User login
Shorter H pylori Treatment With Vonoprazan Shows Better Results
PHILADELPHIA — with omeprazole, amoxicillin, and clarithromycin, according to the results of a randomized, multicenter study.
In addition, the triple therapy regimen with vonoprazan was generally better tolerated than the 14-day omeprazole-based regimen.
The new treatment combination was created to tackle the two main reasons that patients with H pylori experience treatment failure: Inadequate acid suppressant activity and antibiotic resistance, said principal investigator Kachonsak Yongwatana, MD, from Phramongkutklao Hospital in Bangkok, Thailand.
“Vonoprazan” is the more potent option for acid suppression, and “levofloxacin” addresses antibiotic resistance, he explained.
Yongwatana presented the findings (Abstract 41) at the American College of Gastroenterology (ACG) 2024 Annual Scientific Meeting. The ACG recently released a clinical guideline on the treatment of H pylori infection.
Robust Eradication Rates
Yongwatana and colleagues enrolled adult patients with H pylori infections at four hospitals in Thailand between December 2022 and September 2023. The presence of H pylori was confirmed by upper gastrointestinal endoscopy with positive rapid urease test or positive test on tissue biopsy.
Patients were then randomized into two treatment groups: The 10-day VAL group (vonoprazan 20 mg twice daily, amoxicillin 1000 mg twice daily, and levofloxacin 500 mg once daily for 10 days) and the 14-day OAC group (omeprazole 20 mg twice daily, amoxicillin 1000 mg twice daily, and clarithromycin 500 mg twice daily for 14 days). Eradication was assessed by urea breath test 4 weeks after completion of treatment.
There were 280 patients in total, with 140 in each group. There were no significant differences in baseline characteristics between the groups. The most common endoscopic findings among all participants included erosive gastritis (38%), nonerosive gastritis (27%), and gastric ulcer (17%).
In comparing the treatments, the researchers found that 10-day VAL led to significantly greater H pylori eradication rate than the 14-day OAC group in both intention-to-treat analysis (91.4 % vs 80.7%, P = .009) and per-protocol analysis (93.4% vs 83.7%, P = .012).
Vonoprazan-based therapy was also well tolerated by participants. Patients in the 10-day VAL group had significantly lower rates of experiencing a bitter taste (2.1% vs 42.9%, P < .001) and bloating (5% vs 12.1%, P = .033) than those in the 14-day OAC group.
Isolating the BMI Effect
The researchers conducted a subgroup analysis on potential factors influencing response, which revealed that having a body mass index (BMI) < 23.5 was significantly associated with a higher chance at successful H pylori eradication (relative risk [RR], 2.27; P = .049).
They then analyzed whether this BMI threshold was predictive in the separate treatment regimens. Although having a BMI < 23.5 was significantly associated with a higher eradication rate in the 14-day OAC group (RR, 3.34; P = .026), no such effect was noted in the 10-day VAL group (RR, 1.10; P = .888).
The influence of BMI could be caused by the bioavailability of the treatments used in the regimen, Younwatana said in an interview. He and his colleagues recommended against using the 14-day OAC regimen in those with BMI ≥ 23.5.
“In patients with a high BMI, we should be concerned that normal proton pump inhibitors may not work,” he said. “You have to step up to the higher-potency options.”
Seeking Confirmation in Other Populations
Session comoderator Felice Schnoll-Sussman, MD, MSc, professor of clinical medicine and the director of the Jay Monahan Center for Gastrointestinal Health, director of the DIGEST program, and the associate chair of medicine for Outreach and Network at New York–Presbyterian Brooklyn Methodist Hospital in New York City, said in an interview that the promising results merit confirmation in other populations.
“When you see a study that is coming out of one country, when there could be issues related to antibiotic sensitivity in H pylori, it really is important to decide whether or not this is applicable to other patient populations,” said Schnoll-Sussman, who was not involved in the study.
She noted that this is also true of the findings from the subgroup as it is unclear whether average rates of BMI are notably lower in Thailand from other countries.
“As we know, BMI affects so many things with disease states. So, it’s a possibility in a country where the BMI is actually lower, there may be something else about these individuals in terms of their wellness status that could be underlying the effect.”
The study had no specific funding, although Takeda supplied treatments used in the analysis. Yongwatana reported no relevant financial relationships. Schnoll-Sussman reported serving as an advisory committee/board member for Braintree, Ethicon, Implantica, and Phathom.
A version of this article first appeared on Medscape.com.
PHILADELPHIA — with omeprazole, amoxicillin, and clarithromycin, according to the results of a randomized, multicenter study.
In addition, the triple therapy regimen with vonoprazan was generally better tolerated than the 14-day omeprazole-based regimen.
The new treatment combination was created to tackle the two main reasons that patients with H pylori experience treatment failure: Inadequate acid suppressant activity and antibiotic resistance, said principal investigator Kachonsak Yongwatana, MD, from Phramongkutklao Hospital in Bangkok, Thailand.
“Vonoprazan” is the more potent option for acid suppression, and “levofloxacin” addresses antibiotic resistance, he explained.
Yongwatana presented the findings (Abstract 41) at the American College of Gastroenterology (ACG) 2024 Annual Scientific Meeting. The ACG recently released a clinical guideline on the treatment of H pylori infection.
Robust Eradication Rates
Yongwatana and colleagues enrolled adult patients with H pylori infections at four hospitals in Thailand between December 2022 and September 2023. The presence of H pylori was confirmed by upper gastrointestinal endoscopy with positive rapid urease test or positive test on tissue biopsy.
Patients were then randomized into two treatment groups: The 10-day VAL group (vonoprazan 20 mg twice daily, amoxicillin 1000 mg twice daily, and levofloxacin 500 mg once daily for 10 days) and the 14-day OAC group (omeprazole 20 mg twice daily, amoxicillin 1000 mg twice daily, and clarithromycin 500 mg twice daily for 14 days). Eradication was assessed by urea breath test 4 weeks after completion of treatment.
There were 280 patients in total, with 140 in each group. There were no significant differences in baseline characteristics between the groups. The most common endoscopic findings among all participants included erosive gastritis (38%), nonerosive gastritis (27%), and gastric ulcer (17%).
In comparing the treatments, the researchers found that 10-day VAL led to significantly greater H pylori eradication rate than the 14-day OAC group in both intention-to-treat analysis (91.4 % vs 80.7%, P = .009) and per-protocol analysis (93.4% vs 83.7%, P = .012).
Vonoprazan-based therapy was also well tolerated by participants. Patients in the 10-day VAL group had significantly lower rates of experiencing a bitter taste (2.1% vs 42.9%, P < .001) and bloating (5% vs 12.1%, P = .033) than those in the 14-day OAC group.
Isolating the BMI Effect
The researchers conducted a subgroup analysis on potential factors influencing response, which revealed that having a body mass index (BMI) < 23.5 was significantly associated with a higher chance at successful H pylori eradication (relative risk [RR], 2.27; P = .049).
They then analyzed whether this BMI threshold was predictive in the separate treatment regimens. Although having a BMI < 23.5 was significantly associated with a higher eradication rate in the 14-day OAC group (RR, 3.34; P = .026), no such effect was noted in the 10-day VAL group (RR, 1.10; P = .888).
The influence of BMI could be caused by the bioavailability of the treatments used in the regimen, Younwatana said in an interview. He and his colleagues recommended against using the 14-day OAC regimen in those with BMI ≥ 23.5.
“In patients with a high BMI, we should be concerned that normal proton pump inhibitors may not work,” he said. “You have to step up to the higher-potency options.”
Seeking Confirmation in Other Populations
Session comoderator Felice Schnoll-Sussman, MD, MSc, professor of clinical medicine and the director of the Jay Monahan Center for Gastrointestinal Health, director of the DIGEST program, and the associate chair of medicine for Outreach and Network at New York–Presbyterian Brooklyn Methodist Hospital in New York City, said in an interview that the promising results merit confirmation in other populations.
“When you see a study that is coming out of one country, when there could be issues related to antibiotic sensitivity in H pylori, it really is important to decide whether or not this is applicable to other patient populations,” said Schnoll-Sussman, who was not involved in the study.
She noted that this is also true of the findings from the subgroup as it is unclear whether average rates of BMI are notably lower in Thailand from other countries.
“As we know, BMI affects so many things with disease states. So, it’s a possibility in a country where the BMI is actually lower, there may be something else about these individuals in terms of their wellness status that could be underlying the effect.”
The study had no specific funding, although Takeda supplied treatments used in the analysis. Yongwatana reported no relevant financial relationships. Schnoll-Sussman reported serving as an advisory committee/board member for Braintree, Ethicon, Implantica, and Phathom.
A version of this article first appeared on Medscape.com.
PHILADELPHIA — with omeprazole, amoxicillin, and clarithromycin, according to the results of a randomized, multicenter study.
In addition, the triple therapy regimen with vonoprazan was generally better tolerated than the 14-day omeprazole-based regimen.
The new treatment combination was created to tackle the two main reasons that patients with H pylori experience treatment failure: Inadequate acid suppressant activity and antibiotic resistance, said principal investigator Kachonsak Yongwatana, MD, from Phramongkutklao Hospital in Bangkok, Thailand.
“Vonoprazan” is the more potent option for acid suppression, and “levofloxacin” addresses antibiotic resistance, he explained.
Yongwatana presented the findings (Abstract 41) at the American College of Gastroenterology (ACG) 2024 Annual Scientific Meeting. The ACG recently released a clinical guideline on the treatment of H pylori infection.
Robust Eradication Rates
Yongwatana and colleagues enrolled adult patients with H pylori infections at four hospitals in Thailand between December 2022 and September 2023. The presence of H pylori was confirmed by upper gastrointestinal endoscopy with positive rapid urease test or positive test on tissue biopsy.
Patients were then randomized into two treatment groups: The 10-day VAL group (vonoprazan 20 mg twice daily, amoxicillin 1000 mg twice daily, and levofloxacin 500 mg once daily for 10 days) and the 14-day OAC group (omeprazole 20 mg twice daily, amoxicillin 1000 mg twice daily, and clarithromycin 500 mg twice daily for 14 days). Eradication was assessed by urea breath test 4 weeks after completion of treatment.
There were 280 patients in total, with 140 in each group. There were no significant differences in baseline characteristics between the groups. The most common endoscopic findings among all participants included erosive gastritis (38%), nonerosive gastritis (27%), and gastric ulcer (17%).
In comparing the treatments, the researchers found that 10-day VAL led to significantly greater H pylori eradication rate than the 14-day OAC group in both intention-to-treat analysis (91.4 % vs 80.7%, P = .009) and per-protocol analysis (93.4% vs 83.7%, P = .012).
Vonoprazan-based therapy was also well tolerated by participants. Patients in the 10-day VAL group had significantly lower rates of experiencing a bitter taste (2.1% vs 42.9%, P < .001) and bloating (5% vs 12.1%, P = .033) than those in the 14-day OAC group.
Isolating the BMI Effect
The researchers conducted a subgroup analysis on potential factors influencing response, which revealed that having a body mass index (BMI) < 23.5 was significantly associated with a higher chance at successful H pylori eradication (relative risk [RR], 2.27; P = .049).
They then analyzed whether this BMI threshold was predictive in the separate treatment regimens. Although having a BMI < 23.5 was significantly associated with a higher eradication rate in the 14-day OAC group (RR, 3.34; P = .026), no such effect was noted in the 10-day VAL group (RR, 1.10; P = .888).
The influence of BMI could be caused by the bioavailability of the treatments used in the regimen, Younwatana said in an interview. He and his colleagues recommended against using the 14-day OAC regimen in those with BMI ≥ 23.5.
“In patients with a high BMI, we should be concerned that normal proton pump inhibitors may not work,” he said. “You have to step up to the higher-potency options.”
Seeking Confirmation in Other Populations
Session comoderator Felice Schnoll-Sussman, MD, MSc, professor of clinical medicine and the director of the Jay Monahan Center for Gastrointestinal Health, director of the DIGEST program, and the associate chair of medicine for Outreach and Network at New York–Presbyterian Brooklyn Methodist Hospital in New York City, said in an interview that the promising results merit confirmation in other populations.
“When you see a study that is coming out of one country, when there could be issues related to antibiotic sensitivity in H pylori, it really is important to decide whether or not this is applicable to other patient populations,” said Schnoll-Sussman, who was not involved in the study.
She noted that this is also true of the findings from the subgroup as it is unclear whether average rates of BMI are notably lower in Thailand from other countries.
“As we know, BMI affects so many things with disease states. So, it’s a possibility in a country where the BMI is actually lower, there may be something else about these individuals in terms of their wellness status that could be underlying the effect.”
The study had no specific funding, although Takeda supplied treatments used in the analysis. Yongwatana reported no relevant financial relationships. Schnoll-Sussman reported serving as an advisory committee/board member for Braintree, Ethicon, Implantica, and Phathom.
A version of this article first appeared on Medscape.com.
FROM ACG 2024
No Link Between PPI Use and Risk for Cardiovascular Events
TOPLINE:
There is no significant association between the use of proton pump inhibitors (PPIs) and risk for cardiovascular events, a meta-analysis shows. However, patients with gastroesophageal reflux disease (GERD) do experience a slight increase in cardiovascular events with PPI use.
METHODOLOGY:
- PPIs are commonly used gastric acid suppressants; however, they have pleiotropic effects, some of which have been hypothesized to augment cardiovascular disorders.
- Researchers conducted a meta-analysis of randomized clinical trials with at least 100 patients and treatment durations > 30 days, which compared groups receiving PPIs to those on placebo or other active treatments.
- The primary outcome was a composite of nonfatal myocardial infarctions, nonfatal strokes, fatal cardiovascular adverse events, coronary revascularizations, and hospitalizations for unstable angina.
TAKEAWAY:
- Researchers included data from 52 placebo-controlled trials, with 14,988 patients and 8323 patients randomized to receive a PPI or placebo, respectively; the mean treatment duration was 0.45 person-years for those treated with PPIs and 0.32 person-years for those treated with placebo.
- Among placebo-controlled trials, 24 were conducted in patients with GERD.
- Researchers also included 61 active-controlled trials that compared PPIs with histamine-2 receptor antagonists (51 trials) or other active treatments.
- The incidence rate ratio for the primary outcome was 0.72 when comparing PPI to placebo, indicating no significant association between PPI and cardiovascular events.
- Among patients with GERD, cardiovascular events occurred only in those treated with PPIs, leading to approximately one excess cardiovascular event per 100 person-years of PPI treatment relative to placebo.
- Researchers found no association between PPI treatment and the risk for cardiovascular events in trials comparing PPIs with other active treatments.
IN PRACTICE:
“We found no association of cardiovascular events with PPI treatment,” the authors wrote. “Cardiovascular events appeared more frequent with PPI treatment in GERD trials, but results from this subgroup should be interpreted with the limitations of the analysis in mind.”
SOURCE:
The study, led by Andrew D. Mosholder, MD, MPH, Division of Epidemiology, US Food and Drug Administration Center for Drug Evaluation and Research, Silver Spring, Maryland, was published online in The American Journal of Gastroenterology.
LIMITATIONS:
This study lacked individual patient data, which precluded a time-to-event analysis or an analysis accounting for patient characteristics such as age or sex. The mean duration of PPI treatment in these trials was a few months, limiting the assessment of cardiovascular risk with extended use. The risk estimates were influenced the most by data on omeprazole and esomeprazole.
DISCLOSURES:
This study did not receive any funding. The authors declared no conflicts of interests.
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:
There is no significant association between the use of proton pump inhibitors (PPIs) and risk for cardiovascular events, a meta-analysis shows. However, patients with gastroesophageal reflux disease (GERD) do experience a slight increase in cardiovascular events with PPI use.
METHODOLOGY:
- PPIs are commonly used gastric acid suppressants; however, they have pleiotropic effects, some of which have been hypothesized to augment cardiovascular disorders.
- Researchers conducted a meta-analysis of randomized clinical trials with at least 100 patients and treatment durations > 30 days, which compared groups receiving PPIs to those on placebo or other active treatments.
- The primary outcome was a composite of nonfatal myocardial infarctions, nonfatal strokes, fatal cardiovascular adverse events, coronary revascularizations, and hospitalizations for unstable angina.
TAKEAWAY:
- Researchers included data from 52 placebo-controlled trials, with 14,988 patients and 8323 patients randomized to receive a PPI or placebo, respectively; the mean treatment duration was 0.45 person-years for those treated with PPIs and 0.32 person-years for those treated with placebo.
- Among placebo-controlled trials, 24 were conducted in patients with GERD.
- Researchers also included 61 active-controlled trials that compared PPIs with histamine-2 receptor antagonists (51 trials) or other active treatments.
- The incidence rate ratio for the primary outcome was 0.72 when comparing PPI to placebo, indicating no significant association between PPI and cardiovascular events.
- Among patients with GERD, cardiovascular events occurred only in those treated with PPIs, leading to approximately one excess cardiovascular event per 100 person-years of PPI treatment relative to placebo.
- Researchers found no association between PPI treatment and the risk for cardiovascular events in trials comparing PPIs with other active treatments.
IN PRACTICE:
“We found no association of cardiovascular events with PPI treatment,” the authors wrote. “Cardiovascular events appeared more frequent with PPI treatment in GERD trials, but results from this subgroup should be interpreted with the limitations of the analysis in mind.”
SOURCE:
The study, led by Andrew D. Mosholder, MD, MPH, Division of Epidemiology, US Food and Drug Administration Center for Drug Evaluation and Research, Silver Spring, Maryland, was published online in The American Journal of Gastroenterology.
LIMITATIONS:
This study lacked individual patient data, which precluded a time-to-event analysis or an analysis accounting for patient characteristics such as age or sex. The mean duration of PPI treatment in these trials was a few months, limiting the assessment of cardiovascular risk with extended use. The risk estimates were influenced the most by data on omeprazole and esomeprazole.
DISCLOSURES:
This study did not receive any funding. The authors declared no conflicts of interests.
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:
There is no significant association between the use of proton pump inhibitors (PPIs) and risk for cardiovascular events, a meta-analysis shows. However, patients with gastroesophageal reflux disease (GERD) do experience a slight increase in cardiovascular events with PPI use.
METHODOLOGY:
- PPIs are commonly used gastric acid suppressants; however, they have pleiotropic effects, some of which have been hypothesized to augment cardiovascular disorders.
- Researchers conducted a meta-analysis of randomized clinical trials with at least 100 patients and treatment durations > 30 days, which compared groups receiving PPIs to those on placebo or other active treatments.
- The primary outcome was a composite of nonfatal myocardial infarctions, nonfatal strokes, fatal cardiovascular adverse events, coronary revascularizations, and hospitalizations for unstable angina.
TAKEAWAY:
- Researchers included data from 52 placebo-controlled trials, with 14,988 patients and 8323 patients randomized to receive a PPI or placebo, respectively; the mean treatment duration was 0.45 person-years for those treated with PPIs and 0.32 person-years for those treated with placebo.
- Among placebo-controlled trials, 24 were conducted in patients with GERD.
- Researchers also included 61 active-controlled trials that compared PPIs with histamine-2 receptor antagonists (51 trials) or other active treatments.
- The incidence rate ratio for the primary outcome was 0.72 when comparing PPI to placebo, indicating no significant association between PPI and cardiovascular events.
- Among patients with GERD, cardiovascular events occurred only in those treated with PPIs, leading to approximately one excess cardiovascular event per 100 person-years of PPI treatment relative to placebo.
- Researchers found no association between PPI treatment and the risk for cardiovascular events in trials comparing PPIs with other active treatments.
IN PRACTICE:
“We found no association of cardiovascular events with PPI treatment,” the authors wrote. “Cardiovascular events appeared more frequent with PPI treatment in GERD trials, but results from this subgroup should be interpreted with the limitations of the analysis in mind.”
SOURCE:
The study, led by Andrew D. Mosholder, MD, MPH, Division of Epidemiology, US Food and Drug Administration Center for Drug Evaluation and Research, Silver Spring, Maryland, was published online in The American Journal of Gastroenterology.
LIMITATIONS:
This study lacked individual patient data, which precluded a time-to-event analysis or an analysis accounting for patient characteristics such as age or sex. The mean duration of PPI treatment in these trials was a few months, limiting the assessment of cardiovascular risk with extended use. The risk estimates were influenced the most by data on omeprazole and esomeprazole.
DISCLOSURES:
This study did not receive any funding. The authors declared no conflicts of interests.
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.
When Your Malpractice Insurer Investigates You: What to Know
When psychiatrist Paul Sartain, MD (not his real name), received a letter from his state’s medical board, he was concerned. A patient’s family complained that he made sexual advances to a young woman he treated for psychotic depression.
“There was absolutely no evidence, and the claims were vague,” he said. “I think the family was angry at me and with the system — the woman had not gotten better.” Sartain reviewed his medical records and then called his malpractice insurer.
The insurer asked about his involvement with the patient’s case, if there was anything credible to the patient’s complaint, and if he had thorough documentation. Then, the carrier offered Sartain his choice of several attorneys who could represent him. The medical board ultimately closed the case with no findings against him, and the patient’s family never sued him.
“If I’m wrongly accused, I’m defended (by the carrier). If I had stolen money or had a sexual relationship with the patient, then you’re acting outside the bounds of what is protected (by the carrier),” he said.
How Medical Board and Malpractice Insurer Investigations Differ
Medical board complaints differ from malpractice claims, in which patients seek damages. The investigation process also varies.
When a patient reports a doctor to a state medical board, they may also sue the doctor for monetary damages in civil court. The medical board responds to patient complaints made directly to them, but it also may also initiate its own investigations. Those can be prompted by a malpractice claim resolution, with a court verdict against the doctor, or a settlement recorded in the National Practitioner Data Bank.
Malpractice insurers may offer limited legal representation for medical board investigations, requiring the doctor to report the medical board issue to them before the doctor takes any action. Often, they will cover up to $50,000 in defense costs but not cover any subsequent medical board fines or required classes or medical board fees.
When a doctor contacts the carrier about a medical board investigation, the carrier may ask for the medical board document and the medical records, said Alex Keoskey, a partner in Frier Levitt’s life sciences group.
The carrier may want to ask about the patient, staff members involved, the doctor’s background, if there have been previous medical board investigations or lawsuits against this doctor, and the doctor’s opinion of the allegations. The doctor should be transparent with the carrier, Keoskey said.
Some carriers conduct more in-depth investigations, examining record-keeping, prescription practices, patient consent processes, and continuing medical education status. That’s because the medical board may inquire about these as well should its own investigation expand.
Not all carriers explore cases like these, even if reimbursing for defense costs, said Karen Frisella, director of professional liability claims at BETA Healthcare Group in California. In her experience, a licensing investigation usually follows a claim resolution that was already worked up by the carrier. If a complaint was made directly to the licensing board without an accompanying liability claim, the carrier’s ability to initiate an investigation on the incident depends on the policy terms or coverage available.
“Typically, a professional liability policy requires that the insured report a claim to trigger coverage. The carrier can’t unilaterally decide to open a claim,” she said. A licensing board investigation is not a claim by definition and therefore does not provide a mechanism for the carrier to open a liability claim file, she added.
If the medical board ultimately restricts the doctor’s license or puts the doctor on probation, that becomes public, and the underwriting department may then look into it.
Malpractice insurers routinely monitor licensing board discipline notices. A reprimand or restrictions on a doctor’s license could trigger a review of the physician’s future insurability and lead to higher premiums or even nonrenewal, Frisella said.
If a carrier investigates a reported claim and determines there are issues with the care rendered, whether there is an accompanying medical board action, that also can affect underwriting decisions, Frisella said.
Who Is Your Attorney Really Working for?
The doctor should understand whose interests the attorney represents. In a medical board claim, the attorney — even if defense is paid by the carrier — represents the doctor.
Frisella said her organization provides pass-through coverage, meaning it reimburses the doctor for medical board defense costs. “Because the carrier isn’t directing the medical board defense, it is not generally privy to the work product.”
If a patient files a malpractice claim, however, the attorney ultimately represents the insurance company.
“The panel counsel who works for the insurer does not work for the doctor, and that’s always important to remember,” Keoskey said. While the attorney will do their best to aggressively defend the doctor, “he’s going to protect the insurer’s interest before the doctor’s.”
Physicians who find any conflict of interest with their insurer should seek counsel.
Such conflicts could include:
- Disagreements over the case’s ultimate worth. For example, a physician might want a case to settle for less than their carrier is willing to pay.
- The legal judgment may exceed the carrier’s policy limits, or there are punitive damages or allegations of criminal acts that the insurer does not cover.
In these cases, the insurance company should recommend the doctor get personal counsel. They will send a reservation of rights letter saying they will defend the doctor for now, but if the facts show the doctor committed some type of misconduct, they may decline coverage, said Keoskey. Some states, including California, require that the carrier pay for this independent counsel.
Unless there is a conflict of interest, though, having a personal attorney just makes the situation more complicated, said Frisella.
A version of this article first appeared on Medscape.com.
When psychiatrist Paul Sartain, MD (not his real name), received a letter from his state’s medical board, he was concerned. A patient’s family complained that he made sexual advances to a young woman he treated for psychotic depression.
“There was absolutely no evidence, and the claims were vague,” he said. “I think the family was angry at me and with the system — the woman had not gotten better.” Sartain reviewed his medical records and then called his malpractice insurer.
The insurer asked about his involvement with the patient’s case, if there was anything credible to the patient’s complaint, and if he had thorough documentation. Then, the carrier offered Sartain his choice of several attorneys who could represent him. The medical board ultimately closed the case with no findings against him, and the patient’s family never sued him.
“If I’m wrongly accused, I’m defended (by the carrier). If I had stolen money or had a sexual relationship with the patient, then you’re acting outside the bounds of what is protected (by the carrier),” he said.
How Medical Board and Malpractice Insurer Investigations Differ
Medical board complaints differ from malpractice claims, in which patients seek damages. The investigation process also varies.
When a patient reports a doctor to a state medical board, they may also sue the doctor for monetary damages in civil court. The medical board responds to patient complaints made directly to them, but it also may also initiate its own investigations. Those can be prompted by a malpractice claim resolution, with a court verdict against the doctor, or a settlement recorded in the National Practitioner Data Bank.
Malpractice insurers may offer limited legal representation for medical board investigations, requiring the doctor to report the medical board issue to them before the doctor takes any action. Often, they will cover up to $50,000 in defense costs but not cover any subsequent medical board fines or required classes or medical board fees.
When a doctor contacts the carrier about a medical board investigation, the carrier may ask for the medical board document and the medical records, said Alex Keoskey, a partner in Frier Levitt’s life sciences group.
The carrier may want to ask about the patient, staff members involved, the doctor’s background, if there have been previous medical board investigations or lawsuits against this doctor, and the doctor’s opinion of the allegations. The doctor should be transparent with the carrier, Keoskey said.
Some carriers conduct more in-depth investigations, examining record-keeping, prescription practices, patient consent processes, and continuing medical education status. That’s because the medical board may inquire about these as well should its own investigation expand.
Not all carriers explore cases like these, even if reimbursing for defense costs, said Karen Frisella, director of professional liability claims at BETA Healthcare Group in California. In her experience, a licensing investigation usually follows a claim resolution that was already worked up by the carrier. If a complaint was made directly to the licensing board without an accompanying liability claim, the carrier’s ability to initiate an investigation on the incident depends on the policy terms or coverage available.
“Typically, a professional liability policy requires that the insured report a claim to trigger coverage. The carrier can’t unilaterally decide to open a claim,” she said. A licensing board investigation is not a claim by definition and therefore does not provide a mechanism for the carrier to open a liability claim file, she added.
If the medical board ultimately restricts the doctor’s license or puts the doctor on probation, that becomes public, and the underwriting department may then look into it.
Malpractice insurers routinely monitor licensing board discipline notices. A reprimand or restrictions on a doctor’s license could trigger a review of the physician’s future insurability and lead to higher premiums or even nonrenewal, Frisella said.
If a carrier investigates a reported claim and determines there are issues with the care rendered, whether there is an accompanying medical board action, that also can affect underwriting decisions, Frisella said.
Who Is Your Attorney Really Working for?
The doctor should understand whose interests the attorney represents. In a medical board claim, the attorney — even if defense is paid by the carrier — represents the doctor.
Frisella said her organization provides pass-through coverage, meaning it reimburses the doctor for medical board defense costs. “Because the carrier isn’t directing the medical board defense, it is not generally privy to the work product.”
If a patient files a malpractice claim, however, the attorney ultimately represents the insurance company.
“The panel counsel who works for the insurer does not work for the doctor, and that’s always important to remember,” Keoskey said. While the attorney will do their best to aggressively defend the doctor, “he’s going to protect the insurer’s interest before the doctor’s.”
Physicians who find any conflict of interest with their insurer should seek counsel.
Such conflicts could include:
- Disagreements over the case’s ultimate worth. For example, a physician might want a case to settle for less than their carrier is willing to pay.
- The legal judgment may exceed the carrier’s policy limits, or there are punitive damages or allegations of criminal acts that the insurer does not cover.
In these cases, the insurance company should recommend the doctor get personal counsel. They will send a reservation of rights letter saying they will defend the doctor for now, but if the facts show the doctor committed some type of misconduct, they may decline coverage, said Keoskey. Some states, including California, require that the carrier pay for this independent counsel.
Unless there is a conflict of interest, though, having a personal attorney just makes the situation more complicated, said Frisella.
A version of this article first appeared on Medscape.com.
When psychiatrist Paul Sartain, MD (not his real name), received a letter from his state’s medical board, he was concerned. A patient’s family complained that he made sexual advances to a young woman he treated for psychotic depression.
“There was absolutely no evidence, and the claims were vague,” he said. “I think the family was angry at me and with the system — the woman had not gotten better.” Sartain reviewed his medical records and then called his malpractice insurer.
The insurer asked about his involvement with the patient’s case, if there was anything credible to the patient’s complaint, and if he had thorough documentation. Then, the carrier offered Sartain his choice of several attorneys who could represent him. The medical board ultimately closed the case with no findings against him, and the patient’s family never sued him.
“If I’m wrongly accused, I’m defended (by the carrier). If I had stolen money or had a sexual relationship with the patient, then you’re acting outside the bounds of what is protected (by the carrier),” he said.
How Medical Board and Malpractice Insurer Investigations Differ
Medical board complaints differ from malpractice claims, in which patients seek damages. The investigation process also varies.
When a patient reports a doctor to a state medical board, they may also sue the doctor for monetary damages in civil court. The medical board responds to patient complaints made directly to them, but it also may also initiate its own investigations. Those can be prompted by a malpractice claim resolution, with a court verdict against the doctor, or a settlement recorded in the National Practitioner Data Bank.
Malpractice insurers may offer limited legal representation for medical board investigations, requiring the doctor to report the medical board issue to them before the doctor takes any action. Often, they will cover up to $50,000 in defense costs but not cover any subsequent medical board fines or required classes or medical board fees.
When a doctor contacts the carrier about a medical board investigation, the carrier may ask for the medical board document and the medical records, said Alex Keoskey, a partner in Frier Levitt’s life sciences group.
The carrier may want to ask about the patient, staff members involved, the doctor’s background, if there have been previous medical board investigations or lawsuits against this doctor, and the doctor’s opinion of the allegations. The doctor should be transparent with the carrier, Keoskey said.
Some carriers conduct more in-depth investigations, examining record-keeping, prescription practices, patient consent processes, and continuing medical education status. That’s because the medical board may inquire about these as well should its own investigation expand.
Not all carriers explore cases like these, even if reimbursing for defense costs, said Karen Frisella, director of professional liability claims at BETA Healthcare Group in California. In her experience, a licensing investigation usually follows a claim resolution that was already worked up by the carrier. If a complaint was made directly to the licensing board without an accompanying liability claim, the carrier’s ability to initiate an investigation on the incident depends on the policy terms or coverage available.
“Typically, a professional liability policy requires that the insured report a claim to trigger coverage. The carrier can’t unilaterally decide to open a claim,” she said. A licensing board investigation is not a claim by definition and therefore does not provide a mechanism for the carrier to open a liability claim file, she added.
If the medical board ultimately restricts the doctor’s license or puts the doctor on probation, that becomes public, and the underwriting department may then look into it.
Malpractice insurers routinely monitor licensing board discipline notices. A reprimand or restrictions on a doctor’s license could trigger a review of the physician’s future insurability and lead to higher premiums or even nonrenewal, Frisella said.
If a carrier investigates a reported claim and determines there are issues with the care rendered, whether there is an accompanying medical board action, that also can affect underwriting decisions, Frisella said.
Who Is Your Attorney Really Working for?
The doctor should understand whose interests the attorney represents. In a medical board claim, the attorney — even if defense is paid by the carrier — represents the doctor.
Frisella said her organization provides pass-through coverage, meaning it reimburses the doctor for medical board defense costs. “Because the carrier isn’t directing the medical board defense, it is not generally privy to the work product.”
If a patient files a malpractice claim, however, the attorney ultimately represents the insurance company.
“The panel counsel who works for the insurer does not work for the doctor, and that’s always important to remember,” Keoskey said. While the attorney will do their best to aggressively defend the doctor, “he’s going to protect the insurer’s interest before the doctor’s.”
Physicians who find any conflict of interest with their insurer should seek counsel.
Such conflicts could include:
- Disagreements over the case’s ultimate worth. For example, a physician might want a case to settle for less than their carrier is willing to pay.
- The legal judgment may exceed the carrier’s policy limits, or there are punitive damages or allegations of criminal acts that the insurer does not cover.
In these cases, the insurance company should recommend the doctor get personal counsel. They will send a reservation of rights letter saying they will defend the doctor for now, but if the facts show the doctor committed some type of misconduct, they may decline coverage, said Keoskey. Some states, including California, require that the carrier pay for this independent counsel.
Unless there is a conflict of interest, though, having a personal attorney just makes the situation more complicated, said Frisella.
A version of this article first appeared on Medscape.com.
The Rise of Sham Peer Reviews
While a medical peer review occurs once a patient, fellow doctor, or staff member reports that a physician failed to treat a patient up to standards or acted improperly, a “sham peer review” is undertaken for ulterior motives.
They’re typically undertaken due to professional competition or institutional politics rather than to promote quality care or uphold professional standards.
Physicians should be concerned. In a soon-to-be-published Medscape report on peer reviews, 56% of US physicians surveyed expressed higher levels of concern that a peer review could be misused to punish a physician for reasons unrelated to the matter being reviewed.
This is a troublesome issue, and many doctors may not be aware of it or how often it occurs.
“The biggest misconception about sham peer reviews is a denial of how pervasive they are,” said Andy Schlafly, general counsel for the Association of American Physicians and Surgeons (AAPS), which offers a free legal consultation service for physicians facing a sham peer review. “Many hospital administrations are as dangerous to good physicians as street gangs can be in a crime-ridden neighborhood.”
“Physicians should become aware of whether sham peer reviews are prevalent at their hospital and, if so, those physicians should look to practice somewhere else,” Schlafly said in an interview.
Unfortunately, there are limited data on how often this happens. When it does, it can be a career killer, said Lawrence Huntoon, MD, PhD, who has run the AAPS sham peer review hotline for over 20 years.
The physicians at the most risk for a sham peer review tend to be those who work for large hospital systems — as this is one way for hospitals to get rid of the doctors they don’t want to retain on staff, Huntoon said.
“Hospitals want a model whereby every physician on the medical staff is an employee,” Huntoon added. “This gives them complete power and control over these physicians, including the way they practice and how many patients they see per day, which, for some, is 20-50 a day to generate sufficient revenue.”
Complaints are generally filed via incident reporting software.
“The complaint could be that the physician is ‘disruptive,’ which can include facial expression, tone of voice, and body language — for example, ‘I found his facial expression demeaning’ or ‘I found her tone condescending’ — and this can be used to prosecute a doctor,” Huntoon said.
After the complaint is filed, the leaders of a hospital’s peer review committee meet to discuss the incident, followed by a panel of fellow physicians convened to review the matter. Once the date for a meeting is set, the accused doctor is allowed to testify, offer evidence, and have attorney representation.
The entire experience can take a physician by surprise.
“A sham peer review is difficult to prepare for because no physician thinks this is going to happen to them,” said Laurie L. York, a medical law attorney in Austin, Texas.
York added that there may also be a misperception of what is actually happening.
“When a physician becomes aware of an investigation, it initially may look like a regular peer review, and the physician may feel there has been a ‘misunderstanding’ that they can make right by explaining things,” York said. “The window of opportunity to shut down a sham peer review happens quickly. That’s why the physician needs the help of an experienced attorney as early in the process as possible.”
If You’re a Victim of a Sham Peer Review
Be vigilant. The most important thing you should think about when it comes to sham peer reviews is that this can, indeed, happen to you, Huntoon said. “I’ve written articles to help educate physicians about the tactics that are used,” he said. “You need to be educated and read medical staff bylaws to know your rights before something bad happens.”
Stay in your job. No matter what, if you’re under review, do not resign your position, no matter how difficult this may be. “A resignation during a sham peer review triggers an adverse report to the National Practitioner Data Bank [NPDB],” Schlafly said. The NPDB is a flagging system created by Congress to improve healthcare quality and reduce healthcare fraud and abuse. “A resignation also waives the physician’s right to contest the unfair review. In addition, leverage to negotiate a favorable settlement is lost if the physician simply resigns.”
Get a lawyer on board early. This is the only way to protect your rights. “Don’t wait a year to get an attorney involved,” Huntoon said. But this also can’t be any lawyer. It’s critical to find someone who specializes in sham peer reviews, so be sure to ask about their experience in handling peer review matters in hospitals and how knowledgeable they are about databank reporting requirements. “Sometimes, doctors will hire a malpractice attorney with no knowledge of what happens with sham peer reviews, and they may give bad advice,” he said. “Others may hire an employment attorney and that attorney will be up on employment law but has no experience with peer review matters in hospitals.”
Given the seriousness of a sham peer review, following these guidelines can help.
Contact the AAPA right away. There are things that can be done early on like getting a withdrawal of the request for corrective action as well as obtaining a preliminary injunction. Preparing for the fallout that may occur can be just as challenging.
“After this situation, the doctor is damaged goods,” Huntoon said. “What hospital will want to hire damaged goods to be part of their medical staff? Finding employment is going to be challenging and opening your own practice may also be difficult because the insurers have access to data bank reports.”
Ultimately, the best advice Huntoon can offer is to do your best to stay one step ahead of any work issues that could even lead to a sham peer review.
“Try and shield yourself from a sham peer review and be prepared should it happen,” he said. “I’ve seen careers end in the blink of an eye — wrongfully.”
A version of this article first appeared on Medscape.com.
While a medical peer review occurs once a patient, fellow doctor, or staff member reports that a physician failed to treat a patient up to standards or acted improperly, a “sham peer review” is undertaken for ulterior motives.
They’re typically undertaken due to professional competition or institutional politics rather than to promote quality care or uphold professional standards.
Physicians should be concerned. In a soon-to-be-published Medscape report on peer reviews, 56% of US physicians surveyed expressed higher levels of concern that a peer review could be misused to punish a physician for reasons unrelated to the matter being reviewed.
This is a troublesome issue, and many doctors may not be aware of it or how often it occurs.
“The biggest misconception about sham peer reviews is a denial of how pervasive they are,” said Andy Schlafly, general counsel for the Association of American Physicians and Surgeons (AAPS), which offers a free legal consultation service for physicians facing a sham peer review. “Many hospital administrations are as dangerous to good physicians as street gangs can be in a crime-ridden neighborhood.”
“Physicians should become aware of whether sham peer reviews are prevalent at their hospital and, if so, those physicians should look to practice somewhere else,” Schlafly said in an interview.
Unfortunately, there are limited data on how often this happens. When it does, it can be a career killer, said Lawrence Huntoon, MD, PhD, who has run the AAPS sham peer review hotline for over 20 years.
The physicians at the most risk for a sham peer review tend to be those who work for large hospital systems — as this is one way for hospitals to get rid of the doctors they don’t want to retain on staff, Huntoon said.
“Hospitals want a model whereby every physician on the medical staff is an employee,” Huntoon added. “This gives them complete power and control over these physicians, including the way they practice and how many patients they see per day, which, for some, is 20-50 a day to generate sufficient revenue.”
Complaints are generally filed via incident reporting software.
“The complaint could be that the physician is ‘disruptive,’ which can include facial expression, tone of voice, and body language — for example, ‘I found his facial expression demeaning’ or ‘I found her tone condescending’ — and this can be used to prosecute a doctor,” Huntoon said.
After the complaint is filed, the leaders of a hospital’s peer review committee meet to discuss the incident, followed by a panel of fellow physicians convened to review the matter. Once the date for a meeting is set, the accused doctor is allowed to testify, offer evidence, and have attorney representation.
The entire experience can take a physician by surprise.
“A sham peer review is difficult to prepare for because no physician thinks this is going to happen to them,” said Laurie L. York, a medical law attorney in Austin, Texas.
York added that there may also be a misperception of what is actually happening.
“When a physician becomes aware of an investigation, it initially may look like a regular peer review, and the physician may feel there has been a ‘misunderstanding’ that they can make right by explaining things,” York said. “The window of opportunity to shut down a sham peer review happens quickly. That’s why the physician needs the help of an experienced attorney as early in the process as possible.”
If You’re a Victim of a Sham Peer Review
Be vigilant. The most important thing you should think about when it comes to sham peer reviews is that this can, indeed, happen to you, Huntoon said. “I’ve written articles to help educate physicians about the tactics that are used,” he said. “You need to be educated and read medical staff bylaws to know your rights before something bad happens.”
Stay in your job. No matter what, if you’re under review, do not resign your position, no matter how difficult this may be. “A resignation during a sham peer review triggers an adverse report to the National Practitioner Data Bank [NPDB],” Schlafly said. The NPDB is a flagging system created by Congress to improve healthcare quality and reduce healthcare fraud and abuse. “A resignation also waives the physician’s right to contest the unfair review. In addition, leverage to negotiate a favorable settlement is lost if the physician simply resigns.”
Get a lawyer on board early. This is the only way to protect your rights. “Don’t wait a year to get an attorney involved,” Huntoon said. But this also can’t be any lawyer. It’s critical to find someone who specializes in sham peer reviews, so be sure to ask about their experience in handling peer review matters in hospitals and how knowledgeable they are about databank reporting requirements. “Sometimes, doctors will hire a malpractice attorney with no knowledge of what happens with sham peer reviews, and they may give bad advice,” he said. “Others may hire an employment attorney and that attorney will be up on employment law but has no experience with peer review matters in hospitals.”
Given the seriousness of a sham peer review, following these guidelines can help.
Contact the AAPA right away. There are things that can be done early on like getting a withdrawal of the request for corrective action as well as obtaining a preliminary injunction. Preparing for the fallout that may occur can be just as challenging.
“After this situation, the doctor is damaged goods,” Huntoon said. “What hospital will want to hire damaged goods to be part of their medical staff? Finding employment is going to be challenging and opening your own practice may also be difficult because the insurers have access to data bank reports.”
Ultimately, the best advice Huntoon can offer is to do your best to stay one step ahead of any work issues that could even lead to a sham peer review.
“Try and shield yourself from a sham peer review and be prepared should it happen,” he said. “I’ve seen careers end in the blink of an eye — wrongfully.”
A version of this article first appeared on Medscape.com.
While a medical peer review occurs once a patient, fellow doctor, or staff member reports that a physician failed to treat a patient up to standards or acted improperly, a “sham peer review” is undertaken for ulterior motives.
They’re typically undertaken due to professional competition or institutional politics rather than to promote quality care or uphold professional standards.
Physicians should be concerned. In a soon-to-be-published Medscape report on peer reviews, 56% of US physicians surveyed expressed higher levels of concern that a peer review could be misused to punish a physician for reasons unrelated to the matter being reviewed.
This is a troublesome issue, and many doctors may not be aware of it or how often it occurs.
“The biggest misconception about sham peer reviews is a denial of how pervasive they are,” said Andy Schlafly, general counsel for the Association of American Physicians and Surgeons (AAPS), which offers a free legal consultation service for physicians facing a sham peer review. “Many hospital administrations are as dangerous to good physicians as street gangs can be in a crime-ridden neighborhood.”
“Physicians should become aware of whether sham peer reviews are prevalent at their hospital and, if so, those physicians should look to practice somewhere else,” Schlafly said in an interview.
Unfortunately, there are limited data on how often this happens. When it does, it can be a career killer, said Lawrence Huntoon, MD, PhD, who has run the AAPS sham peer review hotline for over 20 years.
The physicians at the most risk for a sham peer review tend to be those who work for large hospital systems — as this is one way for hospitals to get rid of the doctors they don’t want to retain on staff, Huntoon said.
“Hospitals want a model whereby every physician on the medical staff is an employee,” Huntoon added. “This gives them complete power and control over these physicians, including the way they practice and how many patients they see per day, which, for some, is 20-50 a day to generate sufficient revenue.”
Complaints are generally filed via incident reporting software.
“The complaint could be that the physician is ‘disruptive,’ which can include facial expression, tone of voice, and body language — for example, ‘I found his facial expression demeaning’ or ‘I found her tone condescending’ — and this can be used to prosecute a doctor,” Huntoon said.
After the complaint is filed, the leaders of a hospital’s peer review committee meet to discuss the incident, followed by a panel of fellow physicians convened to review the matter. Once the date for a meeting is set, the accused doctor is allowed to testify, offer evidence, and have attorney representation.
The entire experience can take a physician by surprise.
“A sham peer review is difficult to prepare for because no physician thinks this is going to happen to them,” said Laurie L. York, a medical law attorney in Austin, Texas.
York added that there may also be a misperception of what is actually happening.
“When a physician becomes aware of an investigation, it initially may look like a regular peer review, and the physician may feel there has been a ‘misunderstanding’ that they can make right by explaining things,” York said. “The window of opportunity to shut down a sham peer review happens quickly. That’s why the physician needs the help of an experienced attorney as early in the process as possible.”
If You’re a Victim of a Sham Peer Review
Be vigilant. The most important thing you should think about when it comes to sham peer reviews is that this can, indeed, happen to you, Huntoon said. “I’ve written articles to help educate physicians about the tactics that are used,” he said. “You need to be educated and read medical staff bylaws to know your rights before something bad happens.”
Stay in your job. No matter what, if you’re under review, do not resign your position, no matter how difficult this may be. “A resignation during a sham peer review triggers an adverse report to the National Practitioner Data Bank [NPDB],” Schlafly said. The NPDB is a flagging system created by Congress to improve healthcare quality and reduce healthcare fraud and abuse. “A resignation also waives the physician’s right to contest the unfair review. In addition, leverage to negotiate a favorable settlement is lost if the physician simply resigns.”
Get a lawyer on board early. This is the only way to protect your rights. “Don’t wait a year to get an attorney involved,” Huntoon said. But this also can’t be any lawyer. It’s critical to find someone who specializes in sham peer reviews, so be sure to ask about their experience in handling peer review matters in hospitals and how knowledgeable they are about databank reporting requirements. “Sometimes, doctors will hire a malpractice attorney with no knowledge of what happens with sham peer reviews, and they may give bad advice,” he said. “Others may hire an employment attorney and that attorney will be up on employment law but has no experience with peer review matters in hospitals.”
Given the seriousness of a sham peer review, following these guidelines can help.
Contact the AAPA right away. There are things that can be done early on like getting a withdrawal of the request for corrective action as well as obtaining a preliminary injunction. Preparing for the fallout that may occur can be just as challenging.
“After this situation, the doctor is damaged goods,” Huntoon said. “What hospital will want to hire damaged goods to be part of their medical staff? Finding employment is going to be challenging and opening your own practice may also be difficult because the insurers have access to data bank reports.”
Ultimately, the best advice Huntoon can offer is to do your best to stay one step ahead of any work issues that could even lead to a sham peer review.
“Try and shield yourself from a sham peer review and be prepared should it happen,” he said. “I’ve seen careers end in the blink of an eye — wrongfully.”
A version of this article first appeared on Medscape.com.
At Last, a Nasal Epinephrine Spray
This summer, the US Food and Drug Administration (FDA) fast-tracked approval of the first-in-its-class nasal epinephrine (neffy). It’s a very welcome addition to our anaphylaxis treatment armamentarium. In healthy volunteers, neffy achieved similar serum epinephrine levels, rises in blood pressure, and pulse compared with IM epinephrine.
The Need for Neffy
It was just a few days ago that I saw a new patient with fire ant anaphylaxis. The last time he tried to use an injectable epinephrine pen, he made two mistakes. First, he placed the wrong end against his thigh, and when it did not inject, he depressed it with his thumb — in other words, he injected his thumb with epinephrine. Of course, that cannot happen with neffy.
I recall a few years ago, a child experienced anaphylaxis but the parent was hesitant to administer the EAI (epinephrine autoinjector). The parent drove to the emergency room but was delayed by traffic, and by the time they reached the ER, the patient had suffered a respiratory arrest and passed away.
Patients are not the only ones who are hesitant to administer epinephrine. Some clinicians do not treat anaphylaxis appropriately. As an allergist, I see patients after-the-fact for diagnosis and management. Patients often tell me of systemic allergic reactions treated with IV antihistamines/corticosteroids and even sometimes with nebulized beta agonists, but not epinephrine.
My opinion is that it’s not just needle phobia. As I mentioned, in my Medscape commentary “Injectable Epinephrine: An Epidemic of Misuse,” I believe it’s due to a misunderstanding of the guidelines and a sense that epinephrine is a potent medication to be used sparingly. Clinicians and patients must understand that epinephrine is a naturally occurring hormone and administration leads to serum levels seen under other natural circumstances (eg, stress — the fight-or-flight surge). The aforementioned article also includes a patient handout, “Don’t Fear Epinephrine,” which I encourage you to read and distribute.
The potential benefits of neffy are clear:
- It should overcome fear of injection ergo being more likely to be used, and used earlier, by both patient/family member and clinicians.
- It’s easier to carry than many larger devices (though not the AUVI-Q).
- It cannot be injected incorrectly.
- Expiration is 8 months longer than the EAI.
- There are no pharmacist substitutions (as there is no equivalent device).
Potential Problems With Neffy and Some Suggested Solutions
As promising and beneficial as it is, I wonder about a few training issues. In the office, patients can be trained with a (reusable) injectable epinephrine trainer but not with a nasal spray device trainer in the office (an important alternative is a small model of a nose in the office for patient education). A training device should also be included in the neffy prescription, as with the EAI.
Neffy and Patients With Nasal Polyps or Nasal Surgery
It’s more complicated than that neffy cannot be used with patients who have had nasal polyps or nasal surgery. It’s really about how much healthy nasal mucosa is required for absorption. Nasal surgery may be simple or complex. Nasal polyps may be obstructive or resolved with nasal steroid or biologic therapy. Nasal polyps affect 2% of the population, but 35% of pediatric food allergy (FA) patients develop allergic rhinitis (AR), and these AR symptoms present even when not triggered by FA. AR is present at baseline in patients with FA. How does this influence neffy absorption? For FA patients who have anaphylactic reactions with severe nasal reactions, neffy absorption could be further compromised, something that has not been studied.
Insurance Coverage
As we don’t yet know the comparative efficacy of neffy in anaphylactic episodes, it’s likely that patients, especially with more severe food sensitivities, will be prescribed both the nasal and IM devices. The question remains whether insurance will cover both.
In “mild cases,” I suspect that doctors might be more inclined to prescribe neffy.
Conclusion
Delay in epinephrine use is frequent despite the clear indication during anaphylactic episodes, which in turn increases risk for mortality. Neffy will probably save many lives.
Dr. Stadtmauer serves on the advisory board of Medscape. He is in private practice in New York City and is affiliated with the Mount Sinai School of Medicine.
A version of this article first appeared on Medscape.com.
This summer, the US Food and Drug Administration (FDA) fast-tracked approval of the first-in-its-class nasal epinephrine (neffy). It’s a very welcome addition to our anaphylaxis treatment armamentarium. In healthy volunteers, neffy achieved similar serum epinephrine levels, rises in blood pressure, and pulse compared with IM epinephrine.
The Need for Neffy
It was just a few days ago that I saw a new patient with fire ant anaphylaxis. The last time he tried to use an injectable epinephrine pen, he made two mistakes. First, he placed the wrong end against his thigh, and when it did not inject, he depressed it with his thumb — in other words, he injected his thumb with epinephrine. Of course, that cannot happen with neffy.
I recall a few years ago, a child experienced anaphylaxis but the parent was hesitant to administer the EAI (epinephrine autoinjector). The parent drove to the emergency room but was delayed by traffic, and by the time they reached the ER, the patient had suffered a respiratory arrest and passed away.
Patients are not the only ones who are hesitant to administer epinephrine. Some clinicians do not treat anaphylaxis appropriately. As an allergist, I see patients after-the-fact for diagnosis and management. Patients often tell me of systemic allergic reactions treated with IV antihistamines/corticosteroids and even sometimes with nebulized beta agonists, but not epinephrine.
My opinion is that it’s not just needle phobia. As I mentioned, in my Medscape commentary “Injectable Epinephrine: An Epidemic of Misuse,” I believe it’s due to a misunderstanding of the guidelines and a sense that epinephrine is a potent medication to be used sparingly. Clinicians and patients must understand that epinephrine is a naturally occurring hormone and administration leads to serum levels seen under other natural circumstances (eg, stress — the fight-or-flight surge). The aforementioned article also includes a patient handout, “Don’t Fear Epinephrine,” which I encourage you to read and distribute.
The potential benefits of neffy are clear:
- It should overcome fear of injection ergo being more likely to be used, and used earlier, by both patient/family member and clinicians.
- It’s easier to carry than many larger devices (though not the AUVI-Q).
- It cannot be injected incorrectly.
- Expiration is 8 months longer than the EAI.
- There are no pharmacist substitutions (as there is no equivalent device).
Potential Problems With Neffy and Some Suggested Solutions
As promising and beneficial as it is, I wonder about a few training issues. In the office, patients can be trained with a (reusable) injectable epinephrine trainer but not with a nasal spray device trainer in the office (an important alternative is a small model of a nose in the office for patient education). A training device should also be included in the neffy prescription, as with the EAI.
Neffy and Patients With Nasal Polyps or Nasal Surgery
It’s more complicated than that neffy cannot be used with patients who have had nasal polyps or nasal surgery. It’s really about how much healthy nasal mucosa is required for absorption. Nasal surgery may be simple or complex. Nasal polyps may be obstructive or resolved with nasal steroid or biologic therapy. Nasal polyps affect 2% of the population, but 35% of pediatric food allergy (FA) patients develop allergic rhinitis (AR), and these AR symptoms present even when not triggered by FA. AR is present at baseline in patients with FA. How does this influence neffy absorption? For FA patients who have anaphylactic reactions with severe nasal reactions, neffy absorption could be further compromised, something that has not been studied.
Insurance Coverage
As we don’t yet know the comparative efficacy of neffy in anaphylactic episodes, it’s likely that patients, especially with more severe food sensitivities, will be prescribed both the nasal and IM devices. The question remains whether insurance will cover both.
In “mild cases,” I suspect that doctors might be more inclined to prescribe neffy.
Conclusion
Delay in epinephrine use is frequent despite the clear indication during anaphylactic episodes, which in turn increases risk for mortality. Neffy will probably save many lives.
Dr. Stadtmauer serves on the advisory board of Medscape. He is in private practice in New York City and is affiliated with the Mount Sinai School of Medicine.
A version of this article first appeared on Medscape.com.
This summer, the US Food and Drug Administration (FDA) fast-tracked approval of the first-in-its-class nasal epinephrine (neffy). It’s a very welcome addition to our anaphylaxis treatment armamentarium. In healthy volunteers, neffy achieved similar serum epinephrine levels, rises in blood pressure, and pulse compared with IM epinephrine.
The Need for Neffy
It was just a few days ago that I saw a new patient with fire ant anaphylaxis. The last time he tried to use an injectable epinephrine pen, he made two mistakes. First, he placed the wrong end against his thigh, and when it did not inject, he depressed it with his thumb — in other words, he injected his thumb with epinephrine. Of course, that cannot happen with neffy.
I recall a few years ago, a child experienced anaphylaxis but the parent was hesitant to administer the EAI (epinephrine autoinjector). The parent drove to the emergency room but was delayed by traffic, and by the time they reached the ER, the patient had suffered a respiratory arrest and passed away.
Patients are not the only ones who are hesitant to administer epinephrine. Some clinicians do not treat anaphylaxis appropriately. As an allergist, I see patients after-the-fact for diagnosis and management. Patients often tell me of systemic allergic reactions treated with IV antihistamines/corticosteroids and even sometimes with nebulized beta agonists, but not epinephrine.
My opinion is that it’s not just needle phobia. As I mentioned, in my Medscape commentary “Injectable Epinephrine: An Epidemic of Misuse,” I believe it’s due to a misunderstanding of the guidelines and a sense that epinephrine is a potent medication to be used sparingly. Clinicians and patients must understand that epinephrine is a naturally occurring hormone and administration leads to serum levels seen under other natural circumstances (eg, stress — the fight-or-flight surge). The aforementioned article also includes a patient handout, “Don’t Fear Epinephrine,” which I encourage you to read and distribute.
The potential benefits of neffy are clear:
- It should overcome fear of injection ergo being more likely to be used, and used earlier, by both patient/family member and clinicians.
- It’s easier to carry than many larger devices (though not the AUVI-Q).
- It cannot be injected incorrectly.
- Expiration is 8 months longer than the EAI.
- There are no pharmacist substitutions (as there is no equivalent device).
Potential Problems With Neffy and Some Suggested Solutions
As promising and beneficial as it is, I wonder about a few training issues. In the office, patients can be trained with a (reusable) injectable epinephrine trainer but not with a nasal spray device trainer in the office (an important alternative is a small model of a nose in the office for patient education). A training device should also be included in the neffy prescription, as with the EAI.
Neffy and Patients With Nasal Polyps or Nasal Surgery
It’s more complicated than that neffy cannot be used with patients who have had nasal polyps or nasal surgery. It’s really about how much healthy nasal mucosa is required for absorption. Nasal surgery may be simple or complex. Nasal polyps may be obstructive or resolved with nasal steroid or biologic therapy. Nasal polyps affect 2% of the population, but 35% of pediatric food allergy (FA) patients develop allergic rhinitis (AR), and these AR symptoms present even when not triggered by FA. AR is present at baseline in patients with FA. How does this influence neffy absorption? For FA patients who have anaphylactic reactions with severe nasal reactions, neffy absorption could be further compromised, something that has not been studied.
Insurance Coverage
As we don’t yet know the comparative efficacy of neffy in anaphylactic episodes, it’s likely that patients, especially with more severe food sensitivities, will be prescribed both the nasal and IM devices. The question remains whether insurance will cover both.
In “mild cases,” I suspect that doctors might be more inclined to prescribe neffy.
Conclusion
Delay in epinephrine use is frequent despite the clear indication during anaphylactic episodes, which in turn increases risk for mortality. Neffy will probably save many lives.
Dr. Stadtmauer serves on the advisory board of Medscape. He is in private practice in New York City and is affiliated with the Mount Sinai School of Medicine.
A version of this article first appeared on Medscape.com.
On the Road to Care: Travel Nurses Still in Demand
Ashly Doran has worked at seven hospitals in four states since she graduated from nursing school in 2020. No, she isn’t job-hopping. Her travel nursing assignments have ranged from level 1 trauma center emergency rooms in big cities to small medical-surgical units in the suburbs. After each 13-week assignment, Doran packs up her belongings and her cats and moves to a new post.
“Travel nursing is so flexible,” she said. “I decide where I want to go and how much I want to make and start looking for travel contracts in that area.”
Nationwide nursing shortages have forced hospitals to hire travel nurses to fill staffing gaps. During the COVID-19 pandemic, the demand for travel nurses increased by 35%. While there is still a demand for nurses to fill short-term contracts, data show that demand has declined 42% between January and July 2022 and has continued the downward trend.
“What we’re seeing now is a shift…to a pre-pandemic market,” said Rachel Neill, RN, senior clinician advocate at Vivian Health. “Travel [nursing] is not going away — there will always be a need for hospital systems and facilities to fill gaps — but hospitals have shifted more into a traditional ... operational environment.”
Traveling a Different Path
For some registered nurses (RNs), short-term assignments offer opportunities to gain experience in different facilities or explore new locations before settling into permanent positions. Even experienced RNs embrace travel nursing for the flexible schedules and opportunities to take longer breaks between contracts.
Burnout and turnover among nurses are high, and flexible schedules, including controlling when to work, are essential to sustaining a clinical nursing career. In fact, 34% of nurses called travel nursing an “ideal option” for their lifestyle, with 14% viewing it as an option for career progression.
Travel nursing is especially appealing to Millennials and Generation Z, according to Brian Weirich, RN, chief nurse innovation officer at Bon Secours Mercy Health in Cincinnati, Ohio. In fact, the average age of a travel nurse is 35 compared with an average age of 52 for all RNs.
These are generations that are more focused on reducing school loan debt and gaining experience, not 401(k) and health insurance, he said in an interview. Pay is also a factor. The average pay for travel nurses was $2588 per month, compared with $1375 for permanent staff nurses.
During the pandemic, Weirich recalls groups of nurses resigning to take travel assignments together. The RNs picked desirable locations, accepted short-term assignments, and moved together, “making top dollar in locations they wanted to explore with their best friends.”
It’s been more than a decade since Kelly Spurlock traded a permanent nursing role in Lake Placid, Florida, for short-term nursing contracts in intensive care units in 20 states.
Spurlock works with a recruiter at Ingenovis Health to secure new contracts and considers travel assignments “working vacations.” In the process of exploring new places and meeting new people, Spurlock believes that travel nursing allows her to prioritize patient care.
“I can be at the bedside and be an advocate for my patient but also keep out of the spotlight for the political part of what we do,” she explained.
The Road Ahead
The appeal of travel nursing is taking new nursing assignments in different cities and earning higher salaries, but there are downsides, too. Travel nurses often receive fewer benefits than staff nurses and end up with less favorable assignments; their levels of dissatisfaction and burnout are also higher, and their sense of work-life balance is lower than staff nurses.
Most travel contracts last between 4 and 13 weeks. Hospitals often put policies and practices in place that limit the number of back-to-back contracts that traveling nurses can accept, which means that RNs can either convert to core staff or move on to new assignments once their contract term is up.
Weirich noted that some hospitals devote considerable effort to recruiting traveling nurses to full-time roles, adding, “There are active initiatives ... to make it such a good experience that they want to stay.”
On the flip side, contracts can be terminated without notice, leaving traveling nurses scrambling to find a new assignment and a new place to live on short notice.
“You’re there as long as the hospital needs you,” said Neill. “You could sign a 12- or 15-week contract, and their needs change a month in, and ... there are budget cuts, and they can’t pay salaries anymore, so they are laying off their nurses.”
Declining demand for travel nurses has made it harder to line up back-to-back contracts. Despite being available for work, Doran once waited 6 weeks to secure a new assignment and had to live off her savings.
Spurlock believes increased competition and declining wages — pay for travel nurses declined more than 9% from January 2023 to January 2024 — have made travel nursing less attractive.
“There has been such an influx of travel nurses ... because of COVID,” said Spurlock. “The rates have now come down [and] everybody’s fighting for jobs, and ... it’s very difficult to get a job that’s paying decent money.”
Despite the challenges, Spurlock continues learning new things from each assignment and hopes to work as a travel nurse until retirement. Doran has worked at hospitals in Washington, Oregon, California, and Wisconsin and would like to add Montana, Utah, and Nevada to the list. The goal: Continue accepting assignments in different cities and states until she finds the place where she wants to put down roots.
“Nursing is a great job, but it’s a hard job [and] it can take its toll at times,” Neill said. It’s important that nurses know their goals and values to be able to find a good fitting position. “And the beauty of it is that travel can be a great way to explore and add some flexibility.”
A version of this article first appeared on Medscape.com.
Ashly Doran has worked at seven hospitals in four states since she graduated from nursing school in 2020. No, she isn’t job-hopping. Her travel nursing assignments have ranged from level 1 trauma center emergency rooms in big cities to small medical-surgical units in the suburbs. After each 13-week assignment, Doran packs up her belongings and her cats and moves to a new post.
“Travel nursing is so flexible,” she said. “I decide where I want to go and how much I want to make and start looking for travel contracts in that area.”
Nationwide nursing shortages have forced hospitals to hire travel nurses to fill staffing gaps. During the COVID-19 pandemic, the demand for travel nurses increased by 35%. While there is still a demand for nurses to fill short-term contracts, data show that demand has declined 42% between January and July 2022 and has continued the downward trend.
“What we’re seeing now is a shift…to a pre-pandemic market,” said Rachel Neill, RN, senior clinician advocate at Vivian Health. “Travel [nursing] is not going away — there will always be a need for hospital systems and facilities to fill gaps — but hospitals have shifted more into a traditional ... operational environment.”
Traveling a Different Path
For some registered nurses (RNs), short-term assignments offer opportunities to gain experience in different facilities or explore new locations before settling into permanent positions. Even experienced RNs embrace travel nursing for the flexible schedules and opportunities to take longer breaks between contracts.
Burnout and turnover among nurses are high, and flexible schedules, including controlling when to work, are essential to sustaining a clinical nursing career. In fact, 34% of nurses called travel nursing an “ideal option” for their lifestyle, with 14% viewing it as an option for career progression.
Travel nursing is especially appealing to Millennials and Generation Z, according to Brian Weirich, RN, chief nurse innovation officer at Bon Secours Mercy Health in Cincinnati, Ohio. In fact, the average age of a travel nurse is 35 compared with an average age of 52 for all RNs.
These are generations that are more focused on reducing school loan debt and gaining experience, not 401(k) and health insurance, he said in an interview. Pay is also a factor. The average pay for travel nurses was $2588 per month, compared with $1375 for permanent staff nurses.
During the pandemic, Weirich recalls groups of nurses resigning to take travel assignments together. The RNs picked desirable locations, accepted short-term assignments, and moved together, “making top dollar in locations they wanted to explore with their best friends.”
It’s been more than a decade since Kelly Spurlock traded a permanent nursing role in Lake Placid, Florida, for short-term nursing contracts in intensive care units in 20 states.
Spurlock works with a recruiter at Ingenovis Health to secure new contracts and considers travel assignments “working vacations.” In the process of exploring new places and meeting new people, Spurlock believes that travel nursing allows her to prioritize patient care.
“I can be at the bedside and be an advocate for my patient but also keep out of the spotlight for the political part of what we do,” she explained.
The Road Ahead
The appeal of travel nursing is taking new nursing assignments in different cities and earning higher salaries, but there are downsides, too. Travel nurses often receive fewer benefits than staff nurses and end up with less favorable assignments; their levels of dissatisfaction and burnout are also higher, and their sense of work-life balance is lower than staff nurses.
Most travel contracts last between 4 and 13 weeks. Hospitals often put policies and practices in place that limit the number of back-to-back contracts that traveling nurses can accept, which means that RNs can either convert to core staff or move on to new assignments once their contract term is up.
Weirich noted that some hospitals devote considerable effort to recruiting traveling nurses to full-time roles, adding, “There are active initiatives ... to make it such a good experience that they want to stay.”
On the flip side, contracts can be terminated without notice, leaving traveling nurses scrambling to find a new assignment and a new place to live on short notice.
“You’re there as long as the hospital needs you,” said Neill. “You could sign a 12- or 15-week contract, and their needs change a month in, and ... there are budget cuts, and they can’t pay salaries anymore, so they are laying off their nurses.”
Declining demand for travel nurses has made it harder to line up back-to-back contracts. Despite being available for work, Doran once waited 6 weeks to secure a new assignment and had to live off her savings.
Spurlock believes increased competition and declining wages — pay for travel nurses declined more than 9% from January 2023 to January 2024 — have made travel nursing less attractive.
“There has been such an influx of travel nurses ... because of COVID,” said Spurlock. “The rates have now come down [and] everybody’s fighting for jobs, and ... it’s very difficult to get a job that’s paying decent money.”
Despite the challenges, Spurlock continues learning new things from each assignment and hopes to work as a travel nurse until retirement. Doran has worked at hospitals in Washington, Oregon, California, and Wisconsin and would like to add Montana, Utah, and Nevada to the list. The goal: Continue accepting assignments in different cities and states until she finds the place where she wants to put down roots.
“Nursing is a great job, but it’s a hard job [and] it can take its toll at times,” Neill said. It’s important that nurses know their goals and values to be able to find a good fitting position. “And the beauty of it is that travel can be a great way to explore and add some flexibility.”
A version of this article first appeared on Medscape.com.
Ashly Doran has worked at seven hospitals in four states since she graduated from nursing school in 2020. No, she isn’t job-hopping. Her travel nursing assignments have ranged from level 1 trauma center emergency rooms in big cities to small medical-surgical units in the suburbs. After each 13-week assignment, Doran packs up her belongings and her cats and moves to a new post.
“Travel nursing is so flexible,” she said. “I decide where I want to go and how much I want to make and start looking for travel contracts in that area.”
Nationwide nursing shortages have forced hospitals to hire travel nurses to fill staffing gaps. During the COVID-19 pandemic, the demand for travel nurses increased by 35%. While there is still a demand for nurses to fill short-term contracts, data show that demand has declined 42% between January and July 2022 and has continued the downward trend.
“What we’re seeing now is a shift…to a pre-pandemic market,” said Rachel Neill, RN, senior clinician advocate at Vivian Health. “Travel [nursing] is not going away — there will always be a need for hospital systems and facilities to fill gaps — but hospitals have shifted more into a traditional ... operational environment.”
Traveling a Different Path
For some registered nurses (RNs), short-term assignments offer opportunities to gain experience in different facilities or explore new locations before settling into permanent positions. Even experienced RNs embrace travel nursing for the flexible schedules and opportunities to take longer breaks between contracts.
Burnout and turnover among nurses are high, and flexible schedules, including controlling when to work, are essential to sustaining a clinical nursing career. In fact, 34% of nurses called travel nursing an “ideal option” for their lifestyle, with 14% viewing it as an option for career progression.
Travel nursing is especially appealing to Millennials and Generation Z, according to Brian Weirich, RN, chief nurse innovation officer at Bon Secours Mercy Health in Cincinnati, Ohio. In fact, the average age of a travel nurse is 35 compared with an average age of 52 for all RNs.
These are generations that are more focused on reducing school loan debt and gaining experience, not 401(k) and health insurance, he said in an interview. Pay is also a factor. The average pay for travel nurses was $2588 per month, compared with $1375 for permanent staff nurses.
During the pandemic, Weirich recalls groups of nurses resigning to take travel assignments together. The RNs picked desirable locations, accepted short-term assignments, and moved together, “making top dollar in locations they wanted to explore with their best friends.”
It’s been more than a decade since Kelly Spurlock traded a permanent nursing role in Lake Placid, Florida, for short-term nursing contracts in intensive care units in 20 states.
Spurlock works with a recruiter at Ingenovis Health to secure new contracts and considers travel assignments “working vacations.” In the process of exploring new places and meeting new people, Spurlock believes that travel nursing allows her to prioritize patient care.
“I can be at the bedside and be an advocate for my patient but also keep out of the spotlight for the political part of what we do,” she explained.
The Road Ahead
The appeal of travel nursing is taking new nursing assignments in different cities and earning higher salaries, but there are downsides, too. Travel nurses often receive fewer benefits than staff nurses and end up with less favorable assignments; their levels of dissatisfaction and burnout are also higher, and their sense of work-life balance is lower than staff nurses.
Most travel contracts last between 4 and 13 weeks. Hospitals often put policies and practices in place that limit the number of back-to-back contracts that traveling nurses can accept, which means that RNs can either convert to core staff or move on to new assignments once their contract term is up.
Weirich noted that some hospitals devote considerable effort to recruiting traveling nurses to full-time roles, adding, “There are active initiatives ... to make it such a good experience that they want to stay.”
On the flip side, contracts can be terminated without notice, leaving traveling nurses scrambling to find a new assignment and a new place to live on short notice.
“You’re there as long as the hospital needs you,” said Neill. “You could sign a 12- or 15-week contract, and their needs change a month in, and ... there are budget cuts, and they can’t pay salaries anymore, so they are laying off their nurses.”
Declining demand for travel nurses has made it harder to line up back-to-back contracts. Despite being available for work, Doran once waited 6 weeks to secure a new assignment and had to live off her savings.
Spurlock believes increased competition and declining wages — pay for travel nurses declined more than 9% from January 2023 to January 2024 — have made travel nursing less attractive.
“There has been such an influx of travel nurses ... because of COVID,” said Spurlock. “The rates have now come down [and] everybody’s fighting for jobs, and ... it’s very difficult to get a job that’s paying decent money.”
Despite the challenges, Spurlock continues learning new things from each assignment and hopes to work as a travel nurse until retirement. Doran has worked at hospitals in Washington, Oregon, California, and Wisconsin and would like to add Montana, Utah, and Nevada to the list. The goal: Continue accepting assignments in different cities and states until she finds the place where she wants to put down roots.
“Nursing is a great job, but it’s a hard job [and] it can take its toll at times,” Neill said. It’s important that nurses know their goals and values to be able to find a good fitting position. “And the beauty of it is that travel can be a great way to explore and add some flexibility.”
A version of this article first appeared on Medscape.com.
The Bad News Behind the Rise in Locum Tenens
I’ve worked locum tenens off and on since 1982. Flexible schedules allowed me to write several books, pursue a parallel career as a medical journalist, lead medical missions in the Philippines, and develop modest expertise as an underwater photographer.
But the recent rise in locum tenens practitioners signals trouble for medicine.
A Multibillion-Dollar Industry
Roughly 52,000 US doctors work locum tenens full or part time. In annual reports by CHG Healthcare, two thirds of healthcare facilities surveyed report using locums and more than half expect to maintain or increase their use in 2024.
Another measure of the industry’s growth is that membership of The National Association of Locum Tenens Organizations (NALTO), formed in 2001 to lead this fledgling industry, has doubled since 2019. Currently, NALTO has 148 member agencies.
Why Locums?
What used to be the preserve of older physicians transitioning to retirement is now becoming a career choice. According to the 2024 Survey of Locum Tenens Physicians and Advanced Practice Professionals by AMN Healthcare, 81% of respondents said they started taking locum tenens assignments immediately after finishing medical training or in mid-career. What entices doctors to move from place to place, repeatedly adapt to new facilities and electronic medical records, live in cheap hotels, and work without paid vacations, health insurance, or retirement benefits?
Supplemental income is one reason. But the elephant in the room is clearly burnout. Rates of burnout in practicing doctors and physicians-in-training have exceeded 50%. Burnout results in medical errors, malpractice suits, and increased healthcare costs.
A recent Doximity poll of 7590 physicians revealed that 63% would not want their children to pursue a medical career. And in a Medscape survey of 7000 physicians, a third of docs under 40 would not choose medicine again if they had a do-over. If a career in medicine brings high income and privileged status, why do so many physicians regret it and discourage their children from taking the same path?
Where Is Marcus Welby, MD?
Private practice is an endangered species that no one is trying to save. According to a 2022 AMA survey, 44% of physicians owned their practices compared with 76% of physicians in the 1980s. Even fewer younger physicians are choosing private practice. Among physicians under 45 years of age, only 32% owned their practices. Most physicians are now employees, not employers. They have lost control over their duties and work hours.
In 2022, barely 13% of physicians were in solo practice. The iconic Dr Marcus Welby of the 1970s TV series has transmuted from an idealized physician to an implausible figure. (My medical students have never heard of him.)
Hospitals and health systems have purchased many private medical groups. Private-equity companies own close to 1000 physician practices and staff up to 40% of emergency rooms. For these firms, profits are paramount.
Canary in a Coal Mine
Locum tenens offers physicians unprecedented flexibility where they work, when they work, and how much they work. It provides an escape from overwhelming and unsatisfying clinical practice. While some physicians have fled to nonclinical careers, locums physicians can practice medicine without the burdens of administration, hospital politics, and ever-increasing overhead.
The locum tenens paradox is that its successful growth indicates a deteriorating traditional healthcare model. Locum tenens is not the problem, but it’s also not the solution. At best, locums is a pair of crutches that helps the current system limp along.
Healthcare is increasingly controlled by those who prioritize profit, not patients. If physicians become nothing more than complicit cogs in a dysfunctional system, burnout will fester. The profession will fail to attract the best and the brightest, the doctor shortage will increase, and the quality of patient care will decline. Everyone will suffer.
It’s already happening.
Andrew Wilner is an associate professor of neurology at the University of Tennessee Health Science Center, Memphis. He reported conflicts of interest from Accordant Health Services.
A version of this article first appeared on Medscape.com.
I’ve worked locum tenens off and on since 1982. Flexible schedules allowed me to write several books, pursue a parallel career as a medical journalist, lead medical missions in the Philippines, and develop modest expertise as an underwater photographer.
But the recent rise in locum tenens practitioners signals trouble for medicine.
A Multibillion-Dollar Industry
Roughly 52,000 US doctors work locum tenens full or part time. In annual reports by CHG Healthcare, two thirds of healthcare facilities surveyed report using locums and more than half expect to maintain or increase their use in 2024.
Another measure of the industry’s growth is that membership of The National Association of Locum Tenens Organizations (NALTO), formed in 2001 to lead this fledgling industry, has doubled since 2019. Currently, NALTO has 148 member agencies.
Why Locums?
What used to be the preserve of older physicians transitioning to retirement is now becoming a career choice. According to the 2024 Survey of Locum Tenens Physicians and Advanced Practice Professionals by AMN Healthcare, 81% of respondents said they started taking locum tenens assignments immediately after finishing medical training or in mid-career. What entices doctors to move from place to place, repeatedly adapt to new facilities and electronic medical records, live in cheap hotels, and work without paid vacations, health insurance, or retirement benefits?
Supplemental income is one reason. But the elephant in the room is clearly burnout. Rates of burnout in practicing doctors and physicians-in-training have exceeded 50%. Burnout results in medical errors, malpractice suits, and increased healthcare costs.
A recent Doximity poll of 7590 physicians revealed that 63% would not want their children to pursue a medical career. And in a Medscape survey of 7000 physicians, a third of docs under 40 would not choose medicine again if they had a do-over. If a career in medicine brings high income and privileged status, why do so many physicians regret it and discourage their children from taking the same path?
Where Is Marcus Welby, MD?
Private practice is an endangered species that no one is trying to save. According to a 2022 AMA survey, 44% of physicians owned their practices compared with 76% of physicians in the 1980s. Even fewer younger physicians are choosing private practice. Among physicians under 45 years of age, only 32% owned their practices. Most physicians are now employees, not employers. They have lost control over their duties and work hours.
In 2022, barely 13% of physicians were in solo practice. The iconic Dr Marcus Welby of the 1970s TV series has transmuted from an idealized physician to an implausible figure. (My medical students have never heard of him.)
Hospitals and health systems have purchased many private medical groups. Private-equity companies own close to 1000 physician practices and staff up to 40% of emergency rooms. For these firms, profits are paramount.
Canary in a Coal Mine
Locum tenens offers physicians unprecedented flexibility where they work, when they work, and how much they work. It provides an escape from overwhelming and unsatisfying clinical practice. While some physicians have fled to nonclinical careers, locums physicians can practice medicine without the burdens of administration, hospital politics, and ever-increasing overhead.
The locum tenens paradox is that its successful growth indicates a deteriorating traditional healthcare model. Locum tenens is not the problem, but it’s also not the solution. At best, locums is a pair of crutches that helps the current system limp along.
Healthcare is increasingly controlled by those who prioritize profit, not patients. If physicians become nothing more than complicit cogs in a dysfunctional system, burnout will fester. The profession will fail to attract the best and the brightest, the doctor shortage will increase, and the quality of patient care will decline. Everyone will suffer.
It’s already happening.
Andrew Wilner is an associate professor of neurology at the University of Tennessee Health Science Center, Memphis. He reported conflicts of interest from Accordant Health Services.
A version of this article first appeared on Medscape.com.
I’ve worked locum tenens off and on since 1982. Flexible schedules allowed me to write several books, pursue a parallel career as a medical journalist, lead medical missions in the Philippines, and develop modest expertise as an underwater photographer.
But the recent rise in locum tenens practitioners signals trouble for medicine.
A Multibillion-Dollar Industry
Roughly 52,000 US doctors work locum tenens full or part time. In annual reports by CHG Healthcare, two thirds of healthcare facilities surveyed report using locums and more than half expect to maintain or increase their use in 2024.
Another measure of the industry’s growth is that membership of The National Association of Locum Tenens Organizations (NALTO), formed in 2001 to lead this fledgling industry, has doubled since 2019. Currently, NALTO has 148 member agencies.
Why Locums?
What used to be the preserve of older physicians transitioning to retirement is now becoming a career choice. According to the 2024 Survey of Locum Tenens Physicians and Advanced Practice Professionals by AMN Healthcare, 81% of respondents said they started taking locum tenens assignments immediately after finishing medical training or in mid-career. What entices doctors to move from place to place, repeatedly adapt to new facilities and electronic medical records, live in cheap hotels, and work without paid vacations, health insurance, or retirement benefits?
Supplemental income is one reason. But the elephant in the room is clearly burnout. Rates of burnout in practicing doctors and physicians-in-training have exceeded 50%. Burnout results in medical errors, malpractice suits, and increased healthcare costs.
A recent Doximity poll of 7590 physicians revealed that 63% would not want their children to pursue a medical career. And in a Medscape survey of 7000 physicians, a third of docs under 40 would not choose medicine again if they had a do-over. If a career in medicine brings high income and privileged status, why do so many physicians regret it and discourage their children from taking the same path?
Where Is Marcus Welby, MD?
Private practice is an endangered species that no one is trying to save. According to a 2022 AMA survey, 44% of physicians owned their practices compared with 76% of physicians in the 1980s. Even fewer younger physicians are choosing private practice. Among physicians under 45 years of age, only 32% owned their practices. Most physicians are now employees, not employers. They have lost control over their duties and work hours.
In 2022, barely 13% of physicians were in solo practice. The iconic Dr Marcus Welby of the 1970s TV series has transmuted from an idealized physician to an implausible figure. (My medical students have never heard of him.)
Hospitals and health systems have purchased many private medical groups. Private-equity companies own close to 1000 physician practices and staff up to 40% of emergency rooms. For these firms, profits are paramount.
Canary in a Coal Mine
Locum tenens offers physicians unprecedented flexibility where they work, when they work, and how much they work. It provides an escape from overwhelming and unsatisfying clinical practice. While some physicians have fled to nonclinical careers, locums physicians can practice medicine without the burdens of administration, hospital politics, and ever-increasing overhead.
The locum tenens paradox is that its successful growth indicates a deteriorating traditional healthcare model. Locum tenens is not the problem, but it’s also not the solution. At best, locums is a pair of crutches that helps the current system limp along.
Healthcare is increasingly controlled by those who prioritize profit, not patients. If physicians become nothing more than complicit cogs in a dysfunctional system, burnout will fester. The profession will fail to attract the best and the brightest, the doctor shortage will increase, and the quality of patient care will decline. Everyone will suffer.
It’s already happening.
Andrew Wilner is an associate professor of neurology at the University of Tennessee Health Science Center, Memphis. He reported conflicts of interest from Accordant Health Services.
A version of this article first appeared on Medscape.com.
A History of Concussion Linked to Maternal Mental Illness
A history of concussion can have serious long-term mental health implications for women, even years after giving birth, according to a new study.
Researchers looked at all people who delivered babies in Ontario, Canada, and found that those with a predelivery history of concussion were 25% more likely to have a serious mental illness up to 14 years after giving birth than those with no history of concussion.
The findings indicate the need for early identification and screening of women with a history of concussion, as well as ongoing, long-term supports to prevent adverse psychiatric outcomes, wrote the authors.
“I played a lot of sports growing up, and I definitely would not have thought about how a concussion could affect childbearing or parenting,” author Samantha Krueger, RM, MSc, told this news organization. She completed the research as part of her studies at the University of Toronto, Ontario.
The data were published on November 4 in The Journal of Clinical Psychiatry.
Implications for Prevention
“Birthing people, and women in general, are an often-overlooked population in the scientific literature on traumatic brain injury, including concussion. There is a potential interplay between concussion history and the challenges of being a new parent (such as labor and birth, lack of sleep, and increased noise) that make this an important population to study,” said Krueger.
The researchers conducted a population-based cohort study of all women who gave birth in Ontario between 2007 and 2017. Follow-up continued until 2021. The primary outcome was severe maternal mental illness, which was defined as a psychiatric emergency department visit, psychiatric hospital admission, or self-harm or suicide in the 14 years after delivery.
The researchers identified 18,064 women with a predelivery history of concussion and 736,689 women without a history of concussion during the study period. Women with a predelivery history of concussion were more likely than those without such a history to live in a rural area and have a history of assault or mental illness.
Overall, 11.3% (n = 2033) of the women with a predelivery history of concussion developed severe maternal mental illness (14.7 per 1000 person-years), compared with 6.8% (n = 49,928) of the women without a predelivery history of concussion (7.9 per 1000 person-years).
The adjusted hazard ratio (aHR) was 1.25. The association was strongest in women who had a predelivery history of concussion but no history of mental illness (aHR, 1.33).
“We hope to increase awareness of the seriousness of having a concussion, even when it is considered a mild head injury,” Krueger said. “The results have important implications for concussion prevention measures for young people and for the provision of postpartum supports (such as mental health and other social supports like sleep relief) to mitigate the risk of serious mental illness outcomes in birthing people with a history of concussion.”
Healthcare providers, including maternity care providers, should be asking about concussion history and providing mental health screening and supports to clients and their families to detect mental illness before a serious outcome occurs, Krueger added.
“Maternity care providers can help birthing people and their families set up supports for after the baby is born and teach families about mental health symptoms to look out for. It’s also important that providers be certain that their care is trauma informed to avoid triggering a trauma response when providing care,” she said.
Area of Concern
“This research is novel and highlights an area of major concern,” Simon Sherry, PhD, professor of psychology and neuroscience at Dalhousie University in Halifax, Nova Scotia, Canada, told this news organization. Sherry did not participate in the study.
“Postpartum depression occurs in approximately 10%-25% of mothers, but it is likely that many more cases go undiagnosed. It is attributed to hormonal changes, genetic predisposition, and environmental factors, and while previous depression or mental illness is frequently considered a risk factor, traumatic brain injuries or concussions usually are not,” Sherry said.
“Mothers are already an at-risk population for mental illness, as illustrated by the high rates of postpartum depression, and so are people with a history of concussion or traumatic brain injury. What sets this study apart is that it shows the heightened risk for women with the combination of those two distinct risk factors. Identifying these risk factors is essential to providing preventive care. If care providers know a patient is at increased risk when starting a pregnancy, then they will likely catch warning signs earlier,” he said.
“Additionally, as the article suggests, maternal mental health often is not studied beyond the first postpartum year,” Sherry said.
“Mental health struggles during the first postpartum year have largely been normalized as part of the transition into parenthood, but mental health issues among parents later in life are less accepted. After birth, so much emphasis is moved from the parent to the child. Parents rightly prioritize their children, but our job as care providers is to ensure we are also prioritizing them. The prolonged period of this study helps illustrate how important the practice of prioritizing mothers’ mental health is,” he added.
The study was supported by ICES, which is funded by an annual grant from the Ontario Ministry of Health and the Ministry of Long-Term Care. The Canadian Institutes of Health Research also supported the study. Krueger is supported by a Canadian Institutes of Health Research Canada Graduate Scholarship Masters Award. Sherry reported no relevant financial relationships.
A version of this article first appeared on Medscape.com.
A history of concussion can have serious long-term mental health implications for women, even years after giving birth, according to a new study.
Researchers looked at all people who delivered babies in Ontario, Canada, and found that those with a predelivery history of concussion were 25% more likely to have a serious mental illness up to 14 years after giving birth than those with no history of concussion.
The findings indicate the need for early identification and screening of women with a history of concussion, as well as ongoing, long-term supports to prevent adverse psychiatric outcomes, wrote the authors.
“I played a lot of sports growing up, and I definitely would not have thought about how a concussion could affect childbearing or parenting,” author Samantha Krueger, RM, MSc, told this news organization. She completed the research as part of her studies at the University of Toronto, Ontario.
The data were published on November 4 in The Journal of Clinical Psychiatry.
Implications for Prevention
“Birthing people, and women in general, are an often-overlooked population in the scientific literature on traumatic brain injury, including concussion. There is a potential interplay between concussion history and the challenges of being a new parent (such as labor and birth, lack of sleep, and increased noise) that make this an important population to study,” said Krueger.
The researchers conducted a population-based cohort study of all women who gave birth in Ontario between 2007 and 2017. Follow-up continued until 2021. The primary outcome was severe maternal mental illness, which was defined as a psychiatric emergency department visit, psychiatric hospital admission, or self-harm or suicide in the 14 years after delivery.
The researchers identified 18,064 women with a predelivery history of concussion and 736,689 women without a history of concussion during the study period. Women with a predelivery history of concussion were more likely than those without such a history to live in a rural area and have a history of assault or mental illness.
Overall, 11.3% (n = 2033) of the women with a predelivery history of concussion developed severe maternal mental illness (14.7 per 1000 person-years), compared with 6.8% (n = 49,928) of the women without a predelivery history of concussion (7.9 per 1000 person-years).
The adjusted hazard ratio (aHR) was 1.25. The association was strongest in women who had a predelivery history of concussion but no history of mental illness (aHR, 1.33).
“We hope to increase awareness of the seriousness of having a concussion, even when it is considered a mild head injury,” Krueger said. “The results have important implications for concussion prevention measures for young people and for the provision of postpartum supports (such as mental health and other social supports like sleep relief) to mitigate the risk of serious mental illness outcomes in birthing people with a history of concussion.”
Healthcare providers, including maternity care providers, should be asking about concussion history and providing mental health screening and supports to clients and their families to detect mental illness before a serious outcome occurs, Krueger added.
“Maternity care providers can help birthing people and their families set up supports for after the baby is born and teach families about mental health symptoms to look out for. It’s also important that providers be certain that their care is trauma informed to avoid triggering a trauma response when providing care,” she said.
Area of Concern
“This research is novel and highlights an area of major concern,” Simon Sherry, PhD, professor of psychology and neuroscience at Dalhousie University in Halifax, Nova Scotia, Canada, told this news organization. Sherry did not participate in the study.
“Postpartum depression occurs in approximately 10%-25% of mothers, but it is likely that many more cases go undiagnosed. It is attributed to hormonal changes, genetic predisposition, and environmental factors, and while previous depression or mental illness is frequently considered a risk factor, traumatic brain injuries or concussions usually are not,” Sherry said.
“Mothers are already an at-risk population for mental illness, as illustrated by the high rates of postpartum depression, and so are people with a history of concussion or traumatic brain injury. What sets this study apart is that it shows the heightened risk for women with the combination of those two distinct risk factors. Identifying these risk factors is essential to providing preventive care. If care providers know a patient is at increased risk when starting a pregnancy, then they will likely catch warning signs earlier,” he said.
“Additionally, as the article suggests, maternal mental health often is not studied beyond the first postpartum year,” Sherry said.
“Mental health struggles during the first postpartum year have largely been normalized as part of the transition into parenthood, but mental health issues among parents later in life are less accepted. After birth, so much emphasis is moved from the parent to the child. Parents rightly prioritize their children, but our job as care providers is to ensure we are also prioritizing them. The prolonged period of this study helps illustrate how important the practice of prioritizing mothers’ mental health is,” he added.
The study was supported by ICES, which is funded by an annual grant from the Ontario Ministry of Health and the Ministry of Long-Term Care. The Canadian Institutes of Health Research also supported the study. Krueger is supported by a Canadian Institutes of Health Research Canada Graduate Scholarship Masters Award. Sherry reported no relevant financial relationships.
A version of this article first appeared on Medscape.com.
A history of concussion can have serious long-term mental health implications for women, even years after giving birth, according to a new study.
Researchers looked at all people who delivered babies in Ontario, Canada, and found that those with a predelivery history of concussion were 25% more likely to have a serious mental illness up to 14 years after giving birth than those with no history of concussion.
The findings indicate the need for early identification and screening of women with a history of concussion, as well as ongoing, long-term supports to prevent adverse psychiatric outcomes, wrote the authors.
“I played a lot of sports growing up, and I definitely would not have thought about how a concussion could affect childbearing or parenting,” author Samantha Krueger, RM, MSc, told this news organization. She completed the research as part of her studies at the University of Toronto, Ontario.
The data were published on November 4 in The Journal of Clinical Psychiatry.
Implications for Prevention
“Birthing people, and women in general, are an often-overlooked population in the scientific literature on traumatic brain injury, including concussion. There is a potential interplay between concussion history and the challenges of being a new parent (such as labor and birth, lack of sleep, and increased noise) that make this an important population to study,” said Krueger.
The researchers conducted a population-based cohort study of all women who gave birth in Ontario between 2007 and 2017. Follow-up continued until 2021. The primary outcome was severe maternal mental illness, which was defined as a psychiatric emergency department visit, psychiatric hospital admission, or self-harm or suicide in the 14 years after delivery.
The researchers identified 18,064 women with a predelivery history of concussion and 736,689 women without a history of concussion during the study period. Women with a predelivery history of concussion were more likely than those without such a history to live in a rural area and have a history of assault or mental illness.
Overall, 11.3% (n = 2033) of the women with a predelivery history of concussion developed severe maternal mental illness (14.7 per 1000 person-years), compared with 6.8% (n = 49,928) of the women without a predelivery history of concussion (7.9 per 1000 person-years).
The adjusted hazard ratio (aHR) was 1.25. The association was strongest in women who had a predelivery history of concussion but no history of mental illness (aHR, 1.33).
“We hope to increase awareness of the seriousness of having a concussion, even when it is considered a mild head injury,” Krueger said. “The results have important implications for concussion prevention measures for young people and for the provision of postpartum supports (such as mental health and other social supports like sleep relief) to mitigate the risk of serious mental illness outcomes in birthing people with a history of concussion.”
Healthcare providers, including maternity care providers, should be asking about concussion history and providing mental health screening and supports to clients and their families to detect mental illness before a serious outcome occurs, Krueger added.
“Maternity care providers can help birthing people and their families set up supports for after the baby is born and teach families about mental health symptoms to look out for. It’s also important that providers be certain that their care is trauma informed to avoid triggering a trauma response when providing care,” she said.
Area of Concern
“This research is novel and highlights an area of major concern,” Simon Sherry, PhD, professor of psychology and neuroscience at Dalhousie University in Halifax, Nova Scotia, Canada, told this news organization. Sherry did not participate in the study.
“Postpartum depression occurs in approximately 10%-25% of mothers, but it is likely that many more cases go undiagnosed. It is attributed to hormonal changes, genetic predisposition, and environmental factors, and while previous depression or mental illness is frequently considered a risk factor, traumatic brain injuries or concussions usually are not,” Sherry said.
“Mothers are already an at-risk population for mental illness, as illustrated by the high rates of postpartum depression, and so are people with a history of concussion or traumatic brain injury. What sets this study apart is that it shows the heightened risk for women with the combination of those two distinct risk factors. Identifying these risk factors is essential to providing preventive care. If care providers know a patient is at increased risk when starting a pregnancy, then they will likely catch warning signs earlier,” he said.
“Additionally, as the article suggests, maternal mental health often is not studied beyond the first postpartum year,” Sherry said.
“Mental health struggles during the first postpartum year have largely been normalized as part of the transition into parenthood, but mental health issues among parents later in life are less accepted. After birth, so much emphasis is moved from the parent to the child. Parents rightly prioritize their children, but our job as care providers is to ensure we are also prioritizing them. The prolonged period of this study helps illustrate how important the practice of prioritizing mothers’ mental health is,” he added.
The study was supported by ICES, which is funded by an annual grant from the Ontario Ministry of Health and the Ministry of Long-Term Care. The Canadian Institutes of Health Research also supported the study. Krueger is supported by a Canadian Institutes of Health Research Canada Graduate Scholarship Masters Award. Sherry reported no relevant financial relationships.
A version of this article first appeared on Medscape.com.
FROM THE JOURNAL OF CLINICAL PSYCHIATRY
Treating Obesity May Reduce Pelvic Organ Prolapse Risk
TOPLINE:
People with central obesity (CO), characterized by excess fat around the abdomen, are at a greater risk for pelvic organ prolapse (POP), particularly those who are younger than 60 years or without a history of hysterectomy. Also, women who have overweight but do not have CO are at greater risk.
METHODOLOGY:
- Researchers conducted a prospective cohort study to estimate the association between CO and general obesity and the risk for POP in individuals using the UK Biobank.
- A total of 251,143 participants (median age, 57 years) without preexisting POP were included, of whom 60.9% were postmenopausal and 17.2% had undergone hysterectomy before enrollment.
- Participants were followed for a median duration of 13.8 years, and POP cases were identified using International Classification of Diseases, 10th Revision (ICD-10) codes.
- Waist circumference, height, and body weight were measured at enrollment for the calculation of waist/height ratio and body mass index (BMI); CO was defined as a waist/height ratio ≥ 0.5.
- The relative risk of POP for the various combinations of waist/height ratio and BMI was evaluated against the reference group (waist/height ratio < 0.5; BMI < 25) using Cox proportional hazards models.
TAKEAWAY:
- During the follow-up period, 9781 cases of POP were identified, of which 71.2% occurred in a single pelvic compartment.
- Around 21.7% of all POP cases were attributable to CO; 2% were attributable to being overweight without CO.
- The risk for POP was 48% higher in individuals with CO regardless of BMI (hazard ratio [HR], 1.48; 95% CI, 1.41-1.56) and 23% higher in those who had overweight without CO (HR, 1.23; 95% CI, 1.14-1.34).
- The association between POP and CO was further strengthened in individuals who were younger than 60 years and those without a history of hysterectomy.
IN PRACTICE:
“We found that waist/height ratio combined with BMI could help differentiate individuals with varying risks of prolapse more accurately. Among individuals within the same BMI category, waist/height ratio can vary, with those having a higher ratio generally facing a greater risk of POP, compared with those with a normal ratio. Therefore, they should not be grouped together based solely on a single measure of obesity. In addition, this combination can help identify more individuals at high risk for POP, compared with using either alone,” the study authors wrote.
SOURCE:
This study was led by Keyi Si, PhD, of Tongji University in Shanghai, China, and was published online in Obstetrics & Gynecology.
LIMITATIONS:
Differences in healthcare-seeking behavior could have biased the association between obesity and risk for POP, as individuals with obesity may have been less likely to notice or report symptoms of POP. The diagnosis of POP was according to ICD-10 codes rather than physical examination, which may have affected accuracy. Other limitations included missing data on delivery mode and history of constipation.
DISCLOSURES:
This study was supported by grants from the National Natural Science Foundation of China, the Science and Technology Commission of Shanghai Municipality, the Shanghai Hospital Development Center, and the Shanghai First Maternity and Infant Hospital. The authors reported no conflicts of interest.
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:
People with central obesity (CO), characterized by excess fat around the abdomen, are at a greater risk for pelvic organ prolapse (POP), particularly those who are younger than 60 years or without a history of hysterectomy. Also, women who have overweight but do not have CO are at greater risk.
METHODOLOGY:
- Researchers conducted a prospective cohort study to estimate the association between CO and general obesity and the risk for POP in individuals using the UK Biobank.
- A total of 251,143 participants (median age, 57 years) without preexisting POP were included, of whom 60.9% were postmenopausal and 17.2% had undergone hysterectomy before enrollment.
- Participants were followed for a median duration of 13.8 years, and POP cases were identified using International Classification of Diseases, 10th Revision (ICD-10) codes.
- Waist circumference, height, and body weight were measured at enrollment for the calculation of waist/height ratio and body mass index (BMI); CO was defined as a waist/height ratio ≥ 0.5.
- The relative risk of POP for the various combinations of waist/height ratio and BMI was evaluated against the reference group (waist/height ratio < 0.5; BMI < 25) using Cox proportional hazards models.
TAKEAWAY:
- During the follow-up period, 9781 cases of POP were identified, of which 71.2% occurred in a single pelvic compartment.
- Around 21.7% of all POP cases were attributable to CO; 2% were attributable to being overweight without CO.
- The risk for POP was 48% higher in individuals with CO regardless of BMI (hazard ratio [HR], 1.48; 95% CI, 1.41-1.56) and 23% higher in those who had overweight without CO (HR, 1.23; 95% CI, 1.14-1.34).
- The association between POP and CO was further strengthened in individuals who were younger than 60 years and those without a history of hysterectomy.
IN PRACTICE:
“We found that waist/height ratio combined with BMI could help differentiate individuals with varying risks of prolapse more accurately. Among individuals within the same BMI category, waist/height ratio can vary, with those having a higher ratio generally facing a greater risk of POP, compared with those with a normal ratio. Therefore, they should not be grouped together based solely on a single measure of obesity. In addition, this combination can help identify more individuals at high risk for POP, compared with using either alone,” the study authors wrote.
SOURCE:
This study was led by Keyi Si, PhD, of Tongji University in Shanghai, China, and was published online in Obstetrics & Gynecology.
LIMITATIONS:
Differences in healthcare-seeking behavior could have biased the association between obesity and risk for POP, as individuals with obesity may have been less likely to notice or report symptoms of POP. The diagnosis of POP was according to ICD-10 codes rather than physical examination, which may have affected accuracy. Other limitations included missing data on delivery mode and history of constipation.
DISCLOSURES:
This study was supported by grants from the National Natural Science Foundation of China, the Science and Technology Commission of Shanghai Municipality, the Shanghai Hospital Development Center, and the Shanghai First Maternity and Infant Hospital. The authors reported no conflicts of interest.
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:
People with central obesity (CO), characterized by excess fat around the abdomen, are at a greater risk for pelvic organ prolapse (POP), particularly those who are younger than 60 years or without a history of hysterectomy. Also, women who have overweight but do not have CO are at greater risk.
METHODOLOGY:
- Researchers conducted a prospective cohort study to estimate the association between CO and general obesity and the risk for POP in individuals using the UK Biobank.
- A total of 251,143 participants (median age, 57 years) without preexisting POP were included, of whom 60.9% were postmenopausal and 17.2% had undergone hysterectomy before enrollment.
- Participants were followed for a median duration of 13.8 years, and POP cases were identified using International Classification of Diseases, 10th Revision (ICD-10) codes.
- Waist circumference, height, and body weight were measured at enrollment for the calculation of waist/height ratio and body mass index (BMI); CO was defined as a waist/height ratio ≥ 0.5.
- The relative risk of POP for the various combinations of waist/height ratio and BMI was evaluated against the reference group (waist/height ratio < 0.5; BMI < 25) using Cox proportional hazards models.
TAKEAWAY:
- During the follow-up period, 9781 cases of POP were identified, of which 71.2% occurred in a single pelvic compartment.
- Around 21.7% of all POP cases were attributable to CO; 2% were attributable to being overweight without CO.
- The risk for POP was 48% higher in individuals with CO regardless of BMI (hazard ratio [HR], 1.48; 95% CI, 1.41-1.56) and 23% higher in those who had overweight without CO (HR, 1.23; 95% CI, 1.14-1.34).
- The association between POP and CO was further strengthened in individuals who were younger than 60 years and those without a history of hysterectomy.
IN PRACTICE:
“We found that waist/height ratio combined with BMI could help differentiate individuals with varying risks of prolapse more accurately. Among individuals within the same BMI category, waist/height ratio can vary, with those having a higher ratio generally facing a greater risk of POP, compared with those with a normal ratio. Therefore, they should not be grouped together based solely on a single measure of obesity. In addition, this combination can help identify more individuals at high risk for POP, compared with using either alone,” the study authors wrote.
SOURCE:
This study was led by Keyi Si, PhD, of Tongji University in Shanghai, China, and was published online in Obstetrics & Gynecology.
LIMITATIONS:
Differences in healthcare-seeking behavior could have biased the association between obesity and risk for POP, as individuals with obesity may have been less likely to notice or report symptoms of POP. The diagnosis of POP was according to ICD-10 codes rather than physical examination, which may have affected accuracy. Other limitations included missing data on delivery mode and history of constipation.
DISCLOSURES:
This study was supported by grants from the National Natural Science Foundation of China, the Science and Technology Commission of Shanghai Municipality, the Shanghai Hospital Development Center, and the Shanghai First Maternity and Infant Hospital. The authors reported no conflicts of interest.
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.
Knowledge Gaps About Obesity Medicine Seen in Primary Care
SAN ANTONIO — Despite the prevalence of obesity in primary care, there appear to be major knowledge gaps among providers regarding obesity management, new research suggests.
Anonymous surveys of 96 primary care providers at a Boston, Massachusetts, safety-net hospital revealed that participants had limited understanding of criteria for prescribing antiobesity medications (AOM), and expressed discomfort in prescribing AOMs because of knowledge concerns, especially for non–glucagon-like peptide 1 (GLP-1) receptor agonists. One third reported that they didn’t prescribe AOMs, and rates of referral for bariatric surgery were also low.
The findings were presented at the Obesity Society’s annual Obesity Week meeting by Alejandro Campos, MD, a third-year resident in the section of internal medicine, Boston Medical Center, and the Department of Medicine, Boston University.
“I think it comes down to education. ... Not only training primary care physicians or residents about criteria and pathophysiology, but also stigma. Perceptions need to be addressed from the start of training in the healthcare field,” Campos told this news organization in an interview.
During his presentation, Campos noted this is the first such study in the setting of a safety-net hospital, which cares for lower-income people who experience disproportionate rates of obesity. But, “these findings are similar to ones observed from non–safety-net settings, which can indicate some potential transferability.”
Asked to comment, session moderator John D. Clark, MD, PhD, Chief Population Health Officer at Sharp Rees-Stealy Medical Group, San Diego, California, told this news organization that the findings didn’t surprise him. “I’d say that medical education around obesity has definitely improved, and training is improving but it’s not uniform. The treatment of obesity as a disease, especially with some of the newer medical treatments, is not standard of care and practiced widely.”
The study involved a standard-model Knowledge, Attitudes, and Practices questionnaire, distributed electronically for anonymous responses among both trained and in-training primary care providers. It contained a total of 43 items, 7 of them demographic, 11 on knowledge, 9 regarding attitudes, and 16 asking about practices.
The hospital is the largest safety-net hospital in New England, with a patient population that includes 58% enrolled in Medicaid, 32% Black/African American individuals, 24% identifying as Hispanic/Latino individuals, and 37% living below the poverty line.
The 96 responding providers (from a total 350 invited) all worked in either family medicine or internal medicine. The trained providers included both attending MDs and nurse practitioners, while those in-training were residents in one of those two specialties. Two thirds were women. The majority were aged 20-30 years (49.45%) or 31-40 years (27.47%).
Overall, 73.63% reported having received some type of obesity training. Just over half (52.08%) reported receiving that training during medical or nursing school, while 43.75% reported receiving it during residency.
When asked to choose from a list of conditions to pick which are considered weight-related comorbidities, between 80% and 90% choose type 2 diabetes, obstructive sleep apnea (OSA), hypertension, hyperlipidemia, nonalcoholic fatty liver disease, and coronary artery disease. Fewer, but still a majority, also listed osteoarthritis and gastroesophageal reflux disease. However, respondents were less likely to cite cancer, mood disorders, or chronic kidney disease as being related to obesity.
Asked to list benefits of a 10% body weight loss, most recognized reductions in OSA, glycemia, cardiovascular disease risk, osteoarthritis, and hepatic steatosis. But, only about half knew weight loss could also improve urinary incontinence.
Only 25% could correctly name both indications for AOMs. Just 27.1% knew that one was a body mass index (BMI) ≥ 27 with comorbidities, while 46.9% knew BMI ≥ 30 without comorbidities was an AOM indication. Only 9.4% were correct on both of those indications for bariatric surgery.
“Reassuringly,” Campos said, the majority either “disagreed” or “strongly disagreed” that “lack of will power” contributes to obesity. However, more than 20% agreed that “lack of exercise or physical activity” contributed.
Overall, 73% of the trained providers and 59% of those in training reported that they prescribe AOMs. Asked about their comfort level in prescribing specific types of AOMs, many more endorsed semaglutide and liraglutide than older medications such as bupropion/naltrexone and phentermine/topiramate.
Asked about factors that influence their comfort with prescribing AOMs, the top five factors selected, in order, were side-effect knowledge, insurance coverage, safety issues, and dosing knowledge. Fewer respondents endorsed “patient’s ideas, concerns, and expectations,” cost, or efficacy.
Referrals to nutrition services were endorsed more often than to obesity medicine specialists or bariatric surgery.
Asked about barriers to obesity treatment in their practices, “time constraints” was the most frequently endorsed, followed by “lack of training or knowledge,” “patient adherence and motivation,” and “limited resources.”
“What are the future directives? We feel we have the need to provide ongoing obesity management, education and assistance to primary care providers, including support for securing coverage for treatments,” Campos said.
He added that Boston Medical Center is now developing and implementing an embedded weight management program within primary care “to assist the front line of obesity care.”
Asked by this news organization whether he believes the rise of GLP-1 drugs will make a difference, Campos said “Definitely, I think with that momentum obesity medicine as a whole will gain more attention and hopefully more implementation in the curricula for medical and nursing schools, because in the end it requires a multidisciplinary approach.”
Campos and Clark had no disclosures.
A version of this article first appeared on Medscape.com.
SAN ANTONIO — Despite the prevalence of obesity in primary care, there appear to be major knowledge gaps among providers regarding obesity management, new research suggests.
Anonymous surveys of 96 primary care providers at a Boston, Massachusetts, safety-net hospital revealed that participants had limited understanding of criteria for prescribing antiobesity medications (AOM), and expressed discomfort in prescribing AOMs because of knowledge concerns, especially for non–glucagon-like peptide 1 (GLP-1) receptor agonists. One third reported that they didn’t prescribe AOMs, and rates of referral for bariatric surgery were also low.
The findings were presented at the Obesity Society’s annual Obesity Week meeting by Alejandro Campos, MD, a third-year resident in the section of internal medicine, Boston Medical Center, and the Department of Medicine, Boston University.
“I think it comes down to education. ... Not only training primary care physicians or residents about criteria and pathophysiology, but also stigma. Perceptions need to be addressed from the start of training in the healthcare field,” Campos told this news organization in an interview.
During his presentation, Campos noted this is the first such study in the setting of a safety-net hospital, which cares for lower-income people who experience disproportionate rates of obesity. But, “these findings are similar to ones observed from non–safety-net settings, which can indicate some potential transferability.”
Asked to comment, session moderator John D. Clark, MD, PhD, Chief Population Health Officer at Sharp Rees-Stealy Medical Group, San Diego, California, told this news organization that the findings didn’t surprise him. “I’d say that medical education around obesity has definitely improved, and training is improving but it’s not uniform. The treatment of obesity as a disease, especially with some of the newer medical treatments, is not standard of care and practiced widely.”
The study involved a standard-model Knowledge, Attitudes, and Practices questionnaire, distributed electronically for anonymous responses among both trained and in-training primary care providers. It contained a total of 43 items, 7 of them demographic, 11 on knowledge, 9 regarding attitudes, and 16 asking about practices.
The hospital is the largest safety-net hospital in New England, with a patient population that includes 58% enrolled in Medicaid, 32% Black/African American individuals, 24% identifying as Hispanic/Latino individuals, and 37% living below the poverty line.
The 96 responding providers (from a total 350 invited) all worked in either family medicine or internal medicine. The trained providers included both attending MDs and nurse practitioners, while those in-training were residents in one of those two specialties. Two thirds were women. The majority were aged 20-30 years (49.45%) or 31-40 years (27.47%).
Overall, 73.63% reported having received some type of obesity training. Just over half (52.08%) reported receiving that training during medical or nursing school, while 43.75% reported receiving it during residency.
When asked to choose from a list of conditions to pick which are considered weight-related comorbidities, between 80% and 90% choose type 2 diabetes, obstructive sleep apnea (OSA), hypertension, hyperlipidemia, nonalcoholic fatty liver disease, and coronary artery disease. Fewer, but still a majority, also listed osteoarthritis and gastroesophageal reflux disease. However, respondents were less likely to cite cancer, mood disorders, or chronic kidney disease as being related to obesity.
Asked to list benefits of a 10% body weight loss, most recognized reductions in OSA, glycemia, cardiovascular disease risk, osteoarthritis, and hepatic steatosis. But, only about half knew weight loss could also improve urinary incontinence.
Only 25% could correctly name both indications for AOMs. Just 27.1% knew that one was a body mass index (BMI) ≥ 27 with comorbidities, while 46.9% knew BMI ≥ 30 without comorbidities was an AOM indication. Only 9.4% were correct on both of those indications for bariatric surgery.
“Reassuringly,” Campos said, the majority either “disagreed” or “strongly disagreed” that “lack of will power” contributes to obesity. However, more than 20% agreed that “lack of exercise or physical activity” contributed.
Overall, 73% of the trained providers and 59% of those in training reported that they prescribe AOMs. Asked about their comfort level in prescribing specific types of AOMs, many more endorsed semaglutide and liraglutide than older medications such as bupropion/naltrexone and phentermine/topiramate.
Asked about factors that influence their comfort with prescribing AOMs, the top five factors selected, in order, were side-effect knowledge, insurance coverage, safety issues, and dosing knowledge. Fewer respondents endorsed “patient’s ideas, concerns, and expectations,” cost, or efficacy.
Referrals to nutrition services were endorsed more often than to obesity medicine specialists or bariatric surgery.
Asked about barriers to obesity treatment in their practices, “time constraints” was the most frequently endorsed, followed by “lack of training or knowledge,” “patient adherence and motivation,” and “limited resources.”
“What are the future directives? We feel we have the need to provide ongoing obesity management, education and assistance to primary care providers, including support for securing coverage for treatments,” Campos said.
He added that Boston Medical Center is now developing and implementing an embedded weight management program within primary care “to assist the front line of obesity care.”
Asked by this news organization whether he believes the rise of GLP-1 drugs will make a difference, Campos said “Definitely, I think with that momentum obesity medicine as a whole will gain more attention and hopefully more implementation in the curricula for medical and nursing schools, because in the end it requires a multidisciplinary approach.”
Campos and Clark had no disclosures.
A version of this article first appeared on Medscape.com.
SAN ANTONIO — Despite the prevalence of obesity in primary care, there appear to be major knowledge gaps among providers regarding obesity management, new research suggests.
Anonymous surveys of 96 primary care providers at a Boston, Massachusetts, safety-net hospital revealed that participants had limited understanding of criteria for prescribing antiobesity medications (AOM), and expressed discomfort in prescribing AOMs because of knowledge concerns, especially for non–glucagon-like peptide 1 (GLP-1) receptor agonists. One third reported that they didn’t prescribe AOMs, and rates of referral for bariatric surgery were also low.
The findings were presented at the Obesity Society’s annual Obesity Week meeting by Alejandro Campos, MD, a third-year resident in the section of internal medicine, Boston Medical Center, and the Department of Medicine, Boston University.
“I think it comes down to education. ... Not only training primary care physicians or residents about criteria and pathophysiology, but also stigma. Perceptions need to be addressed from the start of training in the healthcare field,” Campos told this news organization in an interview.
During his presentation, Campos noted this is the first such study in the setting of a safety-net hospital, which cares for lower-income people who experience disproportionate rates of obesity. But, “these findings are similar to ones observed from non–safety-net settings, which can indicate some potential transferability.”
Asked to comment, session moderator John D. Clark, MD, PhD, Chief Population Health Officer at Sharp Rees-Stealy Medical Group, San Diego, California, told this news organization that the findings didn’t surprise him. “I’d say that medical education around obesity has definitely improved, and training is improving but it’s not uniform. The treatment of obesity as a disease, especially with some of the newer medical treatments, is not standard of care and practiced widely.”
The study involved a standard-model Knowledge, Attitudes, and Practices questionnaire, distributed electronically for anonymous responses among both trained and in-training primary care providers. It contained a total of 43 items, 7 of them demographic, 11 on knowledge, 9 regarding attitudes, and 16 asking about practices.
The hospital is the largest safety-net hospital in New England, with a patient population that includes 58% enrolled in Medicaid, 32% Black/African American individuals, 24% identifying as Hispanic/Latino individuals, and 37% living below the poverty line.
The 96 responding providers (from a total 350 invited) all worked in either family medicine or internal medicine. The trained providers included both attending MDs and nurse practitioners, while those in-training were residents in one of those two specialties. Two thirds were women. The majority were aged 20-30 years (49.45%) or 31-40 years (27.47%).
Overall, 73.63% reported having received some type of obesity training. Just over half (52.08%) reported receiving that training during medical or nursing school, while 43.75% reported receiving it during residency.
When asked to choose from a list of conditions to pick which are considered weight-related comorbidities, between 80% and 90% choose type 2 diabetes, obstructive sleep apnea (OSA), hypertension, hyperlipidemia, nonalcoholic fatty liver disease, and coronary artery disease. Fewer, but still a majority, also listed osteoarthritis and gastroesophageal reflux disease. However, respondents were less likely to cite cancer, mood disorders, or chronic kidney disease as being related to obesity.
Asked to list benefits of a 10% body weight loss, most recognized reductions in OSA, glycemia, cardiovascular disease risk, osteoarthritis, and hepatic steatosis. But, only about half knew weight loss could also improve urinary incontinence.
Only 25% could correctly name both indications for AOMs. Just 27.1% knew that one was a body mass index (BMI) ≥ 27 with comorbidities, while 46.9% knew BMI ≥ 30 without comorbidities was an AOM indication. Only 9.4% were correct on both of those indications for bariatric surgery.
“Reassuringly,” Campos said, the majority either “disagreed” or “strongly disagreed” that “lack of will power” contributes to obesity. However, more than 20% agreed that “lack of exercise or physical activity” contributed.
Overall, 73% of the trained providers and 59% of those in training reported that they prescribe AOMs. Asked about their comfort level in prescribing specific types of AOMs, many more endorsed semaglutide and liraglutide than older medications such as bupropion/naltrexone and phentermine/topiramate.
Asked about factors that influence their comfort with prescribing AOMs, the top five factors selected, in order, were side-effect knowledge, insurance coverage, safety issues, and dosing knowledge. Fewer respondents endorsed “patient’s ideas, concerns, and expectations,” cost, or efficacy.
Referrals to nutrition services were endorsed more often than to obesity medicine specialists or bariatric surgery.
Asked about barriers to obesity treatment in their practices, “time constraints” was the most frequently endorsed, followed by “lack of training or knowledge,” “patient adherence and motivation,” and “limited resources.”
“What are the future directives? We feel we have the need to provide ongoing obesity management, education and assistance to primary care providers, including support for securing coverage for treatments,” Campos said.
He added that Boston Medical Center is now developing and implementing an embedded weight management program within primary care “to assist the front line of obesity care.”
Asked by this news organization whether he believes the rise of GLP-1 drugs will make a difference, Campos said “Definitely, I think with that momentum obesity medicine as a whole will gain more attention and hopefully more implementation in the curricula for medical and nursing schools, because in the end it requires a multidisciplinary approach.”
Campos and Clark had no disclosures.
A version of this article first appeared on Medscape.com.
FROM OBESITY WEEK 2024