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Vacationing Doctors Intervene After Shark Attack
Ryan Forbess, MD: I live at the beach in Orange Beach, Alabama. I’ve lived in Hawaii, the Caymans, and other beach areas for years. I’ve seen a lot of sharks but never a shark attack. Not until now.
Mohammad Ali, MD: Ryan and I have been friends for 20 years. Every year, my family goes to 30A in Florida (a popular resort stretch of highway) to celebrate my wife’s birthday, and the Forbesses always meet us there. This year we had a group of about 18 people.
On Friday, it was beautiful, and we decided to make it a beach day. We had nine kids with us. So by the time we rounded them up and got there, it was noon, and there was nowhere to sit. We almost turned around and went to the pool. But my wife finally found a spot for an umbrella.
Dr. Forbess: We were in the water boogie boarding. I was with my 8-year-old son, and Mo was with his daughter who is the same age. Suddenly, we noticed a lot of commotion just to the left of us. My first thought was: Someone saw a shark, not an attack. They’re so rare. But seeing one would scare people.
We grabbed our kids and started running out of the water. As we got closer to the shore,
Dr. Ali: It was mass panic. People were screaming and running out of the water. Other people were running in and grabbing their kids. Everyone just looked frantic.
We saw two men dragging this poor girl out of the water. It was surreal. The majority of her right leg was severed, her femur bone visible and stark white; it didn’t look real. I kept telling myself I was in a dream and now I’d wake up.
A young EMT who was there had put an informal tourniquet on her leg, but she was still bleeding. So I compressed the femoral artery as hard as I could, something I’m very familiar with doing.
Dr. Forbess: People asked me later what we used for a tourniquet. I said, “Mo’s big hands.” I tease him because most doctors play golf or go fishing; Mo lives in the gym. He was just holding pressure.
The girl’s left hand was also severed off at the wrist. There were two nurses there, and they helped with holding tourniquets on her arm.
Lulu (the girl’s name) was 15 years old. She was in and out of consciousness. At one point, her face started getting really pale, so we tried to lift her extremities up to keep the blood flow to the heart. With such severe blood loss, I thought she might go into cardiovascular shock, and we would have to start compressions. But she had a pulse, and she was breathing.
Dr. Ali: The beach was very crowded, and a lot of people had gathered around. Everyone was emotional, shocked, really shaken up. But they gave us space to work.
Dr. Forbess: People were handing us things — towels, a ratchet strap to use as a tourniquet. There was even an anesthesiologist there who said, “If you need an airway, let me know.” It was like we had a trauma team.
Dr. Ali: Lulu’s mom had been having lunch with friends. When she saw all the commotion, she ran down to the beach to look for her daughter. It was heartbreaking to hear her screams when she saw Lulu. But I was able to tune it out because we had to just concentrate on decreasing the loss of blood.
Dr. Forbess: Another girl came over and said, “That’s my sister.” Lulu has a twin. So she sat there holding Lulu’s hand and being with her the whole time.
Waiting for the EMTs to get there, the seconds were like hours. It seemed like it took forever. Finally, they came, and we were able to get the real tourniquets on, get her boarded and off the beach.
After that, they closed the beach. We got all our stuff and got on the little trolley that would take us back to the house. The lady who was driving asked us, “Did y’all hear about the shark attack?” My wife said, “Yeah, we were there.” And she said, “No, there was one an hour and a half ago.”
Dr. Ali: What we didn’t know was there had been two other attacks that day. Around the same time, one of Lulu’s friends was bitten and got a flesh wound on her heel. And before that, about 4 miles away, there was a serious injury: A lady in her 40s lost her hand and forearm and was bitten in the pelvis.
Dr. Forbess: At that point, my wife leaned back to me and said, “You know we’re never going to the beach again, right? We’re never ever going to the beach.”
If we had known about those attacks, we definitely wouldn’t have been in the water.
Dr. Ali: My wife has never liked going in the water. The evening before, we had debated about taking our daughters in the ocean because she was worried about sharks. I had given her this condescending speech about waist-deep water and the statistical probabilities of ever witnessing a shark attack. I was in trouble.
Dr. Forbess: We didn’t know if Lulu would make it. I’ve done rural family medicine in Oklahoma, so I’ve seen my fair share of injuries — guys on oil rigs, this and that. But I had never seen anything like this kind of trauma and blood loss.
Later that day, I called my office manager to catch up with her and told her what happened. She was actually in Pensacola having dinner across the street from Sacred Heart Hospital where they had taken Lulu. She went over to the emergency room to try to find out Lulu’s status — she was alive.
My office manager was able to go upstairs and talk to Lulu’s mom. Then she called, and we talked to her mom on the phone. She just said, “Thank you for helping my daughter.” It was an emotional moment.
Dr. Ali: It was such a relief. We had no idea how things would turn out. Even if Lulu did survive, was she going to be neurologically sound? But thank God she was. We were so relieved to hear her mom say that it was looking good. We still didn’t know for sure. But at least she was alive and seemed to be functioning.
Dr. Forbess: A few days later, my wife and I went to go visit her at the hospital. Her mom and her grandma were there. They were giving us hugs. We FaceTimed Mo because he was back in Jackson. It was really amazing.
What are the odds? The chances of a shark attack are about one in 12 million. And to have two physicians trained in trauma, a trauma nurse, another nurse, and an anesthesiologist less than 20 yards away when it happened? It’s crazy to think about.
Dr. Ali: And we almost weren’t there. We could have turned away.
Dr. Forbess: Humans are on top of the food chain. Or we think we are. But water really isn’t our element. Against a 12-foot bull shark, we don’t stand a chance. Lulu is here though. It’s unbelievable.
Her mom told me that when Lulu woke up, she just said, “I made it!” That girl is meant to be here. She is a tough girl with a great personality. She has these new prosthetics now that she can move with her mind; it’s like Star Wars. She says she wants to be a physician someday. So she’ll probably cure cancer.
Dr. Forbess is a family medicine physician at Orange Beach Family Medicine in Orange Beach, Alabama. Dr. Ali is an interventional radiologist with Baptist Memorial Health in Jackson, Mississippi.
A version of this article first appeared on Medscape.com.
Ryan Forbess, MD: I live at the beach in Orange Beach, Alabama. I’ve lived in Hawaii, the Caymans, and other beach areas for years. I’ve seen a lot of sharks but never a shark attack. Not until now.
Mohammad Ali, MD: Ryan and I have been friends for 20 years. Every year, my family goes to 30A in Florida (a popular resort stretch of highway) to celebrate my wife’s birthday, and the Forbesses always meet us there. This year we had a group of about 18 people.
On Friday, it was beautiful, and we decided to make it a beach day. We had nine kids with us. So by the time we rounded them up and got there, it was noon, and there was nowhere to sit. We almost turned around and went to the pool. But my wife finally found a spot for an umbrella.
Dr. Forbess: We were in the water boogie boarding. I was with my 8-year-old son, and Mo was with his daughter who is the same age. Suddenly, we noticed a lot of commotion just to the left of us. My first thought was: Someone saw a shark, not an attack. They’re so rare. But seeing one would scare people.
We grabbed our kids and started running out of the water. As we got closer to the shore,
Dr. Ali: It was mass panic. People were screaming and running out of the water. Other people were running in and grabbing their kids. Everyone just looked frantic.
We saw two men dragging this poor girl out of the water. It was surreal. The majority of her right leg was severed, her femur bone visible and stark white; it didn’t look real. I kept telling myself I was in a dream and now I’d wake up.
A young EMT who was there had put an informal tourniquet on her leg, but she was still bleeding. So I compressed the femoral artery as hard as I could, something I’m very familiar with doing.
Dr. Forbess: People asked me later what we used for a tourniquet. I said, “Mo’s big hands.” I tease him because most doctors play golf or go fishing; Mo lives in the gym. He was just holding pressure.
The girl’s left hand was also severed off at the wrist. There were two nurses there, and they helped with holding tourniquets on her arm.
Lulu (the girl’s name) was 15 years old. She was in and out of consciousness. At one point, her face started getting really pale, so we tried to lift her extremities up to keep the blood flow to the heart. With such severe blood loss, I thought she might go into cardiovascular shock, and we would have to start compressions. But she had a pulse, and she was breathing.
Dr. Ali: The beach was very crowded, and a lot of people had gathered around. Everyone was emotional, shocked, really shaken up. But they gave us space to work.
Dr. Forbess: People were handing us things — towels, a ratchet strap to use as a tourniquet. There was even an anesthesiologist there who said, “If you need an airway, let me know.” It was like we had a trauma team.
Dr. Ali: Lulu’s mom had been having lunch with friends. When she saw all the commotion, she ran down to the beach to look for her daughter. It was heartbreaking to hear her screams when she saw Lulu. But I was able to tune it out because we had to just concentrate on decreasing the loss of blood.
Dr. Forbess: Another girl came over and said, “That’s my sister.” Lulu has a twin. So she sat there holding Lulu’s hand and being with her the whole time.
Waiting for the EMTs to get there, the seconds were like hours. It seemed like it took forever. Finally, they came, and we were able to get the real tourniquets on, get her boarded and off the beach.
After that, they closed the beach. We got all our stuff and got on the little trolley that would take us back to the house. The lady who was driving asked us, “Did y’all hear about the shark attack?” My wife said, “Yeah, we were there.” And she said, “No, there was one an hour and a half ago.”
Dr. Ali: What we didn’t know was there had been two other attacks that day. Around the same time, one of Lulu’s friends was bitten and got a flesh wound on her heel. And before that, about 4 miles away, there was a serious injury: A lady in her 40s lost her hand and forearm and was bitten in the pelvis.
Dr. Forbess: At that point, my wife leaned back to me and said, “You know we’re never going to the beach again, right? We’re never ever going to the beach.”
If we had known about those attacks, we definitely wouldn’t have been in the water.
Dr. Ali: My wife has never liked going in the water. The evening before, we had debated about taking our daughters in the ocean because she was worried about sharks. I had given her this condescending speech about waist-deep water and the statistical probabilities of ever witnessing a shark attack. I was in trouble.
Dr. Forbess: We didn’t know if Lulu would make it. I’ve done rural family medicine in Oklahoma, so I’ve seen my fair share of injuries — guys on oil rigs, this and that. But I had never seen anything like this kind of trauma and blood loss.
Later that day, I called my office manager to catch up with her and told her what happened. She was actually in Pensacola having dinner across the street from Sacred Heart Hospital where they had taken Lulu. She went over to the emergency room to try to find out Lulu’s status — she was alive.
My office manager was able to go upstairs and talk to Lulu’s mom. Then she called, and we talked to her mom on the phone. She just said, “Thank you for helping my daughter.” It was an emotional moment.
Dr. Ali: It was such a relief. We had no idea how things would turn out. Even if Lulu did survive, was she going to be neurologically sound? But thank God she was. We were so relieved to hear her mom say that it was looking good. We still didn’t know for sure. But at least she was alive and seemed to be functioning.
Dr. Forbess: A few days later, my wife and I went to go visit her at the hospital. Her mom and her grandma were there. They were giving us hugs. We FaceTimed Mo because he was back in Jackson. It was really amazing.
What are the odds? The chances of a shark attack are about one in 12 million. And to have two physicians trained in trauma, a trauma nurse, another nurse, and an anesthesiologist less than 20 yards away when it happened? It’s crazy to think about.
Dr. Ali: And we almost weren’t there. We could have turned away.
Dr. Forbess: Humans are on top of the food chain. Or we think we are. But water really isn’t our element. Against a 12-foot bull shark, we don’t stand a chance. Lulu is here though. It’s unbelievable.
Her mom told me that when Lulu woke up, she just said, “I made it!” That girl is meant to be here. She is a tough girl with a great personality. She has these new prosthetics now that she can move with her mind; it’s like Star Wars. She says she wants to be a physician someday. So she’ll probably cure cancer.
Dr. Forbess is a family medicine physician at Orange Beach Family Medicine in Orange Beach, Alabama. Dr. Ali is an interventional radiologist with Baptist Memorial Health in Jackson, Mississippi.
A version of this article first appeared on Medscape.com.
Ryan Forbess, MD: I live at the beach in Orange Beach, Alabama. I’ve lived in Hawaii, the Caymans, and other beach areas for years. I’ve seen a lot of sharks but never a shark attack. Not until now.
Mohammad Ali, MD: Ryan and I have been friends for 20 years. Every year, my family goes to 30A in Florida (a popular resort stretch of highway) to celebrate my wife’s birthday, and the Forbesses always meet us there. This year we had a group of about 18 people.
On Friday, it was beautiful, and we decided to make it a beach day. We had nine kids with us. So by the time we rounded them up and got there, it was noon, and there was nowhere to sit. We almost turned around and went to the pool. But my wife finally found a spot for an umbrella.
Dr. Forbess: We were in the water boogie boarding. I was with my 8-year-old son, and Mo was with his daughter who is the same age. Suddenly, we noticed a lot of commotion just to the left of us. My first thought was: Someone saw a shark, not an attack. They’re so rare. But seeing one would scare people.
We grabbed our kids and started running out of the water. As we got closer to the shore,
Dr. Ali: It was mass panic. People were screaming and running out of the water. Other people were running in and grabbing their kids. Everyone just looked frantic.
We saw two men dragging this poor girl out of the water. It was surreal. The majority of her right leg was severed, her femur bone visible and stark white; it didn’t look real. I kept telling myself I was in a dream and now I’d wake up.
A young EMT who was there had put an informal tourniquet on her leg, but she was still bleeding. So I compressed the femoral artery as hard as I could, something I’m very familiar with doing.
Dr. Forbess: People asked me later what we used for a tourniquet. I said, “Mo’s big hands.” I tease him because most doctors play golf or go fishing; Mo lives in the gym. He was just holding pressure.
The girl’s left hand was also severed off at the wrist. There were two nurses there, and they helped with holding tourniquets on her arm.
Lulu (the girl’s name) was 15 years old. She was in and out of consciousness. At one point, her face started getting really pale, so we tried to lift her extremities up to keep the blood flow to the heart. With such severe blood loss, I thought she might go into cardiovascular shock, and we would have to start compressions. But she had a pulse, and she was breathing.
Dr. Ali: The beach was very crowded, and a lot of people had gathered around. Everyone was emotional, shocked, really shaken up. But they gave us space to work.
Dr. Forbess: People were handing us things — towels, a ratchet strap to use as a tourniquet. There was even an anesthesiologist there who said, “If you need an airway, let me know.” It was like we had a trauma team.
Dr. Ali: Lulu’s mom had been having lunch with friends. When she saw all the commotion, she ran down to the beach to look for her daughter. It was heartbreaking to hear her screams when she saw Lulu. But I was able to tune it out because we had to just concentrate on decreasing the loss of blood.
Dr. Forbess: Another girl came over and said, “That’s my sister.” Lulu has a twin. So she sat there holding Lulu’s hand and being with her the whole time.
Waiting for the EMTs to get there, the seconds were like hours. It seemed like it took forever. Finally, they came, and we were able to get the real tourniquets on, get her boarded and off the beach.
After that, they closed the beach. We got all our stuff and got on the little trolley that would take us back to the house. The lady who was driving asked us, “Did y’all hear about the shark attack?” My wife said, “Yeah, we were there.” And she said, “No, there was one an hour and a half ago.”
Dr. Ali: What we didn’t know was there had been two other attacks that day. Around the same time, one of Lulu’s friends was bitten and got a flesh wound on her heel. And before that, about 4 miles away, there was a serious injury: A lady in her 40s lost her hand and forearm and was bitten in the pelvis.
Dr. Forbess: At that point, my wife leaned back to me and said, “You know we’re never going to the beach again, right? We’re never ever going to the beach.”
If we had known about those attacks, we definitely wouldn’t have been in the water.
Dr. Ali: My wife has never liked going in the water. The evening before, we had debated about taking our daughters in the ocean because she was worried about sharks. I had given her this condescending speech about waist-deep water and the statistical probabilities of ever witnessing a shark attack. I was in trouble.
Dr. Forbess: We didn’t know if Lulu would make it. I’ve done rural family medicine in Oklahoma, so I’ve seen my fair share of injuries — guys on oil rigs, this and that. But I had never seen anything like this kind of trauma and blood loss.
Later that day, I called my office manager to catch up with her and told her what happened. She was actually in Pensacola having dinner across the street from Sacred Heart Hospital where they had taken Lulu. She went over to the emergency room to try to find out Lulu’s status — she was alive.
My office manager was able to go upstairs and talk to Lulu’s mom. Then she called, and we talked to her mom on the phone. She just said, “Thank you for helping my daughter.” It was an emotional moment.
Dr. Ali: It was such a relief. We had no idea how things would turn out. Even if Lulu did survive, was she going to be neurologically sound? But thank God she was. We were so relieved to hear her mom say that it was looking good. We still didn’t know for sure. But at least she was alive and seemed to be functioning.
Dr. Forbess: A few days later, my wife and I went to go visit her at the hospital. Her mom and her grandma were there. They were giving us hugs. We FaceTimed Mo because he was back in Jackson. It was really amazing.
What are the odds? The chances of a shark attack are about one in 12 million. And to have two physicians trained in trauma, a trauma nurse, another nurse, and an anesthesiologist less than 20 yards away when it happened? It’s crazy to think about.
Dr. Ali: And we almost weren’t there. We could have turned away.
Dr. Forbess: Humans are on top of the food chain. Or we think we are. But water really isn’t our element. Against a 12-foot bull shark, we don’t stand a chance. Lulu is here though. It’s unbelievable.
Her mom told me that when Lulu woke up, she just said, “I made it!” That girl is meant to be here. She is a tough girl with a great personality. She has these new prosthetics now that she can move with her mind; it’s like Star Wars. She says she wants to be a physician someday. So she’ll probably cure cancer.
Dr. Forbess is a family medicine physician at Orange Beach Family Medicine in Orange Beach, Alabama. Dr. Ali is an interventional radiologist with Baptist Memorial Health in Jackson, Mississippi.
A version of this article first appeared on Medscape.com.
Creative Strategies Hospitals Use to Attract Nursing Talent
In a fiercely competitive healthcare landscape, hospitals are pulling out all the stops to lure top nursing talent through their doors.
As the nursing shortage intensifies, the creative recruitment approach isn’t just about the perks — it’s becoming an essential tool in the race to build a skilled nursing workforce.
Nursing vacancies are as high as 17% — more than double prepandemic levels — and hospitals scrambling to fill them need to do more than raise salaries and bolster benefits packages to entice nurses.
“I am very thankful when I hear of creative ideas that nurse administrators come up with to try to get their ultimate goal, which is enough qualified nurses to take care of patients,” said Linda Plank, dean of the Louise Herrington School of Nursing at Baylor University in Dallas, Texas.
Signing Bonuses, Tuition Reimbursement, and Self-Scheduling, Please
Signing bonuses were among the top perks offered to healthcare workers, with almost 18% of job openings advertising the incentive for new nurse hires; the average signing bonus for registered nurses (RNs) topped $11,000. In 2023, California-based Palomar Health made headlines when it offered eligible RNs a $100,000 signing bonus paid over a 3-year period.
“We are seeing a variety of incentives, like sign-on bonuses, that can be effective at getting the attention of potential new hires,” said Deborah Trautman, PhD, RN, FAAN, president, and CEO of the American Association of Colleges of Nursing. “With the growing competition for registered nurses, especially those prepared in baccalaureate programs, employers should consider what’s most important to nurses entering the field.”
Hospitals have also invested in benefits ranging from tuition reimbursement, student loan forgiveness, and professional development opportunities to expanded parental leave and onsite childcare. Flexible scheduling is a sought-after perk that benefits both new and experienced RNs and could also help with recruitment.
“In the past, [hospitals said], ‘our shift starts at 7 and ends at 7,’ ” Ms. Plank said. “Now, hospitals are a little bit more flexible ... and being open to flexible shifts has merit. If we’re willing to look at things differently, it could get more people involved in patient care.”
An American Nurses Foundation report found that nurses preferred variable and flexible shift lengths, flexible start times, and self-scheduling options over set schedules. In fact, 45% of nurses who left clinical practice would consider returning to work if hospitals switched to a self-scheduling model.
The Cleveland Clinic in Ohio introduced staggered shifts that start at nontraditional times, including 11 AM to 11 PM, flexible shift lengths, and split RN positions that allow clinical care nurses to divide their time between different departments. Last year, Hackensack Meridian Health in New Jersey also piloted a self-scheduling program for its nursing staff.
Hiring Outside the United States
Despite the prevalence of signing bonuses and premium perks, some hospitals still struggled to fill open positions with nurses recruited from outside the United States. Data from The Kaiser Family Foundation show that 32% of hospitals hired foreign-educated RNs in 2022 — more than double the number hired in 2010.
Jennifer Mensik Kennedy, PhD, MBA, RN, NEA-BC, FAAN, president of the American Nurses Association (ANA), is concerned about that trend. The ANA supports the International Council of Nurses and their call for “stronger codes for ethical recruitment of nurses” because international nurse recruitment practices can negatively affect the quality of healthcare in countries that are depleted of nurses.
“Recruiting international nurses as a key strategy for building core staffing is not sustainable in the long term,” Ms. Kennedy said in an interview. “We need to redirect our focus on how to retain staff through fostering healthy work environments and addressing antiquated payment models.”
Reinforcing Retention
Recruiting nurses is just one element of addressing the nursing shortage. Prioritizing job satisfaction is essential to retaining nursing staff. Currently, 33% of nurses who enter the profession quit within the first 2 years.
A growing number of hospitals have implemented programs focused on increasing retention. Lifepoint Health, a national network of 60-plus acute care hospitals, launched a Nurse Residency Program in 2023. The 12-month program, which offers training and mentorship to help recent nursing school graduates, has recruited 750 new nurses and helped them transition to clinical practice.
The Nurse Residency Program has been so successful that the hospital system plans to introduce a 2-year fellowship program in the fall of 2024 that supports the professional development of nurses who want to specialize in areas like acute care, obstetrics, or the intensive care unit.
“We are more focused than ever on increasing partnerships and alignment with our local nursing programs, expanding clinical education opportunities for nursing students, owning and driving a nursing culture, and creating an environment where employees want to work,” said Michelle Watson, MSN, RN, CENP, chief nurse executive and senior vice president of clinical operations at Lifepoint Health.
Ms. Watson also credits their facilities’ chief nursing officers as being “highly engaged and visible leaders” who spend time with RNs to learn about their career aspirations and help them understand how the organization can support their desires for ongoing professional development.
The 2022 Nurse Staffing Task Force, a collaborative initiative by the ANA and other prominent national nursing and healthcare organizations, has developed and widely disseminated a set of recommendations for hospitals focusing on investing in nurse staffing, safe and supportive work environments, and competitive wages.
In addition, the Reimagining Nursing Initiative, started by the American Nurses Foundation, is striving to help nurses feel valued and compensated by creating pilot programs that can help modernize nurses’ reimbursement structure so that they can direct bill.
In the end, attracting and retaining top nursing talent is about more than filling positions — it’s about building a healthcare system where nurses thrive. “In the United States and abroad, we owe it to nurses and the communities they serve to have sustainable and appropriate solutions to staffing and work environment challenges,” said Ms. Kennedy.
A version of this article appeared on Medscape.com.
In a fiercely competitive healthcare landscape, hospitals are pulling out all the stops to lure top nursing talent through their doors.
As the nursing shortage intensifies, the creative recruitment approach isn’t just about the perks — it’s becoming an essential tool in the race to build a skilled nursing workforce.
Nursing vacancies are as high as 17% — more than double prepandemic levels — and hospitals scrambling to fill them need to do more than raise salaries and bolster benefits packages to entice nurses.
“I am very thankful when I hear of creative ideas that nurse administrators come up with to try to get their ultimate goal, which is enough qualified nurses to take care of patients,” said Linda Plank, dean of the Louise Herrington School of Nursing at Baylor University in Dallas, Texas.
Signing Bonuses, Tuition Reimbursement, and Self-Scheduling, Please
Signing bonuses were among the top perks offered to healthcare workers, with almost 18% of job openings advertising the incentive for new nurse hires; the average signing bonus for registered nurses (RNs) topped $11,000. In 2023, California-based Palomar Health made headlines when it offered eligible RNs a $100,000 signing bonus paid over a 3-year period.
“We are seeing a variety of incentives, like sign-on bonuses, that can be effective at getting the attention of potential new hires,” said Deborah Trautman, PhD, RN, FAAN, president, and CEO of the American Association of Colleges of Nursing. “With the growing competition for registered nurses, especially those prepared in baccalaureate programs, employers should consider what’s most important to nurses entering the field.”
Hospitals have also invested in benefits ranging from tuition reimbursement, student loan forgiveness, and professional development opportunities to expanded parental leave and onsite childcare. Flexible scheduling is a sought-after perk that benefits both new and experienced RNs and could also help with recruitment.
“In the past, [hospitals said], ‘our shift starts at 7 and ends at 7,’ ” Ms. Plank said. “Now, hospitals are a little bit more flexible ... and being open to flexible shifts has merit. If we’re willing to look at things differently, it could get more people involved in patient care.”
An American Nurses Foundation report found that nurses preferred variable and flexible shift lengths, flexible start times, and self-scheduling options over set schedules. In fact, 45% of nurses who left clinical practice would consider returning to work if hospitals switched to a self-scheduling model.
The Cleveland Clinic in Ohio introduced staggered shifts that start at nontraditional times, including 11 AM to 11 PM, flexible shift lengths, and split RN positions that allow clinical care nurses to divide their time between different departments. Last year, Hackensack Meridian Health in New Jersey also piloted a self-scheduling program for its nursing staff.
Hiring Outside the United States
Despite the prevalence of signing bonuses and premium perks, some hospitals still struggled to fill open positions with nurses recruited from outside the United States. Data from The Kaiser Family Foundation show that 32% of hospitals hired foreign-educated RNs in 2022 — more than double the number hired in 2010.
Jennifer Mensik Kennedy, PhD, MBA, RN, NEA-BC, FAAN, president of the American Nurses Association (ANA), is concerned about that trend. The ANA supports the International Council of Nurses and their call for “stronger codes for ethical recruitment of nurses” because international nurse recruitment practices can negatively affect the quality of healthcare in countries that are depleted of nurses.
“Recruiting international nurses as a key strategy for building core staffing is not sustainable in the long term,” Ms. Kennedy said in an interview. “We need to redirect our focus on how to retain staff through fostering healthy work environments and addressing antiquated payment models.”
Reinforcing Retention
Recruiting nurses is just one element of addressing the nursing shortage. Prioritizing job satisfaction is essential to retaining nursing staff. Currently, 33% of nurses who enter the profession quit within the first 2 years.
A growing number of hospitals have implemented programs focused on increasing retention. Lifepoint Health, a national network of 60-plus acute care hospitals, launched a Nurse Residency Program in 2023. The 12-month program, which offers training and mentorship to help recent nursing school graduates, has recruited 750 new nurses and helped them transition to clinical practice.
The Nurse Residency Program has been so successful that the hospital system plans to introduce a 2-year fellowship program in the fall of 2024 that supports the professional development of nurses who want to specialize in areas like acute care, obstetrics, or the intensive care unit.
“We are more focused than ever on increasing partnerships and alignment with our local nursing programs, expanding clinical education opportunities for nursing students, owning and driving a nursing culture, and creating an environment where employees want to work,” said Michelle Watson, MSN, RN, CENP, chief nurse executive and senior vice president of clinical operations at Lifepoint Health.
Ms. Watson also credits their facilities’ chief nursing officers as being “highly engaged and visible leaders” who spend time with RNs to learn about their career aspirations and help them understand how the organization can support their desires for ongoing professional development.
The 2022 Nurse Staffing Task Force, a collaborative initiative by the ANA and other prominent national nursing and healthcare organizations, has developed and widely disseminated a set of recommendations for hospitals focusing on investing in nurse staffing, safe and supportive work environments, and competitive wages.
In addition, the Reimagining Nursing Initiative, started by the American Nurses Foundation, is striving to help nurses feel valued and compensated by creating pilot programs that can help modernize nurses’ reimbursement structure so that they can direct bill.
In the end, attracting and retaining top nursing talent is about more than filling positions — it’s about building a healthcare system where nurses thrive. “In the United States and abroad, we owe it to nurses and the communities they serve to have sustainable and appropriate solutions to staffing and work environment challenges,” said Ms. Kennedy.
A version of this article appeared on Medscape.com.
In a fiercely competitive healthcare landscape, hospitals are pulling out all the stops to lure top nursing talent through their doors.
As the nursing shortage intensifies, the creative recruitment approach isn’t just about the perks — it’s becoming an essential tool in the race to build a skilled nursing workforce.
Nursing vacancies are as high as 17% — more than double prepandemic levels — and hospitals scrambling to fill them need to do more than raise salaries and bolster benefits packages to entice nurses.
“I am very thankful when I hear of creative ideas that nurse administrators come up with to try to get their ultimate goal, which is enough qualified nurses to take care of patients,” said Linda Plank, dean of the Louise Herrington School of Nursing at Baylor University in Dallas, Texas.
Signing Bonuses, Tuition Reimbursement, and Self-Scheduling, Please
Signing bonuses were among the top perks offered to healthcare workers, with almost 18% of job openings advertising the incentive for new nurse hires; the average signing bonus for registered nurses (RNs) topped $11,000. In 2023, California-based Palomar Health made headlines when it offered eligible RNs a $100,000 signing bonus paid over a 3-year period.
“We are seeing a variety of incentives, like sign-on bonuses, that can be effective at getting the attention of potential new hires,” said Deborah Trautman, PhD, RN, FAAN, president, and CEO of the American Association of Colleges of Nursing. “With the growing competition for registered nurses, especially those prepared in baccalaureate programs, employers should consider what’s most important to nurses entering the field.”
Hospitals have also invested in benefits ranging from tuition reimbursement, student loan forgiveness, and professional development opportunities to expanded parental leave and onsite childcare. Flexible scheduling is a sought-after perk that benefits both new and experienced RNs and could also help with recruitment.
“In the past, [hospitals said], ‘our shift starts at 7 and ends at 7,’ ” Ms. Plank said. “Now, hospitals are a little bit more flexible ... and being open to flexible shifts has merit. If we’re willing to look at things differently, it could get more people involved in patient care.”
An American Nurses Foundation report found that nurses preferred variable and flexible shift lengths, flexible start times, and self-scheduling options over set schedules. In fact, 45% of nurses who left clinical practice would consider returning to work if hospitals switched to a self-scheduling model.
The Cleveland Clinic in Ohio introduced staggered shifts that start at nontraditional times, including 11 AM to 11 PM, flexible shift lengths, and split RN positions that allow clinical care nurses to divide their time between different departments. Last year, Hackensack Meridian Health in New Jersey also piloted a self-scheduling program for its nursing staff.
Hiring Outside the United States
Despite the prevalence of signing bonuses and premium perks, some hospitals still struggled to fill open positions with nurses recruited from outside the United States. Data from The Kaiser Family Foundation show that 32% of hospitals hired foreign-educated RNs in 2022 — more than double the number hired in 2010.
Jennifer Mensik Kennedy, PhD, MBA, RN, NEA-BC, FAAN, president of the American Nurses Association (ANA), is concerned about that trend. The ANA supports the International Council of Nurses and their call for “stronger codes for ethical recruitment of nurses” because international nurse recruitment practices can negatively affect the quality of healthcare in countries that are depleted of nurses.
“Recruiting international nurses as a key strategy for building core staffing is not sustainable in the long term,” Ms. Kennedy said in an interview. “We need to redirect our focus on how to retain staff through fostering healthy work environments and addressing antiquated payment models.”
Reinforcing Retention
Recruiting nurses is just one element of addressing the nursing shortage. Prioritizing job satisfaction is essential to retaining nursing staff. Currently, 33% of nurses who enter the profession quit within the first 2 years.
A growing number of hospitals have implemented programs focused on increasing retention. Lifepoint Health, a national network of 60-plus acute care hospitals, launched a Nurse Residency Program in 2023. The 12-month program, which offers training and mentorship to help recent nursing school graduates, has recruited 750 new nurses and helped them transition to clinical practice.
The Nurse Residency Program has been so successful that the hospital system plans to introduce a 2-year fellowship program in the fall of 2024 that supports the professional development of nurses who want to specialize in areas like acute care, obstetrics, or the intensive care unit.
“We are more focused than ever on increasing partnerships and alignment with our local nursing programs, expanding clinical education opportunities for nursing students, owning and driving a nursing culture, and creating an environment where employees want to work,” said Michelle Watson, MSN, RN, CENP, chief nurse executive and senior vice president of clinical operations at Lifepoint Health.
Ms. Watson also credits their facilities’ chief nursing officers as being “highly engaged and visible leaders” who spend time with RNs to learn about their career aspirations and help them understand how the organization can support their desires for ongoing professional development.
The 2022 Nurse Staffing Task Force, a collaborative initiative by the ANA and other prominent national nursing and healthcare organizations, has developed and widely disseminated a set of recommendations for hospitals focusing on investing in nurse staffing, safe and supportive work environments, and competitive wages.
In addition, the Reimagining Nursing Initiative, started by the American Nurses Foundation, is striving to help nurses feel valued and compensated by creating pilot programs that can help modernize nurses’ reimbursement structure so that they can direct bill.
In the end, attracting and retaining top nursing talent is about more than filling positions — it’s about building a healthcare system where nurses thrive. “In the United States and abroad, we owe it to nurses and the communities they serve to have sustainable and appropriate solutions to staffing and work environment challenges,” said Ms. Kennedy.
A version of this article appeared on Medscape.com.
Primary Care Physicians Track an Average of 57 Quality Measures for Value-Based Care Pay
A new analysis suggests one reason doctors are wary of value-based care arrangements: Overkill.
Researchers found that primary care physicians in one large integrated health system were required to track an average of 57 different quality measures across multiple insurers that linked outcomes to payments under value-based contracts.
Medicare contracts were the most likely to pile quality measures on physicians with an average of 13.42 measures vs 10.07 for commercial insurer contracts and 5.37 for Medicaid contracts, reported Claire Boone, PhD, of the University of Chicago in Illinois and Providence Research Network, Portland, Oregon, and colleagues in JAMA Health Forum. The analysis, which may be the first of its kind, tracked 890 primary care physicians from 2020 to 2022.
The average of 57 quality measures per physician was unexpectedly high, Dr. Boone said in an interview.
“The magnitude of that number surprised us,” Dr. Boone said. “Primary care physicians and their practices have a lot on their plate. Now we know that one of those things is a very large number of different quality metrics to pay attention to, measure, report on, and implement.
Value-based care programs use quality measures to evaluate how well clinicians are doing their jobs and adjust reimbursement accordingly. A payer, for example, may raise reimbursements if a clinician has higher numbers of patients who meet quality measure standards for depression screening or blood pressure.
Dr. Boone said her research group is studying the impact of quality measures and was surprised that data showed individual primary care physicians had to deal with a high number of value-based contracts.
The researchers tracked value-based contracts for 890 physicians (58.3% women, 41.7% men) in an unidentified West Coast Health system. (Several study authors work for the Providence Health System, which serves several Western States and Texas.) The average number of patients per physician was 1309.
The physicians were part of an average of 11.18 value-based contracts (commercial insurers, 49.50%; Medicaid, 21.49%; and Medicare, 29.01%). This number grew from 9.39 in 2020 to 12.26 in 2022. Quality measure data weren’t available for 29% of contracts.
Quality measures were considered unique if they referenced different conditions.
For example, colorectal cancer screening is unique from depression screening. The researchers also considered measures for the same condition unique if the target value differed — for example, blood pressure control defined as < 140/90 vs blood pressure control defined as < 130/80, Dr. Boone said.
Dr. Boone said she expected payers to coordinate quality measures.
“The fact that they largely are not is really the main finding of this paper. Without coordination, the use of value-based contracts and quality measures at scale leads to many unique measures being used. This may reflect the fact that there are so many important tasks to do in primary care, and there’s no consensus on which ones should be included in quality-based contracts.”
Ronald N. Adler, MD, an associate professor in the Department of Family Medicine and Community Health at UMass Chan Medical School, Worcester, Massachusetts, who’s familiar with the findings but didn’t take part in the research, said the study offers something new — the quantification of quality measures.
He said in an interview that physicians deal with quality measures in different ways. Some clinicians “don’t really care,” and have an attitude of “this is not why I got into medicine.” But others “are very competitive around this, and it leads to a lot of a lot of stress. Trying to address 50-plus measures is impossible and demoralizing.”
The metrics may measure things like mammogram screening that are out of the physician’s control, Dr. Adler said. “I can recommend a mammogram, and my patient can choose not to do it. Or maybe my patient is homeless; she doesn’t have transportation, and it’s not a priority for her, even though she wants to do it.”
Patients may not take medication as prescribed, or they may be unable to afford it, he said. “Can they afford to eat healthy foods? Or is ramen all they can afford, and their sugars are through the roof? There are a lot of factors at play here that are independent of the quality of care provided by the doctor.”
As for his own approach, Dr. Adler said he worries about some measures more than others. “I’m very proactive about screening my patients for colon cancer and maybe a little less so about mammography.”
For colon cancer screening, “there are a lot of benefits and not that many harms as opposed to mammography, which has harms such as false positives and overdiagnosis of breast cancer.”
Dr. Adler is a member of the Quality Measure Alignment Taskforce in Massachusetts, which is trying to establish consensus on appropriate quality measures. But payer participation is voluntary. “Our health systems are too siloed ... so there is no readily available mechanism for enforcing such recommendations.”
Wayne Altman, MD, chair of Family Medicine at Tufts University School of Medicine, Boston, Massachusetts, is also familiar with the study findings but didn’t take part in the research. He said in an interview that clinicians shouldn’t have to deal with more than 5-10 quality measures in total.
He pointed out that many measures don’t make sense in certain populations. Titrating blood pressure to < 140/90 isn’t ideal for elderly patients because aggressive control can send their blood pressure dangerously low. “They’re going to fall down, break a hip, and likely die within a year. You have to have the right population and be aware of unintended consequences.”
Still, Dr. Adler noted, there’s an important role for quality measures in healthcare.
“We need data to inform our quality improvement activities, but they need to be the right measures. People can’t respond reasonably to improve on 50-plus measures,” he said. “They need to be consolidated and prioritized. It would be really helpful if we could have a much lower number of measures that are meaningful, safe, and connect to things that matter.”
No funding has been reported. Dr. Boone disclosed a grant from the National Institute on Aging. Dr. Adler and Dr. Altman had no disclosures.
A version of this article first appeared on Medscape.com.
A new analysis suggests one reason doctors are wary of value-based care arrangements: Overkill.
Researchers found that primary care physicians in one large integrated health system were required to track an average of 57 different quality measures across multiple insurers that linked outcomes to payments under value-based contracts.
Medicare contracts were the most likely to pile quality measures on physicians with an average of 13.42 measures vs 10.07 for commercial insurer contracts and 5.37 for Medicaid contracts, reported Claire Boone, PhD, of the University of Chicago in Illinois and Providence Research Network, Portland, Oregon, and colleagues in JAMA Health Forum. The analysis, which may be the first of its kind, tracked 890 primary care physicians from 2020 to 2022.
The average of 57 quality measures per physician was unexpectedly high, Dr. Boone said in an interview.
“The magnitude of that number surprised us,” Dr. Boone said. “Primary care physicians and their practices have a lot on their plate. Now we know that one of those things is a very large number of different quality metrics to pay attention to, measure, report on, and implement.
Value-based care programs use quality measures to evaluate how well clinicians are doing their jobs and adjust reimbursement accordingly. A payer, for example, may raise reimbursements if a clinician has higher numbers of patients who meet quality measure standards for depression screening or blood pressure.
Dr. Boone said her research group is studying the impact of quality measures and was surprised that data showed individual primary care physicians had to deal with a high number of value-based contracts.
The researchers tracked value-based contracts for 890 physicians (58.3% women, 41.7% men) in an unidentified West Coast Health system. (Several study authors work for the Providence Health System, which serves several Western States and Texas.) The average number of patients per physician was 1309.
The physicians were part of an average of 11.18 value-based contracts (commercial insurers, 49.50%; Medicaid, 21.49%; and Medicare, 29.01%). This number grew from 9.39 in 2020 to 12.26 in 2022. Quality measure data weren’t available for 29% of contracts.
Quality measures were considered unique if they referenced different conditions.
For example, colorectal cancer screening is unique from depression screening. The researchers also considered measures for the same condition unique if the target value differed — for example, blood pressure control defined as < 140/90 vs blood pressure control defined as < 130/80, Dr. Boone said.
Dr. Boone said she expected payers to coordinate quality measures.
“The fact that they largely are not is really the main finding of this paper. Without coordination, the use of value-based contracts and quality measures at scale leads to many unique measures being used. This may reflect the fact that there are so many important tasks to do in primary care, and there’s no consensus on which ones should be included in quality-based contracts.”
Ronald N. Adler, MD, an associate professor in the Department of Family Medicine and Community Health at UMass Chan Medical School, Worcester, Massachusetts, who’s familiar with the findings but didn’t take part in the research, said the study offers something new — the quantification of quality measures.
He said in an interview that physicians deal with quality measures in different ways. Some clinicians “don’t really care,” and have an attitude of “this is not why I got into medicine.” But others “are very competitive around this, and it leads to a lot of a lot of stress. Trying to address 50-plus measures is impossible and demoralizing.”
The metrics may measure things like mammogram screening that are out of the physician’s control, Dr. Adler said. “I can recommend a mammogram, and my patient can choose not to do it. Or maybe my patient is homeless; she doesn’t have transportation, and it’s not a priority for her, even though she wants to do it.”
Patients may not take medication as prescribed, or they may be unable to afford it, he said. “Can they afford to eat healthy foods? Or is ramen all they can afford, and their sugars are through the roof? There are a lot of factors at play here that are independent of the quality of care provided by the doctor.”
As for his own approach, Dr. Adler said he worries about some measures more than others. “I’m very proactive about screening my patients for colon cancer and maybe a little less so about mammography.”
For colon cancer screening, “there are a lot of benefits and not that many harms as opposed to mammography, which has harms such as false positives and overdiagnosis of breast cancer.”
Dr. Adler is a member of the Quality Measure Alignment Taskforce in Massachusetts, which is trying to establish consensus on appropriate quality measures. But payer participation is voluntary. “Our health systems are too siloed ... so there is no readily available mechanism for enforcing such recommendations.”
Wayne Altman, MD, chair of Family Medicine at Tufts University School of Medicine, Boston, Massachusetts, is also familiar with the study findings but didn’t take part in the research. He said in an interview that clinicians shouldn’t have to deal with more than 5-10 quality measures in total.
He pointed out that many measures don’t make sense in certain populations. Titrating blood pressure to < 140/90 isn’t ideal for elderly patients because aggressive control can send their blood pressure dangerously low. “They’re going to fall down, break a hip, and likely die within a year. You have to have the right population and be aware of unintended consequences.”
Still, Dr. Adler noted, there’s an important role for quality measures in healthcare.
“We need data to inform our quality improvement activities, but they need to be the right measures. People can’t respond reasonably to improve on 50-plus measures,” he said. “They need to be consolidated and prioritized. It would be really helpful if we could have a much lower number of measures that are meaningful, safe, and connect to things that matter.”
No funding has been reported. Dr. Boone disclosed a grant from the National Institute on Aging. Dr. Adler and Dr. Altman had no disclosures.
A version of this article first appeared on Medscape.com.
A new analysis suggests one reason doctors are wary of value-based care arrangements: Overkill.
Researchers found that primary care physicians in one large integrated health system were required to track an average of 57 different quality measures across multiple insurers that linked outcomes to payments under value-based contracts.
Medicare contracts were the most likely to pile quality measures on physicians with an average of 13.42 measures vs 10.07 for commercial insurer contracts and 5.37 for Medicaid contracts, reported Claire Boone, PhD, of the University of Chicago in Illinois and Providence Research Network, Portland, Oregon, and colleagues in JAMA Health Forum. The analysis, which may be the first of its kind, tracked 890 primary care physicians from 2020 to 2022.
The average of 57 quality measures per physician was unexpectedly high, Dr. Boone said in an interview.
“The magnitude of that number surprised us,” Dr. Boone said. “Primary care physicians and their practices have a lot on their plate. Now we know that one of those things is a very large number of different quality metrics to pay attention to, measure, report on, and implement.
Value-based care programs use quality measures to evaluate how well clinicians are doing their jobs and adjust reimbursement accordingly. A payer, for example, may raise reimbursements if a clinician has higher numbers of patients who meet quality measure standards for depression screening or blood pressure.
Dr. Boone said her research group is studying the impact of quality measures and was surprised that data showed individual primary care physicians had to deal with a high number of value-based contracts.
The researchers tracked value-based contracts for 890 physicians (58.3% women, 41.7% men) in an unidentified West Coast Health system. (Several study authors work for the Providence Health System, which serves several Western States and Texas.) The average number of patients per physician was 1309.
The physicians were part of an average of 11.18 value-based contracts (commercial insurers, 49.50%; Medicaid, 21.49%; and Medicare, 29.01%). This number grew from 9.39 in 2020 to 12.26 in 2022. Quality measure data weren’t available for 29% of contracts.
Quality measures were considered unique if they referenced different conditions.
For example, colorectal cancer screening is unique from depression screening. The researchers also considered measures for the same condition unique if the target value differed — for example, blood pressure control defined as < 140/90 vs blood pressure control defined as < 130/80, Dr. Boone said.
Dr. Boone said she expected payers to coordinate quality measures.
“The fact that they largely are not is really the main finding of this paper. Without coordination, the use of value-based contracts and quality measures at scale leads to many unique measures being used. This may reflect the fact that there are so many important tasks to do in primary care, and there’s no consensus on which ones should be included in quality-based contracts.”
Ronald N. Adler, MD, an associate professor in the Department of Family Medicine and Community Health at UMass Chan Medical School, Worcester, Massachusetts, who’s familiar with the findings but didn’t take part in the research, said the study offers something new — the quantification of quality measures.
He said in an interview that physicians deal with quality measures in different ways. Some clinicians “don’t really care,” and have an attitude of “this is not why I got into medicine.” But others “are very competitive around this, and it leads to a lot of a lot of stress. Trying to address 50-plus measures is impossible and demoralizing.”
The metrics may measure things like mammogram screening that are out of the physician’s control, Dr. Adler said. “I can recommend a mammogram, and my patient can choose not to do it. Or maybe my patient is homeless; she doesn’t have transportation, and it’s not a priority for her, even though she wants to do it.”
Patients may not take medication as prescribed, or they may be unable to afford it, he said. “Can they afford to eat healthy foods? Or is ramen all they can afford, and their sugars are through the roof? There are a lot of factors at play here that are independent of the quality of care provided by the doctor.”
As for his own approach, Dr. Adler said he worries about some measures more than others. “I’m very proactive about screening my patients for colon cancer and maybe a little less so about mammography.”
For colon cancer screening, “there are a lot of benefits and not that many harms as opposed to mammography, which has harms such as false positives and overdiagnosis of breast cancer.”
Dr. Adler is a member of the Quality Measure Alignment Taskforce in Massachusetts, which is trying to establish consensus on appropriate quality measures. But payer participation is voluntary. “Our health systems are too siloed ... so there is no readily available mechanism for enforcing such recommendations.”
Wayne Altman, MD, chair of Family Medicine at Tufts University School of Medicine, Boston, Massachusetts, is also familiar with the study findings but didn’t take part in the research. He said in an interview that clinicians shouldn’t have to deal with more than 5-10 quality measures in total.
He pointed out that many measures don’t make sense in certain populations. Titrating blood pressure to < 140/90 isn’t ideal for elderly patients because aggressive control can send their blood pressure dangerously low. “They’re going to fall down, break a hip, and likely die within a year. You have to have the right population and be aware of unintended consequences.”
Still, Dr. Adler noted, there’s an important role for quality measures in healthcare.
“We need data to inform our quality improvement activities, but they need to be the right measures. People can’t respond reasonably to improve on 50-plus measures,” he said. “They need to be consolidated and prioritized. It would be really helpful if we could have a much lower number of measures that are meaningful, safe, and connect to things that matter.”
No funding has been reported. Dr. Boone disclosed a grant from the National Institute on Aging. Dr. Adler and Dr. Altman had no disclosures.
A version of this article first appeared on Medscape.com.
FROM JAMA HEALTH FORUM
UCSF Favors Pricey Doctoral Program for Nurse-Midwives Amid Maternal Care Crisis
One of California’s two programs for training nurse-midwives has stopped admitting students while it revamps its curriculum to offer only doctoral degrees, a move that’s drawn howls of protest from alumni, health policy experts, and faculty who accuse the University of California of putting profits above public health needs.
The University of California San Francisco’s (UCSF) renowned nursing school will graduate its final class of certified nurse-midwives in the spring of 2025. Then the university will cancel its 2-year master’s program in nurse-midwifery, along with other nursing disciplines, in favor of a 3-year doctor of nursing practice, or DNP, degree. The change will pause UCSF’s nearly 5 decades–long training of nurse-midwives until at least 2025 and will more than double the cost to students.
State Assembly member Mia Bonta, who chairs the health committee, said she was “disheartened” to learn that UCSF was eliminating its master’s nurse-midwifery program and feared the additional time and costs to get a doctorate would deter potential applicants. “Instead of adding hurdles, we need to be building and expanding a pipeline of culturally and racially concordant providers to support improved birth outcomes, especially for Black and Latina birthing people,” she said in an email.
The switch to doctoral education is part of a national movement to require all advanced-practice registered nurses, including nurse-midwives and nurse practitioners, to earn doctoral degrees, Kristen Bole, a UCSF spokesperson, said in response to written questions. The doctoral training will feature additional classes in leadership and quality improvement.
But the movement, which dates to 2004, has not caught on the way the American Association of Colleges of Nursing envisioned when it called for doctorate-level education to be required for entry-level advanced nursing practice by 2015. That deadline came and went. Now, an acute need for maternal health practitioners has some universities moving in the other direction.
This year, Rutgers University reinstated the nurse-midwifery master’s training it had eliminated in 2016. The University of Alabama at Birmingham also restarted its master’s in nurse-midwifery program in 2022 after a 25-year hiatus. In addition, George Washington University in Washington, DC, Loyola University in New Orleans, and the University of Nevada in Las Vagas added master’s training in nurse-midwifery.
UCSF estimates tuition and fees will cost $152,000 for a 3-year doctoral degree in midwifery, compared with $65,000 for a 2-year master’s. Studies show that 71% of nursing master’s students and 74% of nursing doctoral students rely on student loans, and nurses with doctorates earn negligibly or no more than nurses with master’s degrees.
Kim Q. Dau, who ran UCSF’s nurse-midwifery program for a decade, resigned in June because she was uncomfortable with the elimination of the master’s in favor of a doctoral requirement, she said, which is at odds with the state’s workforce needs and unnecessary for clinical practice.
“They’ll be equally prepared clinically but at more expense to the student and with a greater time investment,” she said.
Nurse-midwives are registered nurses with graduate degrees in nurse-midwifery. Licensed in all 50 states, they work mostly in hospitals and can perform abortions and prescribe medications, though they are also trained in managing labor pain with showers, massage, and other natural means. Certified midwives, by contrast, study midwifery at the graduate level outside of nursing schools and are licensed only in some states. Certified professional midwives attend births outside of hospitals.
The California Nurse-Midwives Association also criticized UCSF’s program change, which comes amid a national maternal mortality crisis, a serious shortage of obstetric providers, and a growing reliance on midwives. According to the 2022 “White House Blueprint for Addressing the Maternal Health Crisis” report, the United States has the highest maternal mortality rate of any developed nation and needs thousands more midwives and other women’s health providers to bridge the swelling gap.
Ginger Breedlove, founder and CEO of Grow Midwives, a national consulting firm, likened UCSF’s switch from master’s to doctoral training to “an earthquake.”
“Why are we delaying the entry of essential care providers by making them go to an additional year of school, which adds nothing to their clinical preparedness or safety to serve the community?” asked Ms. Breedlove, a past president of the American College of Nurse-Midwives. “Why they have chosen this during one of the worst workforce shortages combined with the worst maternal health crisis we have had in 50 years is beyond my imagination.”
A 2020 report published in Nursing Outlook failed to find that advanced-practice registered nurses with doctorates were more clinically proficient than those with master’s degrees. “Unfortunately, to date, the data are sparse,” it concluded.
The American College of Nurse-Midwives also denounced the doctoral requirement, as have trade associations for neonatal nurse practitioners and neonatal nurses, citing “the lack of scientific evidence that ... doctoral-level education is beneficial to patients, practitioners, or society.”
There is no evidence that doctoral-level nurse-midwives will provide better care, Ms. Breedlove said.
“This is profit over purpose,” she added.
Ms. Bole disputed Ms. Breedlove’s accusation of a profit motive. Asked for reasons for the change, she offered broad statements: “The decision to upgrade our program was made to ensure that our graduates are prepared for the challenges they will face in the evolving health care landscape.”
Like Ms. Breedlove, Liz Donnelly, vice chair of the health policy committee for the California Nurse-Midwives Association, worries that UCSF’s switch to a doctoral degree will exacerbate the twin crises of maternal mortality and a shrinking obstetrics workforce across California and the nation.
On average, 10-12 nurse-midwives graduated from the UCSF master’s program each year over the past decade, Ms. Bole said. California’s remaining master’s program in nurse-midwifery is at California State University in Fullerton, south of Los Angeles, and it graduated 8 nurse-midwives in 2023 and 11 in 2024.
More than half of rural counties in the United States lacked obstetric care in 2018, according to a Government Accountability Office report.
In some parts of California, expectant mothers must drive 2 hours for care, said Bethany Sasaki, who runs Midtown Nurse Midwives, a Sacramento birth center. It has had to stop accepting new clients because it cannot find midwives.
Ms. Donnelly predicted the closure of UCSF’s midwifery program will significantly reduce the number of nurse-midwives entering the workforce and will inhibit people with fewer resources from attending the program. “Specifically, I think it’s going to reduce folks of color, people from rural communities, people from poor communities,” she said.
UCSF’s change will also likely undercut efforts to train providers from diverse backgrounds.
Natasha, a 37-year-old Afro-Puerto Rican mother of two, has spent a decade preparing to train as a nurse-midwife so she could help women like herself through pregnancy and childbirth. She asked to be identified only by her first name out of fear of reducing her chances of graduate school admission.
The UCSF program’s pause, plus the added time and expense to get a doctoral degree, has muddied her career path.
“The master’s was just the perfect program,” said Natasha, who lives in the Bay Area and cannot travel to the other end of the state to attend California State University-Fullerton. “I’m frustrated, and I feel deflated. I now have to find another career path.”
This article was produced by KFF Health News, which publishes California Healthline, an editorially independent service of the California Health Care Foundation. KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.
One of California’s two programs for training nurse-midwives has stopped admitting students while it revamps its curriculum to offer only doctoral degrees, a move that’s drawn howls of protest from alumni, health policy experts, and faculty who accuse the University of California of putting profits above public health needs.
The University of California San Francisco’s (UCSF) renowned nursing school will graduate its final class of certified nurse-midwives in the spring of 2025. Then the university will cancel its 2-year master’s program in nurse-midwifery, along with other nursing disciplines, in favor of a 3-year doctor of nursing practice, or DNP, degree. The change will pause UCSF’s nearly 5 decades–long training of nurse-midwives until at least 2025 and will more than double the cost to students.
State Assembly member Mia Bonta, who chairs the health committee, said she was “disheartened” to learn that UCSF was eliminating its master’s nurse-midwifery program and feared the additional time and costs to get a doctorate would deter potential applicants. “Instead of adding hurdles, we need to be building and expanding a pipeline of culturally and racially concordant providers to support improved birth outcomes, especially for Black and Latina birthing people,” she said in an email.
The switch to doctoral education is part of a national movement to require all advanced-practice registered nurses, including nurse-midwives and nurse practitioners, to earn doctoral degrees, Kristen Bole, a UCSF spokesperson, said in response to written questions. The doctoral training will feature additional classes in leadership and quality improvement.
But the movement, which dates to 2004, has not caught on the way the American Association of Colleges of Nursing envisioned when it called for doctorate-level education to be required for entry-level advanced nursing practice by 2015. That deadline came and went. Now, an acute need for maternal health practitioners has some universities moving in the other direction.
This year, Rutgers University reinstated the nurse-midwifery master’s training it had eliminated in 2016. The University of Alabama at Birmingham also restarted its master’s in nurse-midwifery program in 2022 after a 25-year hiatus. In addition, George Washington University in Washington, DC, Loyola University in New Orleans, and the University of Nevada in Las Vagas added master’s training in nurse-midwifery.
UCSF estimates tuition and fees will cost $152,000 for a 3-year doctoral degree in midwifery, compared with $65,000 for a 2-year master’s. Studies show that 71% of nursing master’s students and 74% of nursing doctoral students rely on student loans, and nurses with doctorates earn negligibly or no more than nurses with master’s degrees.
Kim Q. Dau, who ran UCSF’s nurse-midwifery program for a decade, resigned in June because she was uncomfortable with the elimination of the master’s in favor of a doctoral requirement, she said, which is at odds with the state’s workforce needs and unnecessary for clinical practice.
“They’ll be equally prepared clinically but at more expense to the student and with a greater time investment,” she said.
Nurse-midwives are registered nurses with graduate degrees in nurse-midwifery. Licensed in all 50 states, they work mostly in hospitals and can perform abortions and prescribe medications, though they are also trained in managing labor pain with showers, massage, and other natural means. Certified midwives, by contrast, study midwifery at the graduate level outside of nursing schools and are licensed only in some states. Certified professional midwives attend births outside of hospitals.
The California Nurse-Midwives Association also criticized UCSF’s program change, which comes amid a national maternal mortality crisis, a serious shortage of obstetric providers, and a growing reliance on midwives. According to the 2022 “White House Blueprint for Addressing the Maternal Health Crisis” report, the United States has the highest maternal mortality rate of any developed nation and needs thousands more midwives and other women’s health providers to bridge the swelling gap.
Ginger Breedlove, founder and CEO of Grow Midwives, a national consulting firm, likened UCSF’s switch from master’s to doctoral training to “an earthquake.”
“Why are we delaying the entry of essential care providers by making them go to an additional year of school, which adds nothing to their clinical preparedness or safety to serve the community?” asked Ms. Breedlove, a past president of the American College of Nurse-Midwives. “Why they have chosen this during one of the worst workforce shortages combined with the worst maternal health crisis we have had in 50 years is beyond my imagination.”
A 2020 report published in Nursing Outlook failed to find that advanced-practice registered nurses with doctorates were more clinically proficient than those with master’s degrees. “Unfortunately, to date, the data are sparse,” it concluded.
The American College of Nurse-Midwives also denounced the doctoral requirement, as have trade associations for neonatal nurse practitioners and neonatal nurses, citing “the lack of scientific evidence that ... doctoral-level education is beneficial to patients, practitioners, or society.”
There is no evidence that doctoral-level nurse-midwives will provide better care, Ms. Breedlove said.
“This is profit over purpose,” she added.
Ms. Bole disputed Ms. Breedlove’s accusation of a profit motive. Asked for reasons for the change, she offered broad statements: “The decision to upgrade our program was made to ensure that our graduates are prepared for the challenges they will face in the evolving health care landscape.”
Like Ms. Breedlove, Liz Donnelly, vice chair of the health policy committee for the California Nurse-Midwives Association, worries that UCSF’s switch to a doctoral degree will exacerbate the twin crises of maternal mortality and a shrinking obstetrics workforce across California and the nation.
On average, 10-12 nurse-midwives graduated from the UCSF master’s program each year over the past decade, Ms. Bole said. California’s remaining master’s program in nurse-midwifery is at California State University in Fullerton, south of Los Angeles, and it graduated 8 nurse-midwives in 2023 and 11 in 2024.
More than half of rural counties in the United States lacked obstetric care in 2018, according to a Government Accountability Office report.
In some parts of California, expectant mothers must drive 2 hours for care, said Bethany Sasaki, who runs Midtown Nurse Midwives, a Sacramento birth center. It has had to stop accepting new clients because it cannot find midwives.
Ms. Donnelly predicted the closure of UCSF’s midwifery program will significantly reduce the number of nurse-midwives entering the workforce and will inhibit people with fewer resources from attending the program. “Specifically, I think it’s going to reduce folks of color, people from rural communities, people from poor communities,” she said.
UCSF’s change will also likely undercut efforts to train providers from diverse backgrounds.
Natasha, a 37-year-old Afro-Puerto Rican mother of two, has spent a decade preparing to train as a nurse-midwife so she could help women like herself through pregnancy and childbirth. She asked to be identified only by her first name out of fear of reducing her chances of graduate school admission.
The UCSF program’s pause, plus the added time and expense to get a doctoral degree, has muddied her career path.
“The master’s was just the perfect program,” said Natasha, who lives in the Bay Area and cannot travel to the other end of the state to attend California State University-Fullerton. “I’m frustrated, and I feel deflated. I now have to find another career path.”
This article was produced by KFF Health News, which publishes California Healthline, an editorially independent service of the California Health Care Foundation. KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.
One of California’s two programs for training nurse-midwives has stopped admitting students while it revamps its curriculum to offer only doctoral degrees, a move that’s drawn howls of protest from alumni, health policy experts, and faculty who accuse the University of California of putting profits above public health needs.
The University of California San Francisco’s (UCSF) renowned nursing school will graduate its final class of certified nurse-midwives in the spring of 2025. Then the university will cancel its 2-year master’s program in nurse-midwifery, along with other nursing disciplines, in favor of a 3-year doctor of nursing practice, or DNP, degree. The change will pause UCSF’s nearly 5 decades–long training of nurse-midwives until at least 2025 and will more than double the cost to students.
State Assembly member Mia Bonta, who chairs the health committee, said she was “disheartened” to learn that UCSF was eliminating its master’s nurse-midwifery program and feared the additional time and costs to get a doctorate would deter potential applicants. “Instead of adding hurdles, we need to be building and expanding a pipeline of culturally and racially concordant providers to support improved birth outcomes, especially for Black and Latina birthing people,” she said in an email.
The switch to doctoral education is part of a national movement to require all advanced-practice registered nurses, including nurse-midwives and nurse practitioners, to earn doctoral degrees, Kristen Bole, a UCSF spokesperson, said in response to written questions. The doctoral training will feature additional classes in leadership and quality improvement.
But the movement, which dates to 2004, has not caught on the way the American Association of Colleges of Nursing envisioned when it called for doctorate-level education to be required for entry-level advanced nursing practice by 2015. That deadline came and went. Now, an acute need for maternal health practitioners has some universities moving in the other direction.
This year, Rutgers University reinstated the nurse-midwifery master’s training it had eliminated in 2016. The University of Alabama at Birmingham also restarted its master’s in nurse-midwifery program in 2022 after a 25-year hiatus. In addition, George Washington University in Washington, DC, Loyola University in New Orleans, and the University of Nevada in Las Vagas added master’s training in nurse-midwifery.
UCSF estimates tuition and fees will cost $152,000 for a 3-year doctoral degree in midwifery, compared with $65,000 for a 2-year master’s. Studies show that 71% of nursing master’s students and 74% of nursing doctoral students rely on student loans, and nurses with doctorates earn negligibly or no more than nurses with master’s degrees.
Kim Q. Dau, who ran UCSF’s nurse-midwifery program for a decade, resigned in June because she was uncomfortable with the elimination of the master’s in favor of a doctoral requirement, she said, which is at odds with the state’s workforce needs and unnecessary for clinical practice.
“They’ll be equally prepared clinically but at more expense to the student and with a greater time investment,” she said.
Nurse-midwives are registered nurses with graduate degrees in nurse-midwifery. Licensed in all 50 states, they work mostly in hospitals and can perform abortions and prescribe medications, though they are also trained in managing labor pain with showers, massage, and other natural means. Certified midwives, by contrast, study midwifery at the graduate level outside of nursing schools and are licensed only in some states. Certified professional midwives attend births outside of hospitals.
The California Nurse-Midwives Association also criticized UCSF’s program change, which comes amid a national maternal mortality crisis, a serious shortage of obstetric providers, and a growing reliance on midwives. According to the 2022 “White House Blueprint for Addressing the Maternal Health Crisis” report, the United States has the highest maternal mortality rate of any developed nation and needs thousands more midwives and other women’s health providers to bridge the swelling gap.
Ginger Breedlove, founder and CEO of Grow Midwives, a national consulting firm, likened UCSF’s switch from master’s to doctoral training to “an earthquake.”
“Why are we delaying the entry of essential care providers by making them go to an additional year of school, which adds nothing to their clinical preparedness or safety to serve the community?” asked Ms. Breedlove, a past president of the American College of Nurse-Midwives. “Why they have chosen this during one of the worst workforce shortages combined with the worst maternal health crisis we have had in 50 years is beyond my imagination.”
A 2020 report published in Nursing Outlook failed to find that advanced-practice registered nurses with doctorates were more clinically proficient than those with master’s degrees. “Unfortunately, to date, the data are sparse,” it concluded.
The American College of Nurse-Midwives also denounced the doctoral requirement, as have trade associations for neonatal nurse practitioners and neonatal nurses, citing “the lack of scientific evidence that ... doctoral-level education is beneficial to patients, practitioners, or society.”
There is no evidence that doctoral-level nurse-midwives will provide better care, Ms. Breedlove said.
“This is profit over purpose,” she added.
Ms. Bole disputed Ms. Breedlove’s accusation of a profit motive. Asked for reasons for the change, she offered broad statements: “The decision to upgrade our program was made to ensure that our graduates are prepared for the challenges they will face in the evolving health care landscape.”
Like Ms. Breedlove, Liz Donnelly, vice chair of the health policy committee for the California Nurse-Midwives Association, worries that UCSF’s switch to a doctoral degree will exacerbate the twin crises of maternal mortality and a shrinking obstetrics workforce across California and the nation.
On average, 10-12 nurse-midwives graduated from the UCSF master’s program each year over the past decade, Ms. Bole said. California’s remaining master’s program in nurse-midwifery is at California State University in Fullerton, south of Los Angeles, and it graduated 8 nurse-midwives in 2023 and 11 in 2024.
More than half of rural counties in the United States lacked obstetric care in 2018, according to a Government Accountability Office report.
In some parts of California, expectant mothers must drive 2 hours for care, said Bethany Sasaki, who runs Midtown Nurse Midwives, a Sacramento birth center. It has had to stop accepting new clients because it cannot find midwives.
Ms. Donnelly predicted the closure of UCSF’s midwifery program will significantly reduce the number of nurse-midwives entering the workforce and will inhibit people with fewer resources from attending the program. “Specifically, I think it’s going to reduce folks of color, people from rural communities, people from poor communities,” she said.
UCSF’s change will also likely undercut efforts to train providers from diverse backgrounds.
Natasha, a 37-year-old Afro-Puerto Rican mother of two, has spent a decade preparing to train as a nurse-midwife so she could help women like herself through pregnancy and childbirth. She asked to be identified only by her first name out of fear of reducing her chances of graduate school admission.
The UCSF program’s pause, plus the added time and expense to get a doctoral degree, has muddied her career path.
“The master’s was just the perfect program,” said Natasha, who lives in the Bay Area and cannot travel to the other end of the state to attend California State University-Fullerton. “I’m frustrated, and I feel deflated. I now have to find another career path.”
This article was produced by KFF Health News, which publishes California Healthline, an editorially independent service of the California Health Care Foundation. KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.
Gram Stain Doesn’t Improve UTI Diagnosis in the ED
TOPLINE:
Compared with other urine analysis methods, urine Gram stain has a moderate predictive value for detecting gram-negative bacteria in urine culture but does not significantly improve urinary tract infection (UTI) diagnosis in the emergency department (ED).
METHODOLOGY:
- Researchers conducted an observational cohort study at the University Medical Center Groningen in the Netherlands, encompassing 1358 episodes across 1136 patients suspected of having a UTI.
- The study included the following predefined subgroups: patients using urinary catheters and patients with leukopenia (< 4.0×10⁹ leucocytes/L). Urine dipstick nitrite, automated urinalysis, Gram stain, and urine cultures were performed on urine samples collected from patients presenting at the ED.
- The sensitivity and specificity of Gram stain for “many” bacteria (quantified as > 15/high power field) were compared with those of urine dipstick nitrite and automated bacterial counting in urinalysis.
TAKEAWAY:
- The sensitivity and specificity of Gram stain for “many” bacteria were 51.3% and 91.0%, respectively, with an accuracy of 76.8%.
- Gram stain showed a positive predictive value (PPV) of 84.7% for gram-negative rods in urine culture; however, the PPV was only 38.4% for gram-positive cocci.
- In the catheter subgroup, the presence of monomorphic bacteria quantified as “many” had a higher PPV for diagnosing a UTI than the presence of polymorphic bacteria with the same quantification.
- The overall performance of Gram stain in diagnosing a UTI in the ED was comparable to that of automated bacterial counting in urinalysis but better than that of urine dipstick nitrite.
IN PRACTICE:
“With the exception of a moderate prediction of gram-negative bacteria in the UC [urine culture], urine GS [Gram stain] does not improve UTI diagnosis at the ED compared to other urine parameters,” the authors wrote.
SOURCE:
The study was led by Stephanie J.M. Middelkoop, University of Groningen, University Medical Center Groningen, the Netherlands. It was published online on August 16, 2024, in Infectious Diseases.
LIMITATIONS:
The study’s limitations included a small sample size within the leukopenia subgroup, which may have affected the generalizability of the findings. Additionally, the potential influence of refrigeration of urine samples on bacterial growth could have affected the results. In this study, indwelling catheters were not replaced before urine sample collection, which may have affected the accuracy of UTI diagnosis in patients using catheters.
DISCLOSURES:
No conflicts of interest were disclosed by the authors.
This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication. A version of this article first appeared on Medscape.com.
TOPLINE:
Compared with other urine analysis methods, urine Gram stain has a moderate predictive value for detecting gram-negative bacteria in urine culture but does not significantly improve urinary tract infection (UTI) diagnosis in the emergency department (ED).
METHODOLOGY:
- Researchers conducted an observational cohort study at the University Medical Center Groningen in the Netherlands, encompassing 1358 episodes across 1136 patients suspected of having a UTI.
- The study included the following predefined subgroups: patients using urinary catheters and patients with leukopenia (< 4.0×10⁹ leucocytes/L). Urine dipstick nitrite, automated urinalysis, Gram stain, and urine cultures were performed on urine samples collected from patients presenting at the ED.
- The sensitivity and specificity of Gram stain for “many” bacteria (quantified as > 15/high power field) were compared with those of urine dipstick nitrite and automated bacterial counting in urinalysis.
TAKEAWAY:
- The sensitivity and specificity of Gram stain for “many” bacteria were 51.3% and 91.0%, respectively, with an accuracy of 76.8%.
- Gram stain showed a positive predictive value (PPV) of 84.7% for gram-negative rods in urine culture; however, the PPV was only 38.4% for gram-positive cocci.
- In the catheter subgroup, the presence of monomorphic bacteria quantified as “many” had a higher PPV for diagnosing a UTI than the presence of polymorphic bacteria with the same quantification.
- The overall performance of Gram stain in diagnosing a UTI in the ED was comparable to that of automated bacterial counting in urinalysis but better than that of urine dipstick nitrite.
IN PRACTICE:
“With the exception of a moderate prediction of gram-negative bacteria in the UC [urine culture], urine GS [Gram stain] does not improve UTI diagnosis at the ED compared to other urine parameters,” the authors wrote.
SOURCE:
The study was led by Stephanie J.M. Middelkoop, University of Groningen, University Medical Center Groningen, the Netherlands. It was published online on August 16, 2024, in Infectious Diseases.
LIMITATIONS:
The study’s limitations included a small sample size within the leukopenia subgroup, which may have affected the generalizability of the findings. Additionally, the potential influence of refrigeration of urine samples on bacterial growth could have affected the results. In this study, indwelling catheters were not replaced before urine sample collection, which may have affected the accuracy of UTI diagnosis in patients using catheters.
DISCLOSURES:
No conflicts of interest were disclosed by the authors.
This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication. A version of this article first appeared on Medscape.com.
TOPLINE:
Compared with other urine analysis methods, urine Gram stain has a moderate predictive value for detecting gram-negative bacteria in urine culture but does not significantly improve urinary tract infection (UTI) diagnosis in the emergency department (ED).
METHODOLOGY:
- Researchers conducted an observational cohort study at the University Medical Center Groningen in the Netherlands, encompassing 1358 episodes across 1136 patients suspected of having a UTI.
- The study included the following predefined subgroups: patients using urinary catheters and patients with leukopenia (< 4.0×10⁹ leucocytes/L). Urine dipstick nitrite, automated urinalysis, Gram stain, and urine cultures were performed on urine samples collected from patients presenting at the ED.
- The sensitivity and specificity of Gram stain for “many” bacteria (quantified as > 15/high power field) were compared with those of urine dipstick nitrite and automated bacterial counting in urinalysis.
TAKEAWAY:
- The sensitivity and specificity of Gram stain for “many” bacteria were 51.3% and 91.0%, respectively, with an accuracy of 76.8%.
- Gram stain showed a positive predictive value (PPV) of 84.7% for gram-negative rods in urine culture; however, the PPV was only 38.4% for gram-positive cocci.
- In the catheter subgroup, the presence of monomorphic bacteria quantified as “many” had a higher PPV for diagnosing a UTI than the presence of polymorphic bacteria with the same quantification.
- The overall performance of Gram stain in diagnosing a UTI in the ED was comparable to that of automated bacterial counting in urinalysis but better than that of urine dipstick nitrite.
IN PRACTICE:
“With the exception of a moderate prediction of gram-negative bacteria in the UC [urine culture], urine GS [Gram stain] does not improve UTI diagnosis at the ED compared to other urine parameters,” the authors wrote.
SOURCE:
The study was led by Stephanie J.M. Middelkoop, University of Groningen, University Medical Center Groningen, the Netherlands. It was published online on August 16, 2024, in Infectious Diseases.
LIMITATIONS:
The study’s limitations included a small sample size within the leukopenia subgroup, which may have affected the generalizability of the findings. Additionally, the potential influence of refrigeration of urine samples on bacterial growth could have affected the results. In this study, indwelling catheters were not replaced before urine sample collection, which may have affected the accuracy of UTI diagnosis in patients using catheters.
DISCLOSURES:
No conflicts of interest were disclosed by the authors.
This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication. A version of this article first appeared on Medscape.com.
The Wellness Industry: Financially Toxic, Says Ethicist
This transcript has been edited for clarity.
Hi. I’m Art Caplan. I’m at the Division of Medical Ethics at the NYU Grossman School of Medicine in New York City.
We have many debates and arguments that are swirling around about the out-of-control costs of Medicare. Many people are arguing we’ve got to trim it and cut back, and many people note that we can’t just go on and on with that kind of expenditure.
People look around for savings. Rightly, we can’t go on with the prices that we’re paying. No system could. We’ll bankrupt ourselves if we don’t drive prices down.
There’s another area that is driving up cost where, despite the fact that Medicare doesn’t pay for it, we could capture resources and hopefully shift them back to things like Medicare coverage or the insurance of other efficacious procedures. That area is the wellness industry.
That’s money coming out of people’s pockets that we could hopefully aim at the payment of things that we know work, not seeing the money drain out to cover bunk, nonsense, and charlatanism.
Does any or most of this stuff work? Do anything? Help anybody? No. We are spending money on charlatans and quacks. The US Food and Drug Administration (FDA), which you might think is the agency that could step in and start to get rid of some of this nonsense, is just too overwhelmed trying to track drugs, devices, and vaccines to give much attention to the wellness industry.
What am I talking about specifically? I’m talking about everything from gut probiotics that are sold in sodas to probiotic facial creams and the Goop industry of Gwyneth Paltrow, where you have people buying things like wellness mats or vaginal eggs that are supposed to maintain gynecologic health.
We’re talking about things like PEMF, or pulse electronic magnetic fields, where you buy a machine and expose yourself to mild magnetic pulses. I went online to look them up, and the machines cost $5000-$50,000. There’s no evidence that it works. By the way, the machines are not only out there as being sold for pain relief and many other things to humans, but also they’re being sold for your pets.
That industry is completely out of control. Wellness interventions, whether it’s transcranial magnetism or all manner of supplements that are sold in health food stores, over and over again, we see a world in which wellness is promoted but no data are introduced to show that any of it helps, works, or does anybody any good.
It may not be all that harmful, but it’s certainly financially toxic to many people who end up spending good amounts of money using these things. I think doctors need to ask patients if they are using any of these things, particularly if they have chronic conditions. They’re likely, many of them, to be seduced by online advertisement to get involved with this stuff because it’s preventive or it’ll help treat some condition that they have.
The industry is out of control. We’re trying to figure out how to spend money on things we know work in medicine, and yet we continue to tolerate bunk, nonsense, quackery, and charlatanism, just letting it grow and grow and grow in terms of cost.
That’s money that could go elsewhere. That is money that is being taken out of the pockets of patients. They’re doing things that may even delay medical treatment, which won’t really help them, and they are doing things that perhaps might even interfere with medical care that really is known to be beneficial.
I think it’s time to push for more money for the FDA to regulate the wellness side. I think it’s time for the Federal Trade Commission to go after ads that promise health benefits. I think it’s time to have some honest conversations with patients: What are you using? What are you doing? Tell me about it, and here’s why I think you could probably spend your money in a better way.
Dr. Caplan, director, Division of Medical Ethics, New York University Langone Medical Center, New York, disclosed ties with Johnson & Johnson’s Panel for Compassionate Drug Use (unpaid position). He serves as a contributing author and adviser for Medscape.
A version of this article appeared on Medscape.com.
This transcript has been edited for clarity.
Hi. I’m Art Caplan. I’m at the Division of Medical Ethics at the NYU Grossman School of Medicine in New York City.
We have many debates and arguments that are swirling around about the out-of-control costs of Medicare. Many people are arguing we’ve got to trim it and cut back, and many people note that we can’t just go on and on with that kind of expenditure.
People look around for savings. Rightly, we can’t go on with the prices that we’re paying. No system could. We’ll bankrupt ourselves if we don’t drive prices down.
There’s another area that is driving up cost where, despite the fact that Medicare doesn’t pay for it, we could capture resources and hopefully shift them back to things like Medicare coverage or the insurance of other efficacious procedures. That area is the wellness industry.
That’s money coming out of people’s pockets that we could hopefully aim at the payment of things that we know work, not seeing the money drain out to cover bunk, nonsense, and charlatanism.
Does any or most of this stuff work? Do anything? Help anybody? No. We are spending money on charlatans and quacks. The US Food and Drug Administration (FDA), which you might think is the agency that could step in and start to get rid of some of this nonsense, is just too overwhelmed trying to track drugs, devices, and vaccines to give much attention to the wellness industry.
What am I talking about specifically? I’m talking about everything from gut probiotics that are sold in sodas to probiotic facial creams and the Goop industry of Gwyneth Paltrow, where you have people buying things like wellness mats or vaginal eggs that are supposed to maintain gynecologic health.
We’re talking about things like PEMF, or pulse electronic magnetic fields, where you buy a machine and expose yourself to mild magnetic pulses. I went online to look them up, and the machines cost $5000-$50,000. There’s no evidence that it works. By the way, the machines are not only out there as being sold for pain relief and many other things to humans, but also they’re being sold for your pets.
That industry is completely out of control. Wellness interventions, whether it’s transcranial magnetism or all manner of supplements that are sold in health food stores, over and over again, we see a world in which wellness is promoted but no data are introduced to show that any of it helps, works, or does anybody any good.
It may not be all that harmful, but it’s certainly financially toxic to many people who end up spending good amounts of money using these things. I think doctors need to ask patients if they are using any of these things, particularly if they have chronic conditions. They’re likely, many of them, to be seduced by online advertisement to get involved with this stuff because it’s preventive or it’ll help treat some condition that they have.
The industry is out of control. We’re trying to figure out how to spend money on things we know work in medicine, and yet we continue to tolerate bunk, nonsense, quackery, and charlatanism, just letting it grow and grow and grow in terms of cost.
That’s money that could go elsewhere. That is money that is being taken out of the pockets of patients. They’re doing things that may even delay medical treatment, which won’t really help them, and they are doing things that perhaps might even interfere with medical care that really is known to be beneficial.
I think it’s time to push for more money for the FDA to regulate the wellness side. I think it’s time for the Federal Trade Commission to go after ads that promise health benefits. I think it’s time to have some honest conversations with patients: What are you using? What are you doing? Tell me about it, and here’s why I think you could probably spend your money in a better way.
Dr. Caplan, director, Division of Medical Ethics, New York University Langone Medical Center, New York, disclosed ties with Johnson & Johnson’s Panel for Compassionate Drug Use (unpaid position). He serves as a contributing author and adviser for Medscape.
A version of this article appeared on Medscape.com.
This transcript has been edited for clarity.
Hi. I’m Art Caplan. I’m at the Division of Medical Ethics at the NYU Grossman School of Medicine in New York City.
We have many debates and arguments that are swirling around about the out-of-control costs of Medicare. Many people are arguing we’ve got to trim it and cut back, and many people note that we can’t just go on and on with that kind of expenditure.
People look around for savings. Rightly, we can’t go on with the prices that we’re paying. No system could. We’ll bankrupt ourselves if we don’t drive prices down.
There’s another area that is driving up cost where, despite the fact that Medicare doesn’t pay for it, we could capture resources and hopefully shift them back to things like Medicare coverage or the insurance of other efficacious procedures. That area is the wellness industry.
That’s money coming out of people’s pockets that we could hopefully aim at the payment of things that we know work, not seeing the money drain out to cover bunk, nonsense, and charlatanism.
Does any or most of this stuff work? Do anything? Help anybody? No. We are spending money on charlatans and quacks. The US Food and Drug Administration (FDA), which you might think is the agency that could step in and start to get rid of some of this nonsense, is just too overwhelmed trying to track drugs, devices, and vaccines to give much attention to the wellness industry.
What am I talking about specifically? I’m talking about everything from gut probiotics that are sold in sodas to probiotic facial creams and the Goop industry of Gwyneth Paltrow, where you have people buying things like wellness mats or vaginal eggs that are supposed to maintain gynecologic health.
We’re talking about things like PEMF, or pulse electronic magnetic fields, where you buy a machine and expose yourself to mild magnetic pulses. I went online to look them up, and the machines cost $5000-$50,000. There’s no evidence that it works. By the way, the machines are not only out there as being sold for pain relief and many other things to humans, but also they’re being sold for your pets.
That industry is completely out of control. Wellness interventions, whether it’s transcranial magnetism or all manner of supplements that are sold in health food stores, over and over again, we see a world in which wellness is promoted but no data are introduced to show that any of it helps, works, or does anybody any good.
It may not be all that harmful, but it’s certainly financially toxic to many people who end up spending good amounts of money using these things. I think doctors need to ask patients if they are using any of these things, particularly if they have chronic conditions. They’re likely, many of them, to be seduced by online advertisement to get involved with this stuff because it’s preventive or it’ll help treat some condition that they have.
The industry is out of control. We’re trying to figure out how to spend money on things we know work in medicine, and yet we continue to tolerate bunk, nonsense, quackery, and charlatanism, just letting it grow and grow and grow in terms of cost.
That’s money that could go elsewhere. That is money that is being taken out of the pockets of patients. They’re doing things that may even delay medical treatment, which won’t really help them, and they are doing things that perhaps might even interfere with medical care that really is known to be beneficial.
I think it’s time to push for more money for the FDA to regulate the wellness side. I think it’s time for the Federal Trade Commission to go after ads that promise health benefits. I think it’s time to have some honest conversations with patients: What are you using? What are you doing? Tell me about it, and here’s why I think you could probably spend your money in a better way.
Dr. Caplan, director, Division of Medical Ethics, New York University Langone Medical Center, New York, disclosed ties with Johnson & Johnson’s Panel for Compassionate Drug Use (unpaid position). He serves as a contributing author and adviser for Medscape.
A version of this article appeared on Medscape.com.
Listeriosis During Pregnancy Can Be Fatal for the Fetus
Listeriosis during pregnancy, when invasive, can be fatal for the fetus, with a rate of fetal loss or neonatal death of 29%, investigators reported in an article alerting clinicians to this condition.
The article was prompted when the Reproductive Infectious Diseases team at The University of British Columbia in Vancouver, British Columbia, Canada, “received many phone calls from concerned doctors and patients after the plant-based milk recall in early July,” Jeffrey Man Hay Wong, MD, told this news organization. “With such concerns, we updated our British Columbia guidelines for our patients but quickly realized that our recommendations would be useful across the country.”
The article was published online in the Canadian Medical Association Journal.
Five Key Points
Dr. Wong and colleagues provided the following five points and recommendations:
First, invasive listeriosis (bacteremia or meningitis) in pregnancy can have major fetal consequences, including fetal loss or neonatal death in 29% of cases. Affected patients can be asymptomatic or experience gastrointestinal symptoms, myalgias, fevers, acute respiratory distress syndrome, or sepsis.
Second, pregnant people should avoid foods at a high risk for Listeria monocytogenes contamination, including unpasteurized dairy products, luncheon meats, refrigerated meat spreads, and prepared salads. They also should stay aware of Health Canada recalls.
Third, it is not necessary to investigate or treat patients who may have ingested contaminated food but are asymptomatic. Listeriosis can present at 2-3 months after exposure because the incubation period can be as long as 70 days.
Fourth, for patients with mild gastroenteritis or flu-like symptoms who may have ingested contaminated food, obtaining blood cultures or starting a 2-week course of oral amoxicillin (500 mg, three times daily) could be considered.
Fifth, for patients with fever and possible exposure to L monocytogenes, blood cultures should be drawn immediately, and high-dose ampicillin should be initiated, along with electronic fetal heart rate monitoring.
“While choosing safer foods in pregnancy is recommended, it is most important to be aware of Health Canada food recalls and pay attention to symptoms if you’ve ingested these foods,” said Dr. Wong. “Working with the BC Centre for Disease Control, our teams are actively monitoring for cases of listeriosis in pregnancy here in British Columbia.
“Thankfully,” he said, “there haven’t been any confirmed cases in British Columbia related to the plant-based milk recall, though the bacteria’s incubation period can be up to 70 days in pregnancy.”
No Increase Suspected
Commenting on the article, Khady Diouf, MD, director of global obstetrics and gynecology at Brigham and Women’s Hospital in Boston, said, “It summarizes the main management, which is based mostly on expert opinion.”
US clinicians also should be reminded about listeriosis in pregnancy, she noted, pointing to “helpful guidance” from the American College of Obstetrics and Gynecology.
Although the United States similarly experienced a recent listeriosis outbreak resulting from contaminated deli meats, both Dr. Wong and Dr. Diouf said that these outbreaks do not seem to signal an increase in listeriosis cases overall.
“Food-borne listeriosis seems to come in waves,” said Dr. Wong. “At a public health level, we certainly have better surveillance programs for Listeria infections. In 2023, Health Canada updated its Policy on L monocytogenes in ready-to-eat foods, which emphasizes the good manufacturing practices recommended for food processing environments to identify outbreaks earlier.”
“I think we get these recalls yearly, and this has been the case for as long as I can remember,” Dr. Diouf agreed.
No funding was declared, and the authors declared no relevant financial relationships.
A version of this article first appeared on Medscape.com.
Listeriosis during pregnancy, when invasive, can be fatal for the fetus, with a rate of fetal loss or neonatal death of 29%, investigators reported in an article alerting clinicians to this condition.
The article was prompted when the Reproductive Infectious Diseases team at The University of British Columbia in Vancouver, British Columbia, Canada, “received many phone calls from concerned doctors and patients after the plant-based milk recall in early July,” Jeffrey Man Hay Wong, MD, told this news organization. “With such concerns, we updated our British Columbia guidelines for our patients but quickly realized that our recommendations would be useful across the country.”
The article was published online in the Canadian Medical Association Journal.
Five Key Points
Dr. Wong and colleagues provided the following five points and recommendations:
First, invasive listeriosis (bacteremia or meningitis) in pregnancy can have major fetal consequences, including fetal loss or neonatal death in 29% of cases. Affected patients can be asymptomatic or experience gastrointestinal symptoms, myalgias, fevers, acute respiratory distress syndrome, or sepsis.
Second, pregnant people should avoid foods at a high risk for Listeria monocytogenes contamination, including unpasteurized dairy products, luncheon meats, refrigerated meat spreads, and prepared salads. They also should stay aware of Health Canada recalls.
Third, it is not necessary to investigate or treat patients who may have ingested contaminated food but are asymptomatic. Listeriosis can present at 2-3 months after exposure because the incubation period can be as long as 70 days.
Fourth, for patients with mild gastroenteritis or flu-like symptoms who may have ingested contaminated food, obtaining blood cultures or starting a 2-week course of oral amoxicillin (500 mg, three times daily) could be considered.
Fifth, for patients with fever and possible exposure to L monocytogenes, blood cultures should be drawn immediately, and high-dose ampicillin should be initiated, along with electronic fetal heart rate monitoring.
“While choosing safer foods in pregnancy is recommended, it is most important to be aware of Health Canada food recalls and pay attention to symptoms if you’ve ingested these foods,” said Dr. Wong. “Working with the BC Centre for Disease Control, our teams are actively monitoring for cases of listeriosis in pregnancy here in British Columbia.
“Thankfully,” he said, “there haven’t been any confirmed cases in British Columbia related to the plant-based milk recall, though the bacteria’s incubation period can be up to 70 days in pregnancy.”
No Increase Suspected
Commenting on the article, Khady Diouf, MD, director of global obstetrics and gynecology at Brigham and Women’s Hospital in Boston, said, “It summarizes the main management, which is based mostly on expert opinion.”
US clinicians also should be reminded about listeriosis in pregnancy, she noted, pointing to “helpful guidance” from the American College of Obstetrics and Gynecology.
Although the United States similarly experienced a recent listeriosis outbreak resulting from contaminated deli meats, both Dr. Wong and Dr. Diouf said that these outbreaks do not seem to signal an increase in listeriosis cases overall.
“Food-borne listeriosis seems to come in waves,” said Dr. Wong. “At a public health level, we certainly have better surveillance programs for Listeria infections. In 2023, Health Canada updated its Policy on L monocytogenes in ready-to-eat foods, which emphasizes the good manufacturing practices recommended for food processing environments to identify outbreaks earlier.”
“I think we get these recalls yearly, and this has been the case for as long as I can remember,” Dr. Diouf agreed.
No funding was declared, and the authors declared no relevant financial relationships.
A version of this article first appeared on Medscape.com.
Listeriosis during pregnancy, when invasive, can be fatal for the fetus, with a rate of fetal loss or neonatal death of 29%, investigators reported in an article alerting clinicians to this condition.
The article was prompted when the Reproductive Infectious Diseases team at The University of British Columbia in Vancouver, British Columbia, Canada, “received many phone calls from concerned doctors and patients after the plant-based milk recall in early July,” Jeffrey Man Hay Wong, MD, told this news organization. “With such concerns, we updated our British Columbia guidelines for our patients but quickly realized that our recommendations would be useful across the country.”
The article was published online in the Canadian Medical Association Journal.
Five Key Points
Dr. Wong and colleagues provided the following five points and recommendations:
First, invasive listeriosis (bacteremia or meningitis) in pregnancy can have major fetal consequences, including fetal loss or neonatal death in 29% of cases. Affected patients can be asymptomatic or experience gastrointestinal symptoms, myalgias, fevers, acute respiratory distress syndrome, or sepsis.
Second, pregnant people should avoid foods at a high risk for Listeria monocytogenes contamination, including unpasteurized dairy products, luncheon meats, refrigerated meat spreads, and prepared salads. They also should stay aware of Health Canada recalls.
Third, it is not necessary to investigate or treat patients who may have ingested contaminated food but are asymptomatic. Listeriosis can present at 2-3 months after exposure because the incubation period can be as long as 70 days.
Fourth, for patients with mild gastroenteritis or flu-like symptoms who may have ingested contaminated food, obtaining blood cultures or starting a 2-week course of oral amoxicillin (500 mg, three times daily) could be considered.
Fifth, for patients with fever and possible exposure to L monocytogenes, blood cultures should be drawn immediately, and high-dose ampicillin should be initiated, along with electronic fetal heart rate monitoring.
“While choosing safer foods in pregnancy is recommended, it is most important to be aware of Health Canada food recalls and pay attention to symptoms if you’ve ingested these foods,” said Dr. Wong. “Working with the BC Centre for Disease Control, our teams are actively monitoring for cases of listeriosis in pregnancy here in British Columbia.
“Thankfully,” he said, “there haven’t been any confirmed cases in British Columbia related to the plant-based milk recall, though the bacteria’s incubation period can be up to 70 days in pregnancy.”
No Increase Suspected
Commenting on the article, Khady Diouf, MD, director of global obstetrics and gynecology at Brigham and Women’s Hospital in Boston, said, “It summarizes the main management, which is based mostly on expert opinion.”
US clinicians also should be reminded about listeriosis in pregnancy, she noted, pointing to “helpful guidance” from the American College of Obstetrics and Gynecology.
Although the United States similarly experienced a recent listeriosis outbreak resulting from contaminated deli meats, both Dr. Wong and Dr. Diouf said that these outbreaks do not seem to signal an increase in listeriosis cases overall.
“Food-borne listeriosis seems to come in waves,” said Dr. Wong. “At a public health level, we certainly have better surveillance programs for Listeria infections. In 2023, Health Canada updated its Policy on L monocytogenes in ready-to-eat foods, which emphasizes the good manufacturing practices recommended for food processing environments to identify outbreaks earlier.”
“I think we get these recalls yearly, and this has been the case for as long as I can remember,” Dr. Diouf agreed.
No funding was declared, and the authors declared no relevant financial relationships.
A version of this article first appeared on Medscape.com.
FROM THE CANADIAN MEDICAL ASSOCIATION JOURNAL
Hospital to home tracheostomy care
SLEEP MEDICINE NETWORK
Home-Based Mechanical Ventilation and Neuromuscular Section
Technological improvement has enhanced our ability to support these patients with complex conditions in their home settings. However, clinical practice guidelines are lacking, and current practice relies on a consensus of expert opinions.1-3
Once a patient who has had a tracheostomy begins transitioning care to home, identifying caregivers is vital.
Caregivers need to be educated on daily tracheostomy care, airway clearance, and ventilator management.
Protocols to standardize this transition, such as the “Trach Trail” protocol, help reduce ICU readmissions with new tracheostomies (P = .05), eliminate predischarge mortality (P = .05), and may decrease ICU length of stay (P = 0.72).4 Standardized protocols for aspects of tracheostomy care, such as the “Go-Bag” from Boston Children’s Hospital, ensure that a consistent approach keeps providers, families, and patients familiar with their equipment and safety procedures, improving outcomes and decreasing tracheostomy-related adverse events.4-6
Understanding the landscape surrounding which equipment companies have trained field respiratory therapists is crucial. Airway clearance is key to improving ventilation and oxygenation and maintaining tracheostomy patency. Knowing the types of airway clearance modalities used for each patient remains critical.
Trach care may look substantially different for some populations, like patients in the neonatal ICU. Trach changes may happen more frequently. Speaking valve times may be gradually increased while planning for possible decannulation. Skin care involving granulation tissue and stoma complications is particularly important for this population. Active infants need well-fitting trach ties to balance enough support to maintain their trach without causing skin breakdown or discomfort. Securing the trach to prevent pulling or dislodgement as infants become more active is crucial as developmental milestones are achieved.
We hope national societies prioritize standardizing care for this vulnerable population while promoting additional high-quality, patient-centered outcomes in research studies. Implementation strategies to promote interprofessional teams to enhance education, communication, and outcomes will reduce health care disparities.
References
1. Am J Respir Crit Care Med Vol 161. pp Sherman JM, Davis S, Albamonte-Petrick S, et al. Care of the child with a chronic tracheostomy. This official statement of the American Thoracic Society was adopted by the ATS Board of Directors, July 1999. Am J Respir Crit Care Med. 2000;161(1):297-308. doi: 10.1164/ajrccm.161.1.ats1-00 297-308, 2000
2. Mitchell RB, Hussey HM, Setzen G, et al. Clinical consensus statement: tracheostomy care. Otolaryngol Head Neck Surg. 2013;148(1):6-20. Preprint. Posted online September 18, 2012. PMID: 22990518. doi: 10.1177/0194599812460376
3. Sterni LM, Collaco JM, Baker CD, et al; ATS Pediatric Chronic Home Ventilation Workgroup. An official American Thoracic Society clinical practice guideline: pediatric chronic home invasive ventilation. Am J Respir Crit Care Med. 2016;193(8):e16-35. PMID: 27082538; PMCID: PMC5439679. doi: 10.1164/rccm.201602-0276ST
4. Cherney RL, Pandian V, Ninan A, et al. The Trach Trail: a systems-based pathway to improve quality of tracheostomy care and interdisciplinary collaboration. Otolaryngol Head Neck Surg. 2020;163(2):232-243. doi: 10.1177/0194599820917427
5. Brown J. Tracheostomy to noninvasive ventilation: from acute care to home. Sleep Med Clin. 2020;15(4):593-598. doi: 10.1016/j.jsmc.2020.08.003
6. Kohn J, McKeon M, Munhall D, Blanchette S, Wells S, Watters K. Standardization of pediatric tracheostomy care with “Go-bags.” Int J Pediatr Otorhinolaryngol. 2019;121:154-156. doi: 10.1016/j.ijporl.2019.03.022
SLEEP MEDICINE NETWORK
Home-Based Mechanical Ventilation and Neuromuscular Section
Technological improvement has enhanced our ability to support these patients with complex conditions in their home settings. However, clinical practice guidelines are lacking, and current practice relies on a consensus of expert opinions.1-3
Once a patient who has had a tracheostomy begins transitioning care to home, identifying caregivers is vital.
Caregivers need to be educated on daily tracheostomy care, airway clearance, and ventilator management.
Protocols to standardize this transition, such as the “Trach Trail” protocol, help reduce ICU readmissions with new tracheostomies (P = .05), eliminate predischarge mortality (P = .05), and may decrease ICU length of stay (P = 0.72).4 Standardized protocols for aspects of tracheostomy care, such as the “Go-Bag” from Boston Children’s Hospital, ensure that a consistent approach keeps providers, families, and patients familiar with their equipment and safety procedures, improving outcomes and decreasing tracheostomy-related adverse events.4-6
Understanding the landscape surrounding which equipment companies have trained field respiratory therapists is crucial. Airway clearance is key to improving ventilation and oxygenation and maintaining tracheostomy patency. Knowing the types of airway clearance modalities used for each patient remains critical.
Trach care may look substantially different for some populations, like patients in the neonatal ICU. Trach changes may happen more frequently. Speaking valve times may be gradually increased while planning for possible decannulation. Skin care involving granulation tissue and stoma complications is particularly important for this population. Active infants need well-fitting trach ties to balance enough support to maintain their trach without causing skin breakdown or discomfort. Securing the trach to prevent pulling or dislodgement as infants become more active is crucial as developmental milestones are achieved.
We hope national societies prioritize standardizing care for this vulnerable population while promoting additional high-quality, patient-centered outcomes in research studies. Implementation strategies to promote interprofessional teams to enhance education, communication, and outcomes will reduce health care disparities.
References
1. Am J Respir Crit Care Med Vol 161. pp Sherman JM, Davis S, Albamonte-Petrick S, et al. Care of the child with a chronic tracheostomy. This official statement of the American Thoracic Society was adopted by the ATS Board of Directors, July 1999. Am J Respir Crit Care Med. 2000;161(1):297-308. doi: 10.1164/ajrccm.161.1.ats1-00 297-308, 2000
2. Mitchell RB, Hussey HM, Setzen G, et al. Clinical consensus statement: tracheostomy care. Otolaryngol Head Neck Surg. 2013;148(1):6-20. Preprint. Posted online September 18, 2012. PMID: 22990518. doi: 10.1177/0194599812460376
3. Sterni LM, Collaco JM, Baker CD, et al; ATS Pediatric Chronic Home Ventilation Workgroup. An official American Thoracic Society clinical practice guideline: pediatric chronic home invasive ventilation. Am J Respir Crit Care Med. 2016;193(8):e16-35. PMID: 27082538; PMCID: PMC5439679. doi: 10.1164/rccm.201602-0276ST
4. Cherney RL, Pandian V, Ninan A, et al. The Trach Trail: a systems-based pathway to improve quality of tracheostomy care and interdisciplinary collaboration. Otolaryngol Head Neck Surg. 2020;163(2):232-243. doi: 10.1177/0194599820917427
5. Brown J. Tracheostomy to noninvasive ventilation: from acute care to home. Sleep Med Clin. 2020;15(4):593-598. doi: 10.1016/j.jsmc.2020.08.003
6. Kohn J, McKeon M, Munhall D, Blanchette S, Wells S, Watters K. Standardization of pediatric tracheostomy care with “Go-bags.” Int J Pediatr Otorhinolaryngol. 2019;121:154-156. doi: 10.1016/j.ijporl.2019.03.022
SLEEP MEDICINE NETWORK
Home-Based Mechanical Ventilation and Neuromuscular Section
Technological improvement has enhanced our ability to support these patients with complex conditions in their home settings. However, clinical practice guidelines are lacking, and current practice relies on a consensus of expert opinions.1-3
Once a patient who has had a tracheostomy begins transitioning care to home, identifying caregivers is vital.
Caregivers need to be educated on daily tracheostomy care, airway clearance, and ventilator management.
Protocols to standardize this transition, such as the “Trach Trail” protocol, help reduce ICU readmissions with new tracheostomies (P = .05), eliminate predischarge mortality (P = .05), and may decrease ICU length of stay (P = 0.72).4 Standardized protocols for aspects of tracheostomy care, such as the “Go-Bag” from Boston Children’s Hospital, ensure that a consistent approach keeps providers, families, and patients familiar with their equipment and safety procedures, improving outcomes and decreasing tracheostomy-related adverse events.4-6
Understanding the landscape surrounding which equipment companies have trained field respiratory therapists is crucial. Airway clearance is key to improving ventilation and oxygenation and maintaining tracheostomy patency. Knowing the types of airway clearance modalities used for each patient remains critical.
Trach care may look substantially different for some populations, like patients in the neonatal ICU. Trach changes may happen more frequently. Speaking valve times may be gradually increased while planning for possible decannulation. Skin care involving granulation tissue and stoma complications is particularly important for this population. Active infants need well-fitting trach ties to balance enough support to maintain their trach without causing skin breakdown or discomfort. Securing the trach to prevent pulling or dislodgement as infants become more active is crucial as developmental milestones are achieved.
We hope national societies prioritize standardizing care for this vulnerable population while promoting additional high-quality, patient-centered outcomes in research studies. Implementation strategies to promote interprofessional teams to enhance education, communication, and outcomes will reduce health care disparities.
References
1. Am J Respir Crit Care Med Vol 161. pp Sherman JM, Davis S, Albamonte-Petrick S, et al. Care of the child with a chronic tracheostomy. This official statement of the American Thoracic Society was adopted by the ATS Board of Directors, July 1999. Am J Respir Crit Care Med. 2000;161(1):297-308. doi: 10.1164/ajrccm.161.1.ats1-00 297-308, 2000
2. Mitchell RB, Hussey HM, Setzen G, et al. Clinical consensus statement: tracheostomy care. Otolaryngol Head Neck Surg. 2013;148(1):6-20. Preprint. Posted online September 18, 2012. PMID: 22990518. doi: 10.1177/0194599812460376
3. Sterni LM, Collaco JM, Baker CD, et al; ATS Pediatric Chronic Home Ventilation Workgroup. An official American Thoracic Society clinical practice guideline: pediatric chronic home invasive ventilation. Am J Respir Crit Care Med. 2016;193(8):e16-35. PMID: 27082538; PMCID: PMC5439679. doi: 10.1164/rccm.201602-0276ST
4. Cherney RL, Pandian V, Ninan A, et al. The Trach Trail: a systems-based pathway to improve quality of tracheostomy care and interdisciplinary collaboration. Otolaryngol Head Neck Surg. 2020;163(2):232-243. doi: 10.1177/0194599820917427
5. Brown J. Tracheostomy to noninvasive ventilation: from acute care to home. Sleep Med Clin. 2020;15(4):593-598. doi: 10.1016/j.jsmc.2020.08.003
6. Kohn J, McKeon M, Munhall D, Blanchette S, Wells S, Watters K. Standardization of pediatric tracheostomy care with “Go-bags.” Int J Pediatr Otorhinolaryngol. 2019;121:154-156. doi: 10.1016/j.ijporl.2019.03.022
HALT early recognition is key
DIFFUSE LUNG DISEASE AND LUNG TRANSPLANT NETWORK
Lung Transplant Section
Hyperammonemia after lung transplantation (HALT) is a rare but serious complication occurring in 1% to 4% of patients with high morbidity and mortality. Early recognition is crucial, as mortality rates can reach 75%.1
HALT arises from excess ammonia production or decreased clearance and is often linked to infections by urea-splitting organisms, including mycoplasma and ureaplasma. Prompt, aggressive treatment is essential and typically includes dietary protein restriction, renal replacement therapy (ideally intermittent hemodialysis), bowel decontamination (lactulose, rifaximin, metronidazole, or neomycin), amino acids (arginine and levocarnitine), nitrogen scavengers (sodium phenylbutyrate or glycerol phenylbutyrate), and empiric antimicrobial coverage for urea-splitting organisms.2 Given concerns for calcineurin inhibitor-induced hyperammonemia, transition to an alternative agent may be considered.
Given the severe risks associated with HALT, vigilance is vital, particularly in intubated and sedated patients where monitoring of neurologic status is more challenging. Protocols may involve routine serum ammonia monitoring, polymerase chain reaction testing for mycoplasma and ureaplasma at the time of transplant or with postoperative bronchoscopy, and empiric antimicrobial treatment. No definitive ammonia threshold exists, but altered sensorium with elevated levels warrants immediate and more aggressive treatment with levels >75 μmol/L. Early testing and symptom recognition can significantly improve survival rates in this potentially devastating condition.
References
1. Leger RF, Silverman MS, Hauck ES, Guvakova KD. Hyperammonemia post lung transplantation: a review. Clin Med Insights Circ Respir Pulm Med. 2020;14:1179548420966234. doi:10.1177/1179548420966234
2. Chen C, Bain KB, Luppa JA. Hyperammonemia syndrome after lung transplantation: a single center experience. Transplantation. 2016;100(3):678-684. doi:10.1097/TP.0000000000000868
DIFFUSE LUNG DISEASE AND LUNG TRANSPLANT NETWORK
Lung Transplant Section
Hyperammonemia after lung transplantation (HALT) is a rare but serious complication occurring in 1% to 4% of patients with high morbidity and mortality. Early recognition is crucial, as mortality rates can reach 75%.1
HALT arises from excess ammonia production or decreased clearance and is often linked to infections by urea-splitting organisms, including mycoplasma and ureaplasma. Prompt, aggressive treatment is essential and typically includes dietary protein restriction, renal replacement therapy (ideally intermittent hemodialysis), bowel decontamination (lactulose, rifaximin, metronidazole, or neomycin), amino acids (arginine and levocarnitine), nitrogen scavengers (sodium phenylbutyrate or glycerol phenylbutyrate), and empiric antimicrobial coverage for urea-splitting organisms.2 Given concerns for calcineurin inhibitor-induced hyperammonemia, transition to an alternative agent may be considered.
Given the severe risks associated with HALT, vigilance is vital, particularly in intubated and sedated patients where monitoring of neurologic status is more challenging. Protocols may involve routine serum ammonia monitoring, polymerase chain reaction testing for mycoplasma and ureaplasma at the time of transplant or with postoperative bronchoscopy, and empiric antimicrobial treatment. No definitive ammonia threshold exists, but altered sensorium with elevated levels warrants immediate and more aggressive treatment with levels >75 μmol/L. Early testing and symptom recognition can significantly improve survival rates in this potentially devastating condition.
References
1. Leger RF, Silverman MS, Hauck ES, Guvakova KD. Hyperammonemia post lung transplantation: a review. Clin Med Insights Circ Respir Pulm Med. 2020;14:1179548420966234. doi:10.1177/1179548420966234
2. Chen C, Bain KB, Luppa JA. Hyperammonemia syndrome after lung transplantation: a single center experience. Transplantation. 2016;100(3):678-684. doi:10.1097/TP.0000000000000868
DIFFUSE LUNG DISEASE AND LUNG TRANSPLANT NETWORK
Lung Transplant Section
Hyperammonemia after lung transplantation (HALT) is a rare but serious complication occurring in 1% to 4% of patients with high morbidity and mortality. Early recognition is crucial, as mortality rates can reach 75%.1
HALT arises from excess ammonia production or decreased clearance and is often linked to infections by urea-splitting organisms, including mycoplasma and ureaplasma. Prompt, aggressive treatment is essential and typically includes dietary protein restriction, renal replacement therapy (ideally intermittent hemodialysis), bowel decontamination (lactulose, rifaximin, metronidazole, or neomycin), amino acids (arginine and levocarnitine), nitrogen scavengers (sodium phenylbutyrate or glycerol phenylbutyrate), and empiric antimicrobial coverage for urea-splitting organisms.2 Given concerns for calcineurin inhibitor-induced hyperammonemia, transition to an alternative agent may be considered.
Given the severe risks associated with HALT, vigilance is vital, particularly in intubated and sedated patients where monitoring of neurologic status is more challenging. Protocols may involve routine serum ammonia monitoring, polymerase chain reaction testing for mycoplasma and ureaplasma at the time of transplant or with postoperative bronchoscopy, and empiric antimicrobial treatment. No definitive ammonia threshold exists, but altered sensorium with elevated levels warrants immediate and more aggressive treatment with levels >75 μmol/L. Early testing and symptom recognition can significantly improve survival rates in this potentially devastating condition.
References
1. Leger RF, Silverman MS, Hauck ES, Guvakova KD. Hyperammonemia post lung transplantation: a review. Clin Med Insights Circ Respir Pulm Med. 2020;14:1179548420966234. doi:10.1177/1179548420966234
2. Chen C, Bain KB, Luppa JA. Hyperammonemia syndrome after lung transplantation: a single center experience. Transplantation. 2016;100(3):678-684. doi:10.1097/TP.0000000000000868
SURMOUNT-OSA Results: ‘Impressive’ in Improving Sleep Apnea
This transcript has been edited for clarity.
Akshay B. Jain, MD: Welcome. I’m Dr. Akshay Jain, an endocrinologist in Vancouver, Canada, and with me is a very special guest. Today we have Dr. James Kim, a primary care physician working in Calgary, Canada. Both Dr. Kim and I were fortunate to attend the recently concluded American Diabetes Association annual conference in Orlando in June.
We thought we could share with you some of the key learnings that we found very insightful and clinically quite relevant. We were hoping to bring our own conclusion regarding what these findings were, both from a primary care perspective and an endocrinology perspective.
There were so many different studies that, frankly, it was difficult to pick them, but we handpicked a few studies we felt we could do a bit of a deeper dive on, and we’ll talk about each of these studies.
Welcome, Dr. Kim, and thanks for joining us.
James W. Kim, MBBCh, PgDip, MScCH: Thank you so much, Dr Jain. It’s a pleasure to be here.
Dr. Jain: Probably the best place to start would be with the SURMOUNT-OSA study. This was highlighted at the American Diabetes Association conference. Essentially, it looked at people who are living with obesity who also had obstructive sleep apnea.
This was a randomized controlled trial where individuals tested either got tirzepatide (trade name, Mounjaro) or placebo treatment. They looked at the change in their apnea-hypopnea index at the end of the study.
This included both people who were using CPAP machines and those who were not using CPAP machines at baseline. We do know that many individuals with sleep apnea may not use these machines.
That was a big reduction.
Dr. Kim, what’s the relevance of this study in primary care?
Dr. Kim: Oh, it’s massive. Obstructive sleep apnea is probably one of the most underdiagnosed yet huge cardiac risk factors that we tend to overlook in primary care. We sometimes say, oh, it’s just sleep apnea; what’s the big deal? We know it’s a big problem. We know that more than 50% of people with type 2 diabetes have obstructive sleep apnea, and some studies have even quoted that 90% of their population cohorts had sleep apnea. This is a big deal.
What do we know so far? We know that obstructive sleep apnea, which I’m just going to call OSA, increases the risk for hypertension, bad cholesterol, and worsening blood glucose in terms of A1c and fasting glucose, which eventually leads to myocardial infarction, arrhythmia, stroke, and eventually cardiovascular death.
We also know that people with type 2 diabetes have an increased risk for OSA. There seems to be a bidirectional relationship between diabetes and OSA. It seems like weight plays the biggest role in terms of developing OSA, and numerous studies have shown this.
Also, thankfully, some of the studies showed that weight loss improves not just OSA but also blood pressure, cholesterol, blood glucose, and insulin sensitivities. These have been fascinating. We see these patients every single day. If you think about it in your population, for 50%-90% of the patients to have OSA is a large number. If you haven’t seen a person with OSA this week, you probably missed them, very likely.
Therefore, the SURMOUNT-OSA trial was quite fascinating with, as you mentioned, 50%-60% reduction in the severity of OSA, which is very impressive. Even more impressive, I think, is that for about 50% of the patients on tirzepatide, the OSA improves so much that they may not even need to be on CPAP machines.
Those who were on CPAP may not need to be on CPAP any longer. These are huge data, especially for primary care, because as you mentioned, we see these people every single day.
Dr. Jain: Thanks for pointing that out. Clearly, it’s very clinically relevant. I think the most important takeaway for me from this study was the correlation between weight loss and AHI improvement.
Clearly, it showed that placebo had about a 6% drop in AHI, whereas there was a 60% drop in the tirzepatide group, so you can see that it’s significantly different. The placebo group did not have any significant degree of weight loss, whereas the tirzepatide group had nearly 20% weight loss. This again goes to show that there is a very close correlation between weight loss and improvement in OSA.
What’s very important to note is that we’ve seen this in the past as well. We had seen some of these data with other GLP-1 agents, but the extent of improvement that we have seen in the SURMOUNT-OSA trial is significantly more than what we’ve seen in previous studies. There is a ray of hope now where we have medical management to offer people who are living with obesity and obstructive sleep apnea.
Dr. Kim: I want to add that, from a primary care perspective, this study also showed the improvement of the sleep apnea–related symptoms as well. The biggest problem with sleep apnea — or at least what patients’ spouses complain of, is the person snoring too much; it’s a symptom.
It’s the next-day symptoms that really do disturb people, like chronic fatigue. I have numerous patients who say that, once they’ve been treated for sleep apnea, they feel like a brand-new person. They have sudden bursts of energy that they never felt before, and over 50% of these people have huge improvements in the symptoms as well.
This is a huge trial. The only thing that I wish this study included were people with mild obstructive sleep apnea who were symptomatic. I do understand that, with other studies in this population, the data have been conflicting, but it would have been really awesome if they had those patients included. However, it is still a significant study for primary care.
Dr. Jain: That’s a really good point. Fatigue improves and overall quality of life improves. That’s very important from a primary care perspective.
From an endocrinology perspective, we know that management of sleep apnea can often lead to improvement in male hypogonadism, polycystic ovary syndrome, and insulin resistance. The amount of insulin required, or the number of medications needed for managing diabetes, can improve. Hypertension can improve as well. There are multiple benefits that you can get from appropriate management of sleep apnea.
Thanks, Dr. Kim. We really appreciate your insights on SURMOUNT-OSA.
Dr. Jain is a clinical instructor, Department of Endocrinology, University of British Columbia, Vancouver. Dr. Kim is a clinical assistant professor, Department of Family Medicine, University of Calgary in Alberta. Both disclosed conflicts of interest with numerous pharmaceutical companies.
A version of this article appeared on Medscape.com.
This transcript has been edited for clarity.
Akshay B. Jain, MD: Welcome. I’m Dr. Akshay Jain, an endocrinologist in Vancouver, Canada, and with me is a very special guest. Today we have Dr. James Kim, a primary care physician working in Calgary, Canada. Both Dr. Kim and I were fortunate to attend the recently concluded American Diabetes Association annual conference in Orlando in June.
We thought we could share with you some of the key learnings that we found very insightful and clinically quite relevant. We were hoping to bring our own conclusion regarding what these findings were, both from a primary care perspective and an endocrinology perspective.
There were so many different studies that, frankly, it was difficult to pick them, but we handpicked a few studies we felt we could do a bit of a deeper dive on, and we’ll talk about each of these studies.
Welcome, Dr. Kim, and thanks for joining us.
James W. Kim, MBBCh, PgDip, MScCH: Thank you so much, Dr Jain. It’s a pleasure to be here.
Dr. Jain: Probably the best place to start would be with the SURMOUNT-OSA study. This was highlighted at the American Diabetes Association conference. Essentially, it looked at people who are living with obesity who also had obstructive sleep apnea.
This was a randomized controlled trial where individuals tested either got tirzepatide (trade name, Mounjaro) or placebo treatment. They looked at the change in their apnea-hypopnea index at the end of the study.
This included both people who were using CPAP machines and those who were not using CPAP machines at baseline. We do know that many individuals with sleep apnea may not use these machines.
That was a big reduction.
Dr. Kim, what’s the relevance of this study in primary care?
Dr. Kim: Oh, it’s massive. Obstructive sleep apnea is probably one of the most underdiagnosed yet huge cardiac risk factors that we tend to overlook in primary care. We sometimes say, oh, it’s just sleep apnea; what’s the big deal? We know it’s a big problem. We know that more than 50% of people with type 2 diabetes have obstructive sleep apnea, and some studies have even quoted that 90% of their population cohorts had sleep apnea. This is a big deal.
What do we know so far? We know that obstructive sleep apnea, which I’m just going to call OSA, increases the risk for hypertension, bad cholesterol, and worsening blood glucose in terms of A1c and fasting glucose, which eventually leads to myocardial infarction, arrhythmia, stroke, and eventually cardiovascular death.
We also know that people with type 2 diabetes have an increased risk for OSA. There seems to be a bidirectional relationship between diabetes and OSA. It seems like weight plays the biggest role in terms of developing OSA, and numerous studies have shown this.
Also, thankfully, some of the studies showed that weight loss improves not just OSA but also blood pressure, cholesterol, blood glucose, and insulin sensitivities. These have been fascinating. We see these patients every single day. If you think about it in your population, for 50%-90% of the patients to have OSA is a large number. If you haven’t seen a person with OSA this week, you probably missed them, very likely.
Therefore, the SURMOUNT-OSA trial was quite fascinating with, as you mentioned, 50%-60% reduction in the severity of OSA, which is very impressive. Even more impressive, I think, is that for about 50% of the patients on tirzepatide, the OSA improves so much that they may not even need to be on CPAP machines.
Those who were on CPAP may not need to be on CPAP any longer. These are huge data, especially for primary care, because as you mentioned, we see these people every single day.
Dr. Jain: Thanks for pointing that out. Clearly, it’s very clinically relevant. I think the most important takeaway for me from this study was the correlation between weight loss and AHI improvement.
Clearly, it showed that placebo had about a 6% drop in AHI, whereas there was a 60% drop in the tirzepatide group, so you can see that it’s significantly different. The placebo group did not have any significant degree of weight loss, whereas the tirzepatide group had nearly 20% weight loss. This again goes to show that there is a very close correlation between weight loss and improvement in OSA.
What’s very important to note is that we’ve seen this in the past as well. We had seen some of these data with other GLP-1 agents, but the extent of improvement that we have seen in the SURMOUNT-OSA trial is significantly more than what we’ve seen in previous studies. There is a ray of hope now where we have medical management to offer people who are living with obesity and obstructive sleep apnea.
Dr. Kim: I want to add that, from a primary care perspective, this study also showed the improvement of the sleep apnea–related symptoms as well. The biggest problem with sleep apnea — or at least what patients’ spouses complain of, is the person snoring too much; it’s a symptom.
It’s the next-day symptoms that really do disturb people, like chronic fatigue. I have numerous patients who say that, once they’ve been treated for sleep apnea, they feel like a brand-new person. They have sudden bursts of energy that they never felt before, and over 50% of these people have huge improvements in the symptoms as well.
This is a huge trial. The only thing that I wish this study included were people with mild obstructive sleep apnea who were symptomatic. I do understand that, with other studies in this population, the data have been conflicting, but it would have been really awesome if they had those patients included. However, it is still a significant study for primary care.
Dr. Jain: That’s a really good point. Fatigue improves and overall quality of life improves. That’s very important from a primary care perspective.
From an endocrinology perspective, we know that management of sleep apnea can often lead to improvement in male hypogonadism, polycystic ovary syndrome, and insulin resistance. The amount of insulin required, or the number of medications needed for managing diabetes, can improve. Hypertension can improve as well. There are multiple benefits that you can get from appropriate management of sleep apnea.
Thanks, Dr. Kim. We really appreciate your insights on SURMOUNT-OSA.
Dr. Jain is a clinical instructor, Department of Endocrinology, University of British Columbia, Vancouver. Dr. Kim is a clinical assistant professor, Department of Family Medicine, University of Calgary in Alberta. Both disclosed conflicts of interest with numerous pharmaceutical companies.
A version of this article appeared on Medscape.com.
This transcript has been edited for clarity.
Akshay B. Jain, MD: Welcome. I’m Dr. Akshay Jain, an endocrinologist in Vancouver, Canada, and with me is a very special guest. Today we have Dr. James Kim, a primary care physician working in Calgary, Canada. Both Dr. Kim and I were fortunate to attend the recently concluded American Diabetes Association annual conference in Orlando in June.
We thought we could share with you some of the key learnings that we found very insightful and clinically quite relevant. We were hoping to bring our own conclusion regarding what these findings were, both from a primary care perspective and an endocrinology perspective.
There were so many different studies that, frankly, it was difficult to pick them, but we handpicked a few studies we felt we could do a bit of a deeper dive on, and we’ll talk about each of these studies.
Welcome, Dr. Kim, and thanks for joining us.
James W. Kim, MBBCh, PgDip, MScCH: Thank you so much, Dr Jain. It’s a pleasure to be here.
Dr. Jain: Probably the best place to start would be with the SURMOUNT-OSA study. This was highlighted at the American Diabetes Association conference. Essentially, it looked at people who are living with obesity who also had obstructive sleep apnea.
This was a randomized controlled trial where individuals tested either got tirzepatide (trade name, Mounjaro) or placebo treatment. They looked at the change in their apnea-hypopnea index at the end of the study.
This included both people who were using CPAP machines and those who were not using CPAP machines at baseline. We do know that many individuals with sleep apnea may not use these machines.
That was a big reduction.
Dr. Kim, what’s the relevance of this study in primary care?
Dr. Kim: Oh, it’s massive. Obstructive sleep apnea is probably one of the most underdiagnosed yet huge cardiac risk factors that we tend to overlook in primary care. We sometimes say, oh, it’s just sleep apnea; what’s the big deal? We know it’s a big problem. We know that more than 50% of people with type 2 diabetes have obstructive sleep apnea, and some studies have even quoted that 90% of their population cohorts had sleep apnea. This is a big deal.
What do we know so far? We know that obstructive sleep apnea, which I’m just going to call OSA, increases the risk for hypertension, bad cholesterol, and worsening blood glucose in terms of A1c and fasting glucose, which eventually leads to myocardial infarction, arrhythmia, stroke, and eventually cardiovascular death.
We also know that people with type 2 diabetes have an increased risk for OSA. There seems to be a bidirectional relationship between diabetes and OSA. It seems like weight plays the biggest role in terms of developing OSA, and numerous studies have shown this.
Also, thankfully, some of the studies showed that weight loss improves not just OSA but also blood pressure, cholesterol, blood glucose, and insulin sensitivities. These have been fascinating. We see these patients every single day. If you think about it in your population, for 50%-90% of the patients to have OSA is a large number. If you haven’t seen a person with OSA this week, you probably missed them, very likely.
Therefore, the SURMOUNT-OSA trial was quite fascinating with, as you mentioned, 50%-60% reduction in the severity of OSA, which is very impressive. Even more impressive, I think, is that for about 50% of the patients on tirzepatide, the OSA improves so much that they may not even need to be on CPAP machines.
Those who were on CPAP may not need to be on CPAP any longer. These are huge data, especially for primary care, because as you mentioned, we see these people every single day.
Dr. Jain: Thanks for pointing that out. Clearly, it’s very clinically relevant. I think the most important takeaway for me from this study was the correlation between weight loss and AHI improvement.
Clearly, it showed that placebo had about a 6% drop in AHI, whereas there was a 60% drop in the tirzepatide group, so you can see that it’s significantly different. The placebo group did not have any significant degree of weight loss, whereas the tirzepatide group had nearly 20% weight loss. This again goes to show that there is a very close correlation between weight loss and improvement in OSA.
What’s very important to note is that we’ve seen this in the past as well. We had seen some of these data with other GLP-1 agents, but the extent of improvement that we have seen in the SURMOUNT-OSA trial is significantly more than what we’ve seen in previous studies. There is a ray of hope now where we have medical management to offer people who are living with obesity and obstructive sleep apnea.
Dr. Kim: I want to add that, from a primary care perspective, this study also showed the improvement of the sleep apnea–related symptoms as well. The biggest problem with sleep apnea — or at least what patients’ spouses complain of, is the person snoring too much; it’s a symptom.
It’s the next-day symptoms that really do disturb people, like chronic fatigue. I have numerous patients who say that, once they’ve been treated for sleep apnea, they feel like a brand-new person. They have sudden bursts of energy that they never felt before, and over 50% of these people have huge improvements in the symptoms as well.
This is a huge trial. The only thing that I wish this study included were people with mild obstructive sleep apnea who were symptomatic. I do understand that, with other studies in this population, the data have been conflicting, but it would have been really awesome if they had those patients included. However, it is still a significant study for primary care.
Dr. Jain: That’s a really good point. Fatigue improves and overall quality of life improves. That’s very important from a primary care perspective.
From an endocrinology perspective, we know that management of sleep apnea can often lead to improvement in male hypogonadism, polycystic ovary syndrome, and insulin resistance. The amount of insulin required, or the number of medications needed for managing diabetes, can improve. Hypertension can improve as well. There are multiple benefits that you can get from appropriate management of sleep apnea.
Thanks, Dr. Kim. We really appreciate your insights on SURMOUNT-OSA.
Dr. Jain is a clinical instructor, Department of Endocrinology, University of British Columbia, Vancouver. Dr. Kim is a clinical assistant professor, Department of Family Medicine, University of Calgary in Alberta. Both disclosed conflicts of interest with numerous pharmaceutical companies.
A version of this article appeared on Medscape.com.