the Kajava classification system (Table). In a retrospective study of adolescent females with accessory breasts, 91% (10/11) of patients were classified as class IV, and 1 was class II.6 Similarly, our patient was classified as class IV since her accessory breast was composed entirely of glandular tissue and did not include an areola and nipple.
Supernumerary breast structures such as areolas and nipples typically are diagnosed at birth, whereas supernumerary breast tissue is not diagnosed until after hormonal stimulation typically seen during puberty, pregnancy, or breastfeeding. Common symptoms include cyclic pain with menstruation, fluctuation in the size of the mass, and tenderness of the ectopic tissue. There also can be restricted range of motion and increased irritation from clothing. Ultrasonography generally shows a hypoechoic septate indicative of mammary tissue.6 Diagnosis is confirmed by histopathologic studies that show mammary lobules in the dermis with smooth muscle, mammary ducts connected to the nipple, and connective stroma.6
If bothersome, ectopic breast tissue can be surgically removed, either by direct excision or suction lipectomy depending on the size of the mass.2 Postoperative complications are low but can include seroma, bleeding, infection, remnant tissue, or undesired cosmetic results. As with normal breast tissue, ectopic breast tissue can manifest with benign and malignant pathologies.
In conclusion, accessory breast is a benign condition that can cause cyclical pain with menstruation, restricted range of motion, discomfort, anxiety, and cosmetic problems. It is important to keep this diagnosis on the differential when evaluating a soft tissue mass that appears in the axillary region.
- Loukas M, Clarke P, Tubbs RS. Accessory breasts: a historical and current perspective. Am Surg. 2007;73:525-528.
- Bartsich SA, Ofodile FA. Accessory breast tissue in the axilla: classification and treatment. Plast Reconstr Surg. 2011;128:35E-36E. doi:10.1097/PRS.0b013e3182173f95
- Mazine K, Bouassria A, Elbouhaddouti H. Bilateral supernumerary axillary breasts: a case report. Pan Afr Med J. 2020;36:282. doi:10.11604 /pamj.2020.36.282.20445
- Patel RV, Govani D, Patel R, et al. Adolescent right axillary accessory breast with galactorrhoea. BMJ Case Rep. 2014;2014:bcr2014204215. doi:10.1136/bcr-2014-204215
- Surd A, Mironescu A, Gocan H. Fibroadenoma in axillary supernumerary breast in a 17-year-old girl: case report. J Pediatr Adolesc Gynecol. 2016;29:E79-E81. doi:10.1016/j.jpag.2016.04.008
- De la Torre M, Lorca-García C, de Tomás E, et al. Axillary ectopic breast tissue in the adolescent. Pediatr Surg Int. 2022;38:1445-1451. doi:10.1007/s00383-022-05184-1
- Loukas M, Clarke P, Tubbs RS. Accessory breasts: a historical and current perspective. Am Surg. 2007;73:525-528.
- Bartsich SA, Ofodile FA. Accessory breast tissue in the axilla: classification and treatment. Plast Reconstr Surg. 2011;128:35E-36E. doi:10.1097/PRS.0b013e3182173f95
- Mazine K, Bouassria A, Elbouhaddouti H. Bilateral supernumerary axillary breasts: a case report. Pan Afr Med J. 2020;36:282. doi:10.11604 /pamj.2020.36.282.20445
- Patel RV, Govani D, Patel R, et al. Adolescent right axillary accessory breast with galactorrhoea. BMJ Case Rep. 2014;2014:bcr2014204215. doi:10.1136/bcr-2014-204215
- Surd A, Mironescu A, Gocan H. Fibroadenoma in axillary supernumerary breast in a 17-year-old girl: case report. J Pediatr Adolesc Gynecol. 2016;29:E79-E81. doi:10.1016/j.jpag.2016.04.008
- De la Torre M, Lorca-García C, de Tomás E, et al. Axillary ectopic breast tissue in the adolescent. Pediatr Surg Int. 2022;38:1445-1451. doi:10.1007/s00383-022-05184-1
Fluctuant Subcutaneous Nodule in the Axilla of an Adolescent Female
Fluctuant Subcutaneous Nodule in the Axilla of an Adolescent Female
A 15-year-old adolescent female with an unremarkable medical history presented to the dermatology clinic with a mass in the left axilla of 2 years’ duration. The patient reported that there was no drainage of the lesion nor did she have any other similar lesions. She reported tenderness of the lesion during menstruation that resolved after this phase ended. Dermatologic examination revealed a solitary 4.4-cm, flesh-colored, poorly defined, boggy, fluctuant subcutaneous nodule with no central punctum or surface changes. Ultrasonography of the axilla showed a 6.4-cm hypoechoic heterogenous mass. A biopsy of the lesion was performed.
Guselkumab Lowers Serum Biomarker Levels and Improves Disease Activity in Biologic-Naive PsA Patients
Key clinical point: Guselkumab significantly reduced inflammatory and collagen biomarker levels, correlating with improvements in joint and overall disease activity over 2 years in biologic-naive patients with psoriatic arthritis (PsA).
Major finding: Over 2 years, reductions in C-reactive protein, interleukin-6, matrix metalloproteinase (MMP)–degradation type 1 collagen (C1M), and MMP-degradation type VI collagen (C6M) levels correlated with improved Disease Activity in Psoriatic Arthritis (correlation coefficient [r], 0.26-0.30; P < .05). Additionally, reductions in C1M, MMP-degradation type III collagen, MMP-degradation type IV collagen, and C6M levels correlated with improved Psoriatic Arthritis Disease Activity Scores (r, 0.27-0.31; P < .05).
Study details: This post hoc analysis of the phase 3 DISCOVER-2 trial included 739 biologic-naive patients with active PsA who were randomly assigned to receive guselkumab (100 mg every 4 or 8 weeks) or placebo with a crossover to 100 mg guselkumab every 4 weeks at week 24.
Disclosures: This DISCOVER-2 study was funded by Janssen Research & Development, LLC. Four authors reported being employees of Janssen and owning stock or stock options in Johnson & Johnson. Others declared having ties with various sources.
Source: Siebert S, Schett G, Raychaudhuri SP, et al. Correlation of changes in inflammatory and collagen biomarkers with durable guselkumab efficacy through 2 years in participants with active psoriatic arthritis: Results from a phase III randomized controlled trial. Ther Adv Musculoskelet Dis. 2024;16:1-20. Source
Key clinical point: Guselkumab significantly reduced inflammatory and collagen biomarker levels, correlating with improvements in joint and overall disease activity over 2 years in biologic-naive patients with psoriatic arthritis (PsA).
Major finding: Over 2 years, reductions in C-reactive protein, interleukin-6, matrix metalloproteinase (MMP)–degradation type 1 collagen (C1M), and MMP-degradation type VI collagen (C6M) levels correlated with improved Disease Activity in Psoriatic Arthritis (correlation coefficient [r], 0.26-0.30; P < .05). Additionally, reductions in C1M, MMP-degradation type III collagen, MMP-degradation type IV collagen, and C6M levels correlated with improved Psoriatic Arthritis Disease Activity Scores (r, 0.27-0.31; P < .05).
Study details: This post hoc analysis of the phase 3 DISCOVER-2 trial included 739 biologic-naive patients with active PsA who were randomly assigned to receive guselkumab (100 mg every 4 or 8 weeks) or placebo with a crossover to 100 mg guselkumab every 4 weeks at week 24.
Disclosures: This DISCOVER-2 study was funded by Janssen Research & Development, LLC. Four authors reported being employees of Janssen and owning stock or stock options in Johnson & Johnson. Others declared having ties with various sources.
Source: Siebert S, Schett G, Raychaudhuri SP, et al. Correlation of changes in inflammatory and collagen biomarkers with durable guselkumab efficacy through 2 years in participants with active psoriatic arthritis: Results from a phase III randomized controlled trial. Ther Adv Musculoskelet Dis. 2024;16:1-20. Source
Key clinical point: Guselkumab significantly reduced inflammatory and collagen biomarker levels, correlating with improvements in joint and overall disease activity over 2 years in biologic-naive patients with psoriatic arthritis (PsA).
Major finding: Over 2 years, reductions in C-reactive protein, interleukin-6, matrix metalloproteinase (MMP)–degradation type 1 collagen (C1M), and MMP-degradation type VI collagen (C6M) levels correlated with improved Disease Activity in Psoriatic Arthritis (correlation coefficient [r], 0.26-0.30; P < .05). Additionally, reductions in C1M, MMP-degradation type III collagen, MMP-degradation type IV collagen, and C6M levels correlated with improved Psoriatic Arthritis Disease Activity Scores (r, 0.27-0.31; P < .05).
Study details: This post hoc analysis of the phase 3 DISCOVER-2 trial included 739 biologic-naive patients with active PsA who were randomly assigned to receive guselkumab (100 mg every 4 or 8 weeks) or placebo with a crossover to 100 mg guselkumab every 4 weeks at week 24.
Disclosures: This DISCOVER-2 study was funded by Janssen Research & Development, LLC. Four authors reported being employees of Janssen and owning stock or stock options in Johnson & Johnson. Others declared having ties with various sources.
Source: Siebert S, Schett G, Raychaudhuri SP, et al. Correlation of changes in inflammatory and collagen biomarkers with durable guselkumab efficacy through 2 years in participants with active psoriatic arthritis: Results from a phase III randomized controlled trial. Ther Adv Musculoskelet Dis. 2024;16:1-20. Source
Predictors of Treatment Response to b/tsDMARDs in PsA
Key clinical point: Among patients with psoriatic arthritis (PsA), men and those with elevated baseline C-reactive protein (CRP) levels showed an improved response to biologic or targeted synthetic disease-modifying antirheumatic drugs (b/tsDMARDs), whereas older patients and those with severe baseline disease activity showed a worse response.
Major finding: Among patients with PsA, men (odds ratio [OR], 2.188; 95% CI, 1.912-2.503) and those with elevated baseline CRP levels (OR, 1.537; 95% CI, 1.111-2.125) showed an improved response to b/tsDMARDs. Conversely, older patients (OR, 0.982; 95% CI, 0.975-0.99) and those with increased baseline Disease Activity in Psoriatic Arthritis (OR, 0.789; 95% CI, 0.663-0.938), Health Assessment Questionnaire (OR, 0.483; 95% CI, 0.336-0.696), and joint count (OR, 0.97; 95% CI, 0.945-0.996) scores showed a significantly worse b/tsDMARD response.
Study details: This systematic review and meta-analysis of 37 studies included 17,042 patients with PsA.
Disclosures: Open access funding was provided by the University of Zurich. This study did not receive any funding. The authors declared no conflicts of interest.
Source: Künzler T, Bamert M, Sprott H. Factors predicting treatment response to biological and targeted synthetic disease-modifying antirheumatic drugs in psoriatic arthritis—A systematic review and meta-analysis. Clin Rheumatol. Published online October 28, 2024. Source
Key clinical point: Among patients with psoriatic arthritis (PsA), men and those with elevated baseline C-reactive protein (CRP) levels showed an improved response to biologic or targeted synthetic disease-modifying antirheumatic drugs (b/tsDMARDs), whereas older patients and those with severe baseline disease activity showed a worse response.
Major finding: Among patients with PsA, men (odds ratio [OR], 2.188; 95% CI, 1.912-2.503) and those with elevated baseline CRP levels (OR, 1.537; 95% CI, 1.111-2.125) showed an improved response to b/tsDMARDs. Conversely, older patients (OR, 0.982; 95% CI, 0.975-0.99) and those with increased baseline Disease Activity in Psoriatic Arthritis (OR, 0.789; 95% CI, 0.663-0.938), Health Assessment Questionnaire (OR, 0.483; 95% CI, 0.336-0.696), and joint count (OR, 0.97; 95% CI, 0.945-0.996) scores showed a significantly worse b/tsDMARD response.
Study details: This systematic review and meta-analysis of 37 studies included 17,042 patients with PsA.
Disclosures: Open access funding was provided by the University of Zurich. This study did not receive any funding. The authors declared no conflicts of interest.
Source: Künzler T, Bamert M, Sprott H. Factors predicting treatment response to biological and targeted synthetic disease-modifying antirheumatic drugs in psoriatic arthritis—A systematic review and meta-analysis. Clin Rheumatol. Published online October 28, 2024. Source
Key clinical point: Among patients with psoriatic arthritis (PsA), men and those with elevated baseline C-reactive protein (CRP) levels showed an improved response to biologic or targeted synthetic disease-modifying antirheumatic drugs (b/tsDMARDs), whereas older patients and those with severe baseline disease activity showed a worse response.
Major finding: Among patients with PsA, men (odds ratio [OR], 2.188; 95% CI, 1.912-2.503) and those with elevated baseline CRP levels (OR, 1.537; 95% CI, 1.111-2.125) showed an improved response to b/tsDMARDs. Conversely, older patients (OR, 0.982; 95% CI, 0.975-0.99) and those with increased baseline Disease Activity in Psoriatic Arthritis (OR, 0.789; 95% CI, 0.663-0.938), Health Assessment Questionnaire (OR, 0.483; 95% CI, 0.336-0.696), and joint count (OR, 0.97; 95% CI, 0.945-0.996) scores showed a significantly worse b/tsDMARD response.
Study details: This systematic review and meta-analysis of 37 studies included 17,042 patients with PsA.
Disclosures: Open access funding was provided by the University of Zurich. This study did not receive any funding. The authors declared no conflicts of interest.
Source: Künzler T, Bamert M, Sprott H. Factors predicting treatment response to biological and targeted synthetic disease-modifying antirheumatic drugs in psoriatic arthritis—A systematic review and meta-analysis. Clin Rheumatol. Published online October 28, 2024. Source
Real-World Study Shows Severity of Psoriasis Linked to Enthesitis in PsA
Key clinical point: The severity of psoriasis was associated with enthesitis in patients with psoriatic arthritis (PsA) and psoriasis, particularly in older patients and those with a longer history of psoriasis.
Major finding: The severity of psoriasis, as assessed using the Psoriasis Area and Severity Index, was significantly associated with enthesitis (correlation coefficient [ρ], 0.285; P = .013). The association remained significant after adjusting for age (ρ, 0.274; P = .043) and the duration of PsA (ρ, 0.302; P = .027).
Study details: This observational study included 76 adults diagnosed with PsA and psoriasis, comprising 42 men and 34 women.
Disclosures: This study was conducted within the project "Psoriatic arthritis—epidemiology and risk factors of progression" of the Ministry of Health, Education and Sports, Republic of Croatia. No conflicts of interest were reported in this study.
Source: Grazio S, Šitum M, Grubišić F, et al. Association of enthesitis with severity of psoriasis in psoriatic arthritis: An observational study. Rheumatol Int. Published online October 15, 2024. Source
Key clinical point: The severity of psoriasis was associated with enthesitis in patients with psoriatic arthritis (PsA) and psoriasis, particularly in older patients and those with a longer history of psoriasis.
Major finding: The severity of psoriasis, as assessed using the Psoriasis Area and Severity Index, was significantly associated with enthesitis (correlation coefficient [ρ], 0.285; P = .013). The association remained significant after adjusting for age (ρ, 0.274; P = .043) and the duration of PsA (ρ, 0.302; P = .027).
Study details: This observational study included 76 adults diagnosed with PsA and psoriasis, comprising 42 men and 34 women.
Disclosures: This study was conducted within the project "Psoriatic arthritis—epidemiology and risk factors of progression" of the Ministry of Health, Education and Sports, Republic of Croatia. No conflicts of interest were reported in this study.
Source: Grazio S, Šitum M, Grubišić F, et al. Association of enthesitis with severity of psoriasis in psoriatic arthritis: An observational study. Rheumatol Int. Published online October 15, 2024. Source
Key clinical point: The severity of psoriasis was associated with enthesitis in patients with psoriatic arthritis (PsA) and psoriasis, particularly in older patients and those with a longer history of psoriasis.
Major finding: The severity of psoriasis, as assessed using the Psoriasis Area and Severity Index, was significantly associated with enthesitis (correlation coefficient [ρ], 0.285; P = .013). The association remained significant after adjusting for age (ρ, 0.274; P = .043) and the duration of PsA (ρ, 0.302; P = .027).
Study details: This observational study included 76 adults diagnosed with PsA and psoriasis, comprising 42 men and 34 women.
Disclosures: This study was conducted within the project "Psoriatic arthritis—epidemiology and risk factors of progression" of the Ministry of Health, Education and Sports, Republic of Croatia. No conflicts of interest were reported in this study.
Source: Grazio S, Šitum M, Grubišić F, et al. Association of enthesitis with severity of psoriasis in psoriatic arthritis: An observational study. Rheumatol Int. Published online October 15, 2024. Source
Depressive Symptoms Lower the Likelihood of Remission in PsA
Key clinical point: The presence of depressive symptoms within the first 2 years after diagnosis in patients with psoriatic arthritis (PsA) was associated with a decreased likelihood of achieving remission.
Major finding: Overall, 18% patients with PsA had possible depression. During 2 years of follow-up, depression was associated with decreased odds of achieving remission (adjusted odds ratio, 0.24; 95% CI, 0.08-0.71). The presence of depression was also associated with an increased tender joint count, worse general health, and increased pain.
Study details: This study included data from the Dutch Southwest Early Psoriatic Arthritis Cohort study, a prospective cohort study that included 367 patients with PsA, and the Rotterdam Early Arthritis Cohort trial, which included 400 patients with rheumatoid arthritis.
Disclosures: This study was supported by unrestricted grants from ZonMW, Pfizer, and Abbvie B.V. The authors declared no conflicts of interest.
Source: Snoeck Henkemans SVJ, Vis M, Koc GH, et al. Association between depression and anxiety and inability to achieve remission in rheumatoid arthritis and psoriatic arthritis. Rheumatology (Oxford). Published online November 6, 2024. Source
Key clinical point: The presence of depressive symptoms within the first 2 years after diagnosis in patients with psoriatic arthritis (PsA) was associated with a decreased likelihood of achieving remission.
Major finding: Overall, 18% patients with PsA had possible depression. During 2 years of follow-up, depression was associated with decreased odds of achieving remission (adjusted odds ratio, 0.24; 95% CI, 0.08-0.71). The presence of depression was also associated with an increased tender joint count, worse general health, and increased pain.
Study details: This study included data from the Dutch Southwest Early Psoriatic Arthritis Cohort study, a prospective cohort study that included 367 patients with PsA, and the Rotterdam Early Arthritis Cohort trial, which included 400 patients with rheumatoid arthritis.
Disclosures: This study was supported by unrestricted grants from ZonMW, Pfizer, and Abbvie B.V. The authors declared no conflicts of interest.
Source: Snoeck Henkemans SVJ, Vis M, Koc GH, et al. Association between depression and anxiety and inability to achieve remission in rheumatoid arthritis and psoriatic arthritis. Rheumatology (Oxford). Published online November 6, 2024. Source
Key clinical point: The presence of depressive symptoms within the first 2 years after diagnosis in patients with psoriatic arthritis (PsA) was associated with a decreased likelihood of achieving remission.
Major finding: Overall, 18% patients with PsA had possible depression. During 2 years of follow-up, depression was associated with decreased odds of achieving remission (adjusted odds ratio, 0.24; 95% CI, 0.08-0.71). The presence of depression was also associated with an increased tender joint count, worse general health, and increased pain.
Study details: This study included data from the Dutch Southwest Early Psoriatic Arthritis Cohort study, a prospective cohort study that included 367 patients with PsA, and the Rotterdam Early Arthritis Cohort trial, which included 400 patients with rheumatoid arthritis.
Disclosures: This study was supported by unrestricted grants from ZonMW, Pfizer, and Abbvie B.V. The authors declared no conflicts of interest.
Source: Snoeck Henkemans SVJ, Vis M, Koc GH, et al. Association between depression and anxiety and inability to achieve remission in rheumatoid arthritis and psoriatic arthritis. Rheumatology (Oxford). Published online November 6, 2024. Source