A systematic review suggests at least one-third of SARS-CoV-2 infections occur in people who never develop symptoms, providing strong evidence for the prevalence of asymptomatic infections.

The finding that nearly one in three infected people remain symptom free suggests testing should be changed, the investigators noted.

“To reduce transmission from people who are presymptomatic or asymptomatic, we need to shift our testing focus to at-home screening,” lead author Daniel Oran, AM, said in an interview. “Inexpensive rapid antigen tests, provided to millions of people for frequent use, could help us significantly reduce the spread of the virus.”

The systematic review was published online Jan. 22 in Annals of Internal Medicine.

The findings come at a dire time when the official number of COVID-19 cases in the United States exceeds 25 million for the first time. Public health officials have raised concerns about more transmissible, and possibly more deadly, variants of SARS-CoV-2, while a new presidential administration tries to meet the challenge of improving vaccine distribution and acceptance rates.

The results also build on earlier findings from the same research team – Mr. Oran and senior author Eric Topol, MD – that published a review article looking at asymptomatic COVID-19 cases. Even though initial data were more limited, they likewise suggested a broader scope of testing is warranted, pointing out that asymptomatic individuals can transmit SARS-CoV-2 for up to 14 days. Dr. Topol is also editor in chief of Medscape.

In the current systematic review, the highest-quality evidence comes from large studies in England and Spain. The nationally representative evidence included serologic surveys from more than 365,000 people in England and more than 61,000 in Spain. When analyzed separately, about the same proportion of asymptomatic cases emerged: 32.4% in England and 33% in Spain.

“It was really remarkable to find that nationwide antibody testing studies in England and Spain – including hundreds of thousands of people – produced nearly identical results: About one-third of the SARS-CoV-2 infections were completely asymptomatic,” said Mr. Oran, a researcher at Scripps Research Translational Institute in La Jolla, Calif.

The systematic review included 43 studies with PCR testing for active SARS-CoV-2 infection and another 18 with antibody results that indicated present or previous infection. The studies were published up until Nov. 17, 2020.

An appreciation for asymptomatic transmission of SARS-CoV-2 infection has come a long way from initial dismissals about its importance, Dr. Topol noted via Twitter. “When Dr. @camilla_rothe reported an asymptomatic transmission a year ago, the @NEJM report was refuted and disparaged. She was later named a TIME 100 Person of the Year.”
 

Not symptomatic vs. never symptomatic

The term “asymptomatic” could be misleading because some people in this group do progress to develop signs of infection. This “presymptomatic” group of patients is likely a minority, the authors noted. Longitudinal studies indicate that about three-quarters of people who are asymptomatic with SARS-CoV-2 remain so.

Dr. Topol anticipated the one-third asymptomatic finding could draw some feedback about distinguishing asymptomatic from presymptomatic individuals. He tweeted, “Some will argue that there is admixture with presymptomatic cases, but review of all the data supports this estimate as being a conservative one.”

The heterogeneity of the settings, populations and other features of the studies prevented the authors from performing a meta-analysis of the findings.
 

Home is where the test is

Based on their findings, Mr. Oran and Dr. Topol believe “that COVID-19 control strategies must be altered, taking into account the prevalence and transmission risk of asymptomatic SARS-CoV-2 infection.” They suggested frequent use of inexpensive, rapid home tests to identify people who are asymptomatic or presymptomatic, along with programs and housing provided by the government to offer financial assistance and allow this group of people to isolate themselves.

Further research is warranted to determine if and how well vaccines for SARS-CoV-2 prevent asymptomatic infection.

Dr. Topol and Mr. Oran created a short video to highlight the findings from their systematic review.

The study was supported by a grant from the National Institutes of Health.

A version of this article first appeared on Medscape.com.

A systematic review suggests at least one-third of SARS-CoV-2 infections occur in people who never develop symptoms, providing strong evidence for the prevalence of asymptomatic infections.

The finding that nearly one in three infected people remain symptom free suggests testing should be changed, the investigators noted.

“To reduce transmission from people who are presymptomatic or asymptomatic, we need to shift our testing focus to at-home screening,” lead author Daniel Oran, AM, said in an interview. “Inexpensive rapid antigen tests, provided to millions of people for frequent use, could help us significantly reduce the spread of the virus.”

The systematic review was published online Jan. 22 in Annals of Internal Medicine.

The findings come at a dire time when the official number of COVID-19 cases in the United States exceeds 25 million for the first time. Public health officials have raised concerns about more transmissible, and possibly more deadly, variants of SARS-CoV-2, while a new presidential administration tries to meet the challenge of improving vaccine distribution and acceptance rates.

The results also build on earlier findings from the same research team – Mr. Oran and senior author Eric Topol, MD – that published a review article looking at asymptomatic COVID-19 cases. Even though initial data were more limited, they likewise suggested a broader scope of testing is warranted, pointing out that asymptomatic individuals can transmit SARS-CoV-2 for up to 14 days. Dr. Topol is also editor in chief of Medscape.

In the current systematic review, the highest-quality evidence comes from large studies in England and Spain. The nationally representative evidence included serologic surveys from more than 365,000 people in England and more than 61,000 in Spain. When analyzed separately, about the same proportion of asymptomatic cases emerged: 32.4% in England and 33% in Spain.

“It was really remarkable to find that nationwide antibody testing studies in England and Spain – including hundreds of thousands of people – produced nearly identical results: About one-third of the SARS-CoV-2 infections were completely asymptomatic,” said Mr. Oran, a researcher at Scripps Research Translational Institute in La Jolla, Calif.

The systematic review included 43 studies with PCR testing for active SARS-CoV-2 infection and another 18 with antibody results that indicated present or previous infection. The studies were published up until Nov. 17, 2020.

An appreciation for asymptomatic transmission of SARS-CoV-2 infection has come a long way from initial dismissals about its importance, Dr. Topol noted via Twitter. “When Dr. @camilla_rothe reported an asymptomatic transmission a year ago, the @NEJM report was refuted and disparaged. She was later named a TIME 100 Person of the Year.”
 

Not symptomatic vs. never symptomatic

The term “asymptomatic” could be misleading because some people in this group do progress to develop signs of infection. This “presymptomatic” group of patients is likely a minority, the authors noted. Longitudinal studies indicate that about three-quarters of people who are asymptomatic with SARS-CoV-2 remain so.

Dr. Topol anticipated the one-third asymptomatic finding could draw some feedback about distinguishing asymptomatic from presymptomatic individuals. He tweeted, “Some will argue that there is admixture with presymptomatic cases, but review of all the data supports this estimate as being a conservative one.”

The heterogeneity of the settings, populations and other features of the studies prevented the authors from performing a meta-analysis of the findings.
 

Home is where the test is

Based on their findings, Mr. Oran and Dr. Topol believe “that COVID-19 control strategies must be altered, taking into account the prevalence and transmission risk of asymptomatic SARS-CoV-2 infection.” They suggested frequent use of inexpensive, rapid home tests to identify people who are asymptomatic or presymptomatic, along with programs and housing provided by the government to offer financial assistance and allow this group of people to isolate themselves.

Further research is warranted to determine if and how well vaccines for SARS-CoV-2 prevent asymptomatic infection.

Dr. Topol and Mr. Oran created a short video to highlight the findings from their systematic review.

The study was supported by a grant from the National Institutes of Health.

A version of this article first appeared on Medscape.com.

A systematic review suggests at least one-third of SARS-CoV-2 infections occur in people who never develop symptoms, providing strong evidence for the prevalence of asymptomatic infections.

The finding that nearly one in three infected people remain symptom free suggests testing should be changed, the investigators noted.

“To reduce transmission from people who are presymptomatic or asymptomatic, we need to shift our testing focus to at-home screening,” lead author Daniel Oran, AM, said in an interview. “Inexpensive rapid antigen tests, provided to millions of people for frequent use, could help us significantly reduce the spread of the virus.”

The systematic review was published online Jan. 22 in Annals of Internal Medicine.

The findings come at a dire time when the official number of COVID-19 cases in the United States exceeds 25 million for the first time. Public health officials have raised concerns about more transmissible, and possibly more deadly, variants of SARS-CoV-2, while a new presidential administration tries to meet the challenge of improving vaccine distribution and acceptance rates.

The results also build on earlier findings from the same research team – Mr. Oran and senior author Eric Topol, MD – that published a review article looking at asymptomatic COVID-19 cases. Even though initial data were more limited, they likewise suggested a broader scope of testing is warranted, pointing out that asymptomatic individuals can transmit SARS-CoV-2 for up to 14 days. Dr. Topol is also editor in chief of Medscape.

In the current systematic review, the highest-quality evidence comes from large studies in England and Spain. The nationally representative evidence included serologic surveys from more than 365,000 people in England and more than 61,000 in Spain. When analyzed separately, about the same proportion of asymptomatic cases emerged: 32.4% in England and 33% in Spain.

“It was really remarkable to find that nationwide antibody testing studies in England and Spain – including hundreds of thousands of people – produced nearly identical results: About one-third of the SARS-CoV-2 infections were completely asymptomatic,” said Mr. Oran, a researcher at Scripps Research Translational Institute in La Jolla, Calif.

The systematic review included 43 studies with PCR testing for active SARS-CoV-2 infection and another 18 with antibody results that indicated present or previous infection. The studies were published up until Nov. 17, 2020.

An appreciation for asymptomatic transmission of SARS-CoV-2 infection has come a long way from initial dismissals about its importance, Dr. Topol noted via Twitter. “When Dr. @camilla_rothe reported an asymptomatic transmission a year ago, the @NEJM report was refuted and disparaged. She was later named a TIME 100 Person of the Year.”
 

Not symptomatic vs. never symptomatic

The term “asymptomatic” could be misleading because some people in this group do progress to develop signs of infection. This “presymptomatic” group of patients is likely a minority, the authors noted. Longitudinal studies indicate that about three-quarters of people who are asymptomatic with SARS-CoV-2 remain so.

Dr. Topol anticipated the one-third asymptomatic finding could draw some feedback about distinguishing asymptomatic from presymptomatic individuals. He tweeted, “Some will argue that there is admixture with presymptomatic cases, but review of all the data supports this estimate as being a conservative one.”

The heterogeneity of the settings, populations and other features of the studies prevented the authors from performing a meta-analysis of the findings.
 

Home is where the test is

Based on their findings, Mr. Oran and Dr. Topol believe “that COVID-19 control strategies must be altered, taking into account the prevalence and transmission risk of asymptomatic SARS-CoV-2 infection.” They suggested frequent use of inexpensive, rapid home tests to identify people who are asymptomatic or presymptomatic, along with programs and housing provided by the government to offer financial assistance and allow this group of people to isolate themselves.

Further research is warranted to determine if and how well vaccines for SARS-CoV-2 prevent asymptomatic infection.

Dr. Topol and Mr. Oran created a short video to highlight the findings from their systematic review.

The study was supported by a grant from the National Institutes of Health.

A version of this article first appeared on Medscape.com.

Palliative care referrals for inpatients with pulmonary arterial hypertension averaged 2%, a retrospective study of more than 30,000 hospital admissions has found.

“Specialty palliative care services (PCS) are present in the vast majority of hospitals with more than 300 beds, and PCS use for patients who are facing serious illness with potentially life-limiting prognoses increasingly is becoming the standard of care,” wrote Vidhu Anand, MD, of the Mayo Clinic, Rochester, Minn., and colleagues. But despite experts recommending PCS in pulmonary arterial hypertension (PAH), data on the use of palliative care referrals for PAH patients are limited, they added.

In a study published in Chest, the researchers used the National (Nationwide) Inpatient Sample to identify 30,495 admissions with a primary diagnosis of PAH between 2001 through 2017. The primary outcome was the use of PCS in these patients.

Overall, inpatient use of PCS was 2.2%, but that figure increased from 0.5% in 2001 to 7.6% in 2017, representing a fivefold increase over the study period, with a significant increase after 2009. The reason for this notable increase remains unclear; however, “it may be related to recognition of palliative care and hospice as a medical subspecialty with board certification in 2008 or identification of palliative care by the National Priorities Partnership as one of six priority areas in 2008,” the researchers said.
 

Incorporating palliative care in a treatment strategy

The perception of PCS as an element of treatment plans for patients with severe lung disease, and not only as end-of-life care, has certainly increased in recent years, Sachin Gupta, MD, FCCP, said in an interview.

Dr. Gupta is a pulmonologist practicing in the San Francisco Bay area, and he did not take part in the study. He recommended early integration of PCS treating patients with PAH. “I have frequently asked PCS to aid early on during inpatient admission with PAH patients for pain management, as well as for aiding in POLST [Physician Orders for Life-Sustaining Treatment] paperwork to be completed. Increased age and comorbidities are certainly risk factors themselves for a longer hospital course and worse outcomes; in addition, in center-based PAH care there are more means available by which to give a patient with right heart failure that ‘one last shot’ – an opportunity for a longer life. I truly think it is a relationship with the patient, built from the outpatient pulmonary hypertension clinic, that allows the treating physician to have a better sense of a patient’s quality of life longitudinally, and to have the candid conversation when things begin to decline.”

Which patients receive PCS?

The study found that socioeconomic factors, and the severity of illness, are the drivers of PCS referrals. In a multivariate analysis, independent predictors of PCS use included white race, private insurance, and higher socioeconomic status. Additional independent predictors of PCS use included increased comorbidities, admission to an urban hospital, admission to a small hospital, presence of heart failure and cardiogenic shock, acute noncardiac organ failure, and use of extracorporeal membrane oxygenation and noninvasive mechanical ventilation, the researchers noted.

Patients who received PCS consultation were significantly more likely than those not receiving PCS to have DNR status (46.2% vs. 1.8%), longer length of hospital stay (12.9 days vs. 7.2 days), higher hospitalization costs $130,434 vs. $56,499), and higher in-hospital mortality (52.8% vs. 6.4%; P < .001 for all).

Some patients refuse PCS and others are not offered PCS. Dr. Gupta noted that it should be no surprise that not all patients are comfortable with the idea of a PCS referral. “Fear, misunderstanding, and cultural beliefs may be individually or together at the root of resistance to PCS. Their reluctance may be due to a ‘false narrative’ of the purpose of palliative care. The conception of PCS being for end-of-life care may be the result of personal experiences or experience with loved ones. Occasionally, a patient equates PCS with access to narcotics (‘knock me out’), which they may or may not want. I try to reassure patients that there will be no coercion for anything they do not want, and at the end of the day, the medical team is the main driver of their care, not the palliative service.”

Actively drug-abusing PAH patients are a particular challenge, said Dr. Gupta. These patients often refuse palliative care referral both as inpatients and outpatients. “Such patients are an enigma for many PAH-treating physicians as they may survive to discharge, despite a terrible prognosis predicted by their testing.”

In addition, patients in whom organ transplantation is being pursued may not receive timely PCS, he said. “It can be an absolute challenge to bring such patients to the finish line (transplantation), and the timing of PCS referral is often deferred. Arguably, for better or worse, such patients refuse, or more often are not offered, PCS as inpatients while there is still a chance organ transplantation is a viable option for them.”

The use of PCS in less than 10% of PAH admissions is similar to previous studies showing low use of PCS for patients with acute myocardial infarction, heart failure, and COPD, the researchers noted. However, “Given the high morbidity and mortality associated with PAH even after hospitalization, hospital admissions without PCS use represent a missed opportunity,” the investigators wrote.
 

Early warning on the need for PCS

Increasing PCS referrals for PAH patients requires clinicians to be proactive, Dr. Gupta stressed. “Pulmonologists, especially those managing pulmonary hypertension outpatients without the aid of a PAH center, should remain vigilant at all routine visits to calculate a patient’s risk score (i.e. REVEAL 2.0 risk calculator) to stratify their risk of 1-year mortality. Based on this assessment, shared decision making can help guide next steps including early outpatient PCS involvement for those at high risk. I also calculate a patient’s risk score, based on the data I have, when PAH patients are admitted to the hospital. Occasionally, a patient who I initially think is moderate risk turns out to be high risk when I calculate their risk score. In such high-risk patients, PCS consultation should certainly be considered early on.”

The study findings were limited by several factors including the possible coding errors associated with use of discharge diagnosis, lack of data on medication and the cause of PAH, and lack of information on the reasons for PCS referrals, the researchers noted. However, the results “addressed an important knowledge gap highlighting the national use of PCS in PAH,” they said. Further research is needed to address disparities and the integration of PCS into PAH care protocols, they added.

The researchers had no financial conflicts to disclose. The study received no outside funding; one coauthor disclosed support from the National Center for Advancing Translational Sciences Clinical and Translational Science.

Palliative care referrals for inpatients with pulmonary arterial hypertension averaged 2%, a retrospective study of more than 30,000 hospital admissions has found.

“Specialty palliative care services (PCS) are present in the vast majority of hospitals with more than 300 beds, and PCS use for patients who are facing serious illness with potentially life-limiting prognoses increasingly is becoming the standard of care,” wrote Vidhu Anand, MD, of the Mayo Clinic, Rochester, Minn., and colleagues. But despite experts recommending PCS in pulmonary arterial hypertension (PAH), data on the use of palliative care referrals for PAH patients are limited, they added.

In a study published in Chest, the researchers used the National (Nationwide) Inpatient Sample to identify 30,495 admissions with a primary diagnosis of PAH between 2001 through 2017. The primary outcome was the use of PCS in these patients.

Overall, inpatient use of PCS was 2.2%, but that figure increased from 0.5% in 2001 to 7.6% in 2017, representing a fivefold increase over the study period, with a significant increase after 2009. The reason for this notable increase remains unclear; however, “it may be related to recognition of palliative care and hospice as a medical subspecialty with board certification in 2008 or identification of palliative care by the National Priorities Partnership as one of six priority areas in 2008,” the researchers said.
 

Incorporating palliative care in a treatment strategy

The perception of PCS as an element of treatment plans for patients with severe lung disease, and not only as end-of-life care, has certainly increased in recent years, Sachin Gupta, MD, FCCP, said in an interview.

Dr. Gupta is a pulmonologist practicing in the San Francisco Bay area, and he did not take part in the study. He recommended early integration of PCS treating patients with PAH. “I have frequently asked PCS to aid early on during inpatient admission with PAH patients for pain management, as well as for aiding in POLST [Physician Orders for Life-Sustaining Treatment] paperwork to be completed. Increased age and comorbidities are certainly risk factors themselves for a longer hospital course and worse outcomes; in addition, in center-based PAH care there are more means available by which to give a patient with right heart failure that ‘one last shot’ – an opportunity for a longer life. I truly think it is a relationship with the patient, built from the outpatient pulmonary hypertension clinic, that allows the treating physician to have a better sense of a patient’s quality of life longitudinally, and to have the candid conversation when things begin to decline.”

Which patients receive PCS?

The study found that socioeconomic factors, and the severity of illness, are the drivers of PCS referrals. In a multivariate analysis, independent predictors of PCS use included white race, private insurance, and higher socioeconomic status. Additional independent predictors of PCS use included increased comorbidities, admission to an urban hospital, admission to a small hospital, presence of heart failure and cardiogenic shock, acute noncardiac organ failure, and use of extracorporeal membrane oxygenation and noninvasive mechanical ventilation, the researchers noted.

Patients who received PCS consultation were significantly more likely than those not receiving PCS to have DNR status (46.2% vs. 1.8%), longer length of hospital stay (12.9 days vs. 7.2 days), higher hospitalization costs $130,434 vs. $56,499), and higher in-hospital mortality (52.8% vs. 6.4%; P < .001 for all).

Some patients refuse PCS and others are not offered PCS. Dr. Gupta noted that it should be no surprise that not all patients are comfortable with the idea of a PCS referral. “Fear, misunderstanding, and cultural beliefs may be individually or together at the root of resistance to PCS. Their reluctance may be due to a ‘false narrative’ of the purpose of palliative care. The conception of PCS being for end-of-life care may be the result of personal experiences or experience with loved ones. Occasionally, a patient equates PCS with access to narcotics (‘knock me out’), which they may or may not want. I try to reassure patients that there will be no coercion for anything they do not want, and at the end of the day, the medical team is the main driver of their care, not the palliative service.”

Actively drug-abusing PAH patients are a particular challenge, said Dr. Gupta. These patients often refuse palliative care referral both as inpatients and outpatients. “Such patients are an enigma for many PAH-treating physicians as they may survive to discharge, despite a terrible prognosis predicted by their testing.”

In addition, patients in whom organ transplantation is being pursued may not receive timely PCS, he said. “It can be an absolute challenge to bring such patients to the finish line (transplantation), and the timing of PCS referral is often deferred. Arguably, for better or worse, such patients refuse, or more often are not offered, PCS as inpatients while there is still a chance organ transplantation is a viable option for them.”

The use of PCS in less than 10% of PAH admissions is similar to previous studies showing low use of PCS for patients with acute myocardial infarction, heart failure, and COPD, the researchers noted. However, “Given the high morbidity and mortality associated with PAH even after hospitalization, hospital admissions without PCS use represent a missed opportunity,” the investigators wrote.
 

Early warning on the need for PCS

Increasing PCS referrals for PAH patients requires clinicians to be proactive, Dr. Gupta stressed. “Pulmonologists, especially those managing pulmonary hypertension outpatients without the aid of a PAH center, should remain vigilant at all routine visits to calculate a patient’s risk score (i.e. REVEAL 2.0 risk calculator) to stratify their risk of 1-year mortality. Based on this assessment, shared decision making can help guide next steps including early outpatient PCS involvement for those at high risk. I also calculate a patient’s risk score, based on the data I have, when PAH patients are admitted to the hospital. Occasionally, a patient who I initially think is moderate risk turns out to be high risk when I calculate their risk score. In such high-risk patients, PCS consultation should certainly be considered early on.”

The study findings were limited by several factors including the possible coding errors associated with use of discharge diagnosis, lack of data on medication and the cause of PAH, and lack of information on the reasons for PCS referrals, the researchers noted. However, the results “addressed an important knowledge gap highlighting the national use of PCS in PAH,” they said. Further research is needed to address disparities and the integration of PCS into PAH care protocols, they added.

The researchers had no financial conflicts to disclose. The study received no outside funding; one coauthor disclosed support from the National Center for Advancing Translational Sciences Clinical and Translational Science.

Palliative care referrals for inpatients with pulmonary arterial hypertension averaged 2%, a retrospective study of more than 30,000 hospital admissions has found.

“Specialty palliative care services (PCS) are present in the vast majority of hospitals with more than 300 beds, and PCS use for patients who are facing serious illness with potentially life-limiting prognoses increasingly is becoming the standard of care,” wrote Vidhu Anand, MD, of the Mayo Clinic, Rochester, Minn., and colleagues. But despite experts recommending PCS in pulmonary arterial hypertension (PAH), data on the use of palliative care referrals for PAH patients are limited, they added.

In a study published in Chest, the researchers used the National (Nationwide) Inpatient Sample to identify 30,495 admissions with a primary diagnosis of PAH between 2001 through 2017. The primary outcome was the use of PCS in these patients.

Overall, inpatient use of PCS was 2.2%, but that figure increased from 0.5% in 2001 to 7.6% in 2017, representing a fivefold increase over the study period, with a significant increase after 2009. The reason for this notable increase remains unclear; however, “it may be related to recognition of palliative care and hospice as a medical subspecialty with board certification in 2008 or identification of palliative care by the National Priorities Partnership as one of six priority areas in 2008,” the researchers said.
 

Incorporating palliative care in a treatment strategy

The perception of PCS as an element of treatment plans for patients with severe lung disease, and not only as end-of-life care, has certainly increased in recent years, Sachin Gupta, MD, FCCP, said in an interview.

Dr. Gupta is a pulmonologist practicing in the San Francisco Bay area, and he did not take part in the study. He recommended early integration of PCS treating patients with PAH. “I have frequently asked PCS to aid early on during inpatient admission with PAH patients for pain management, as well as for aiding in POLST [Physician Orders for Life-Sustaining Treatment] paperwork to be completed. Increased age and comorbidities are certainly risk factors themselves for a longer hospital course and worse outcomes; in addition, in center-based PAH care there are more means available by which to give a patient with right heart failure that ‘one last shot’ – an opportunity for a longer life. I truly think it is a relationship with the patient, built from the outpatient pulmonary hypertension clinic, that allows the treating physician to have a better sense of a patient’s quality of life longitudinally, and to have the candid conversation when things begin to decline.”

Which patients receive PCS?

The study found that socioeconomic factors, and the severity of illness, are the drivers of PCS referrals. In a multivariate analysis, independent predictors of PCS use included white race, private insurance, and higher socioeconomic status. Additional independent predictors of PCS use included increased comorbidities, admission to an urban hospital, admission to a small hospital, presence of heart failure and cardiogenic shock, acute noncardiac organ failure, and use of extracorporeal membrane oxygenation and noninvasive mechanical ventilation, the researchers noted.

Patients who received PCS consultation were significantly more likely than those not receiving PCS to have DNR status (46.2% vs. 1.8%), longer length of hospital stay (12.9 days vs. 7.2 days), higher hospitalization costs $130,434 vs. $56,499), and higher in-hospital mortality (52.8% vs. 6.4%; P < .001 for all).

Some patients refuse PCS and others are not offered PCS. Dr. Gupta noted that it should be no surprise that not all patients are comfortable with the idea of a PCS referral. “Fear, misunderstanding, and cultural beliefs may be individually or together at the root of resistance to PCS. Their reluctance may be due to a ‘false narrative’ of the purpose of palliative care. The conception of PCS being for end-of-life care may be the result of personal experiences or experience with loved ones. Occasionally, a patient equates PCS with access to narcotics (‘knock me out’), which they may or may not want. I try to reassure patients that there will be no coercion for anything they do not want, and at the end of the day, the medical team is the main driver of their care, not the palliative service.”

Actively drug-abusing PAH patients are a particular challenge, said Dr. Gupta. These patients often refuse palliative care referral both as inpatients and outpatients. “Such patients are an enigma for many PAH-treating physicians as they may survive to discharge, despite a terrible prognosis predicted by their testing.”

In addition, patients in whom organ transplantation is being pursued may not receive timely PCS, he said. “It can be an absolute challenge to bring such patients to the finish line (transplantation), and the timing of PCS referral is often deferred. Arguably, for better or worse, such patients refuse, or more often are not offered, PCS as inpatients while there is still a chance organ transplantation is a viable option for them.”

The use of PCS in less than 10% of PAH admissions is similar to previous studies showing low use of PCS for patients with acute myocardial infarction, heart failure, and COPD, the researchers noted. However, “Given the high morbidity and mortality associated with PAH even after hospitalization, hospital admissions without PCS use represent a missed opportunity,” the investigators wrote.
 

Early warning on the need for PCS

Increasing PCS referrals for PAH patients requires clinicians to be proactive, Dr. Gupta stressed. “Pulmonologists, especially those managing pulmonary hypertension outpatients without the aid of a PAH center, should remain vigilant at all routine visits to calculate a patient’s risk score (i.e. REVEAL 2.0 risk calculator) to stratify their risk of 1-year mortality. Based on this assessment, shared decision making can help guide next steps including early outpatient PCS involvement for those at high risk. I also calculate a patient’s risk score, based on the data I have, when PAH patients are admitted to the hospital. Occasionally, a patient who I initially think is moderate risk turns out to be high risk when I calculate their risk score. In such high-risk patients, PCS consultation should certainly be considered early on.”

The study findings were limited by several factors including the possible coding errors associated with use of discharge diagnosis, lack of data on medication and the cause of PAH, and lack of information on the reasons for PCS referrals, the researchers noted. However, the results “addressed an important knowledge gap highlighting the national use of PCS in PAH,” they said. Further research is needed to address disparities and the integration of PCS into PAH care protocols, they added.

The researchers had no financial conflicts to disclose. The study received no outside funding; one coauthor disclosed support from the National Center for Advancing Translational Sciences Clinical and Translational Science.

Both patients in contact with primary care physicians and patient contact with these physicians in any form – including in office or over the phone – declined over 2-year periods occurring from 2002 to 2017.

The reasons for this less frequent contact and the ramifications for patients and doctors practicing primary care are unclear, according to various experts. But some offered possible explanations for the changes, with patients’ increased participation in high deductible plans and shortages in primary care physicians (PCPs) being among the most often cited.

The findings, which were published online Jan. 11 in Annals of Family Medicine, were derived from researchers using a repeated cross-sectional study of the 2002-2017 Medical Expenditure Panel Survey to characterize trends in primary care use. This survey, which collected information about medical care utilization from individuals and families, included 243,919 participants who were interviewed five times over 2 years. The authors defined primary care physician contact as “in-person visit or contact with a primary care physician (primarily telephone calls) with a reported specialty of family medicine, general internal medicine, geriatrics, general pediatrics, or general practice physician.” According to the paper, “the proportion of individuals with any primary care physician contact was determined for both the population and by age group using logistic regression models,” and negative binomial regression models were used to determine the number of contacts among people with visits during 2-year periods.

The study authors, Michael E. Johansen, MD, MS, and Joshua D. Niforatos, MD, MTS, said their study suggests that previously reported decreases in primary care contact was caused by fewer contacts per patient “as opposed to an absolute decrease in the number of patients in contact with primary care.”

Harold B. Betton, MD, PhD, who practices family medicine in Little Rock, Ark., questioned this claim.

"The paper draws observational conclusions and I fail to see the merit in the observation without knowing what the respondents were asked and not asked," he added. 

Other primary care physicians suggested patients’ participation in alternative pay models and high-deductible plans have played a factor in the declines.

Courtesy of Ada Stewart, MD

“Most of us have gone from fee-for-service, volume-based care to more value-based care,” Ada D. Stewart, MD, president of the American Academy of Family Physicians, said in an interview. The data reflect that trend, “whereas we were rewarded more for the number of people we were seeing, now we are trying to get towards more of the value that we provide,” suggested Dr. Stewart, who also practices family medicine with Cooperative Health in Columbia, S.C.

“Given the rise of high-deductible plans and copays, it is not surprising that younger patients, a generally healthier population, might well decrease their visits to a primary care physician. I would suspect that data for patients over 50 might well be different,” William E. Golden, MD, who is medical director at the Arkansas Department of Health & Human Services, noted in an interview.

Eileen Barrett, MD, MPH, also cited greater participation in high-deductible plans as a possible factor that could be leading some patients to forgo visits, as well as increased financial insecurity, rendering it expensive to have the visit and also to take time from work for the visit.

“I would wonder if some of this is also due to how overloaded most primary care offices are so that instead of stopping accepting new patients or shedding patients, it is just harder for existing patients to be seen,” said Dr. Barrett, who is a general internist and associate professor in the division of hospital medicine, department of internal medicine, at the University of New Mexico, Albuquerque. “Some of this could be from administrative burden – 2 hours per hour of clinic – and consequently reducing clinical time,” continued Dr. Barrett, who also serves on the editorial advisory board of Internal Medicine News, which is affiliated with Family Practice News.

Other experts pointed to data showing an insufficient supply of PCPs as a potential explanation for the new study’s findings. The Health Resources and Services Organization, for example, reported that 83 million Americans live in primary care “health professional shortage areas,” as of Jan. 24, 2021, on their website.
 

New data

“The rate of any contact with a [PCP] for patients in the population over multiple 2-year periods decreased by 2.5% over the study period (adjusted odds ratio, 0.99 per panel; 95% [confidence interval], 0.98-0.99; P < .001),” wrote Dr. Johansen and Dr. Niforatos. The rate of contact for patients aged 18-39 years (aOR, 0.99 per panel; 95% CI, 0.98-0.99; P < .001) and patients aged 40-64 years (aOR, 0.99 per panel; 95% CI, 0.99-1.00; P = .002), specifically, also fell. These decreased contact rates correspond “to a predicted cumulative 5% absolute decrease for the younger group and a 2% absolute decrease for the older group,” the authors added.

“The number of contacts with a [PCP] decreased among individuals with any contact by 0.5 contacts over 2 years (P < .001). A decrease in the number of [PCP] contacts was observed across all age groups (P < .001 for all), with the largest absolute decrease among individuals with higher contact rates (aged less than 4 years and aged greater than 64 years),” according to the paper.

Outlook for PCPs

Physicians questioned about how concerning these data are for the future of PCPs and their ability to keep their practices running were hesitant to speculate, because of uncertainty about the causes of the study findings.

“A quote from the paper indicates that the respondents were interviewed five times over 2 years; however, without a copy of the questionnaire it is impossible to know what they were asked and not asked,” said Dr. Betton, who also serves on the editorial advisory board of Family Practice News and runs his own private practice. “In addition, it is impossible for the reader to know whether they understood what a primary care physician was to do.

“To draw a conclusion that PCP visits are falling off per patient per provider is only helpful if patients are opting out of the primary care model of practice and opting in for point-of-care [urgent] care,” Dr. Betton added.

Internist Alan Nelson, MD, said he was also undecided about whether the findings of the study are good or bad news for the physician specialty of primary care.

“Similar findings have been reported by the Medicare Payment Advisory Commission. They certainly merit further investigation,” noted Dr. Nelson, who is a member of the editorial advisory board of Internal Medicine News. “Is it because primary care physicians are too busy to see additional patients? Is it because nonphysician practitioners seem to be more caring? Should residency training be modified, and if so, how? In the meantime, I would not be surprised if the trend continues, at least in the short term.”

Ann Greiner, president and CEO of the Primary Care Collaborative, a nonprofit organization that advocates to strengthen primary care and make it more responsive to patient needs and preferences, on the other hand, reacted with a concerned outlook for primary care.

This study and others show that “the U.S. health care system is moving away from a primary care orientation, and that is concerning,” Ms. Greiner said in an interview. “Health systems that are more oriented toward primary care have better population health outcomes, do better on measures of equity across different population groups, and are less costly.”
 

Authors’ take

“Future research is needed to determine whether fewer contacts per patient resulted in clinically meaningful differences in outcomes across disease processes,” wrote Dr. Johansen, who is a family medicine doctor affiliated with OhioHealth Family Medicine Grant in Columbus and with the Heritage College of Osteopathic Medicine at Ohio University, Dublin, and Dr. Niforatos, who is affiliated with the department of emergency medicine at Johns Hopkins University, Baltimore.

The study’s limitations included reliance on self-reported categorization of PCP versus specialty care physician contact, insufficient accounting for nurse practitioner and physician assistant contact, and improved contact reporting having started in 2013, they said.
 

How to grow patient contact

For those PCPs looking to grow their visits and patient contact, Dr. Golden suggested they strengthen their medical home model in their practice.

“Medical home models help and transform practice operations. The Arkansas model is a multipayer model – private, Medicaid and CPC+ (Medicare),” said Dr. Golden, who also serves on the editorial advisory board of Internal Medicine News. It includes community-based doctors, not Federally Qualified Health Centers, and “requires 24/7 live voice access that promotes regular contact with patients and can reduce dependency on ER and urgent care center visits.”

“Greater use of patient portals and email communications facilitate access and patient engagement with their PCP,” Dr. Golden explained.

 “Over the last 6 years, the Arkansas [patient-centered medical home] initiatives have altered culture and made our practice sites stronger to withstand COVID and other challenges. As our sites became more patient centered and incorporated behavioral health options, patients perceived greater value in the functionality of primary care” he said.

Dr. Barrett proposed PCPs participate in team-based care “for professional sustainability and also for patients to continue to experience high-quality, person-centered care.” She added that “telemedicine can also help practices maintain and increase patients, as it can lessen burden on patients and clinicians – if it is done right.”

“More flexible clinic hours is also key – after usual business hours and on weekends – but I would recommend in lieu of usual weekday hours and for those who can make it work with their family and other duties,” Dr. Barrett said. “Evening or Saturday morning clinic isn’t an option for everyone, but it is an option for many some of the time, and it would be great for access to care if it were available in more locations.”
 

Pandemic effect

The data examined by Dr. Johansen and Dr. Niforatos predates the pandemic, but PCPs interviewed by this news organization have seen declining patient contact occur in 2020 as well.

In fact, a survey of 1,485 mostly physician primary care practitioners that began after the pandemic onset found that 43% of participants have fewer in-person visits, motivated largely by patient preferences (66%) and safety concerns (74%). This ongoing survey, which was conducted by the Larry Green Center in partnership with the Primary Care Collaborative, also indicated that, while 25% of participants saw a total increase in patient volume, more than half of primary care practitioners reported that chronic and wellness visits are down, 53% and 55%, respectively.

“Sometimes we have to go looking for our patients when we have not seen them in a while,” Dr. Stewart noted. “We saw that with COVID because people were fearful of coming into our offices, and we had to have some outreach.”

The study authors had no conflicts of interest. Dr. Barrett, Dr. Betton, Dr. Golden, Dr. Nelson, and Dr. Stewart had no relevant disclosures.

Jake Remaly contributed to this article.

klennon@mdedge.com

Both patients in contact with primary care physicians and patient contact with these physicians in any form – including in office or over the phone – declined over 2-year periods occurring from 2002 to 2017.

The reasons for this less frequent contact and the ramifications for patients and doctors practicing primary care are unclear, according to various experts. But some offered possible explanations for the changes, with patients’ increased participation in high deductible plans and shortages in primary care physicians (PCPs) being among the most often cited.

The findings, which were published online Jan. 11 in Annals of Family Medicine, were derived from researchers using a repeated cross-sectional study of the 2002-2017 Medical Expenditure Panel Survey to characterize trends in primary care use. This survey, which collected information about medical care utilization from individuals and families, included 243,919 participants who were interviewed five times over 2 years. The authors defined primary care physician contact as “in-person visit or contact with a primary care physician (primarily telephone calls) with a reported specialty of family medicine, general internal medicine, geriatrics, general pediatrics, or general practice physician.” According to the paper, “the proportion of individuals with any primary care physician contact was determined for both the population and by age group using logistic regression models,” and negative binomial regression models were used to determine the number of contacts among people with visits during 2-year periods.

The study authors, Michael E. Johansen, MD, MS, and Joshua D. Niforatos, MD, MTS, said their study suggests that previously reported decreases in primary care contact was caused by fewer contacts per patient “as opposed to an absolute decrease in the number of patients in contact with primary care.”

Harold B. Betton, MD, PhD, who practices family medicine in Little Rock, Ark., questioned this claim.

"The paper draws observational conclusions and I fail to see the merit in the observation without knowing what the respondents were asked and not asked," he added. 

Other primary care physicians suggested patients’ participation in alternative pay models and high-deductible plans have played a factor in the declines.

Courtesy of Ada Stewart, MD

“Most of us have gone from fee-for-service, volume-based care to more value-based care,” Ada D. Stewart, MD, president of the American Academy of Family Physicians, said in an interview. The data reflect that trend, “whereas we were rewarded more for the number of people we were seeing, now we are trying to get towards more of the value that we provide,” suggested Dr. Stewart, who also practices family medicine with Cooperative Health in Columbia, S.C.

“Given the rise of high-deductible plans and copays, it is not surprising that younger patients, a generally healthier population, might well decrease their visits to a primary care physician. I would suspect that data for patients over 50 might well be different,” William E. Golden, MD, who is medical director at the Arkansas Department of Health & Human Services, noted in an interview.

Eileen Barrett, MD, MPH, also cited greater participation in high-deductible plans as a possible factor that could be leading some patients to forgo visits, as well as increased financial insecurity, rendering it expensive to have the visit and also to take time from work for the visit.

“I would wonder if some of this is also due to how overloaded most primary care offices are so that instead of stopping accepting new patients or shedding patients, it is just harder for existing patients to be seen,” said Dr. Barrett, who is a general internist and associate professor in the division of hospital medicine, department of internal medicine, at the University of New Mexico, Albuquerque. “Some of this could be from administrative burden – 2 hours per hour of clinic – and consequently reducing clinical time,” continued Dr. Barrett, who also serves on the editorial advisory board of Internal Medicine News, which is affiliated with Family Practice News.

Other experts pointed to data showing an insufficient supply of PCPs as a potential explanation for the new study’s findings. The Health Resources and Services Organization, for example, reported that 83 million Americans live in primary care “health professional shortage areas,” as of Jan. 24, 2021, on their website.
 

New data

“The rate of any contact with a [PCP] for patients in the population over multiple 2-year periods decreased by 2.5% over the study period (adjusted odds ratio, 0.99 per panel; 95% [confidence interval], 0.98-0.99; P < .001),” wrote Dr. Johansen and Dr. Niforatos. The rate of contact for patients aged 18-39 years (aOR, 0.99 per panel; 95% CI, 0.98-0.99; P < .001) and patients aged 40-64 years (aOR, 0.99 per panel; 95% CI, 0.99-1.00; P = .002), specifically, also fell. These decreased contact rates correspond “to a predicted cumulative 5% absolute decrease for the younger group and a 2% absolute decrease for the older group,” the authors added.

“The number of contacts with a [PCP] decreased among individuals with any contact by 0.5 contacts over 2 years (P < .001). A decrease in the number of [PCP] contacts was observed across all age groups (P < .001 for all), with the largest absolute decrease among individuals with higher contact rates (aged less than 4 years and aged greater than 64 years),” according to the paper.

Outlook for PCPs

Physicians questioned about how concerning these data are for the future of PCPs and their ability to keep their practices running were hesitant to speculate, because of uncertainty about the causes of the study findings.

“A quote from the paper indicates that the respondents were interviewed five times over 2 years; however, without a copy of the questionnaire it is impossible to know what they were asked and not asked,” said Dr. Betton, who also serves on the editorial advisory board of Family Practice News and runs his own private practice. “In addition, it is impossible for the reader to know whether they understood what a primary care physician was to do.

“To draw a conclusion that PCP visits are falling off per patient per provider is only helpful if patients are opting out of the primary care model of practice and opting in for point-of-care [urgent] care,” Dr. Betton added.

Internist Alan Nelson, MD, said he was also undecided about whether the findings of the study are good or bad news for the physician specialty of primary care.

“Similar findings have been reported by the Medicare Payment Advisory Commission. They certainly merit further investigation,” noted Dr. Nelson, who is a member of the editorial advisory board of Internal Medicine News. “Is it because primary care physicians are too busy to see additional patients? Is it because nonphysician practitioners seem to be more caring? Should residency training be modified, and if so, how? In the meantime, I would not be surprised if the trend continues, at least in the short term.”

Ann Greiner, president and CEO of the Primary Care Collaborative, a nonprofit organization that advocates to strengthen primary care and make it more responsive to patient needs and preferences, on the other hand, reacted with a concerned outlook for primary care.

This study and others show that “the U.S. health care system is moving away from a primary care orientation, and that is concerning,” Ms. Greiner said in an interview. “Health systems that are more oriented toward primary care have better population health outcomes, do better on measures of equity across different population groups, and are less costly.”
 

Authors’ take

“Future research is needed to determine whether fewer contacts per patient resulted in clinically meaningful differences in outcomes across disease processes,” wrote Dr. Johansen, who is a family medicine doctor affiliated with OhioHealth Family Medicine Grant in Columbus and with the Heritage College of Osteopathic Medicine at Ohio University, Dublin, and Dr. Niforatos, who is affiliated with the department of emergency medicine at Johns Hopkins University, Baltimore.

The study’s limitations included reliance on self-reported categorization of PCP versus specialty care physician contact, insufficient accounting for nurse practitioner and physician assistant contact, and improved contact reporting having started in 2013, they said.
 

How to grow patient contact

For those PCPs looking to grow their visits and patient contact, Dr. Golden suggested they strengthen their medical home model in their practice.

“Medical home models help and transform practice operations. The Arkansas model is a multipayer model – private, Medicaid and CPC+ (Medicare),” said Dr. Golden, who also serves on the editorial advisory board of Internal Medicine News. It includes community-based doctors, not Federally Qualified Health Centers, and “requires 24/7 live voice access that promotes regular contact with patients and can reduce dependency on ER and urgent care center visits.”

“Greater use of patient portals and email communications facilitate access and patient engagement with their PCP,” Dr. Golden explained.

 “Over the last 6 years, the Arkansas [patient-centered medical home] initiatives have altered culture and made our practice sites stronger to withstand COVID and other challenges. As our sites became more patient centered and incorporated behavioral health options, patients perceived greater value in the functionality of primary care” he said.

Dr. Barrett proposed PCPs participate in team-based care “for professional sustainability and also for patients to continue to experience high-quality, person-centered care.” She added that “telemedicine can also help practices maintain and increase patients, as it can lessen burden on patients and clinicians – if it is done right.”

“More flexible clinic hours is also key – after usual business hours and on weekends – but I would recommend in lieu of usual weekday hours and for those who can make it work with their family and other duties,” Dr. Barrett said. “Evening or Saturday morning clinic isn’t an option for everyone, but it is an option for many some of the time, and it would be great for access to care if it were available in more locations.”
 

Pandemic effect

The data examined by Dr. Johansen and Dr. Niforatos predates the pandemic, but PCPs interviewed by this news organization have seen declining patient contact occur in 2020 as well.

In fact, a survey of 1,485 mostly physician primary care practitioners that began after the pandemic onset found that 43% of participants have fewer in-person visits, motivated largely by patient preferences (66%) and safety concerns (74%). This ongoing survey, which was conducted by the Larry Green Center in partnership with the Primary Care Collaborative, also indicated that, while 25% of participants saw a total increase in patient volume, more than half of primary care practitioners reported that chronic and wellness visits are down, 53% and 55%, respectively.

“Sometimes we have to go looking for our patients when we have not seen them in a while,” Dr. Stewart noted. “We saw that with COVID because people were fearful of coming into our offices, and we had to have some outreach.”

The study authors had no conflicts of interest. Dr. Barrett, Dr. Betton, Dr. Golden, Dr. Nelson, and Dr. Stewart had no relevant disclosures.

Jake Remaly contributed to this article.

klennon@mdedge.com

Both patients in contact with primary care physicians and patient contact with these physicians in any form – including in office or over the phone – declined over 2-year periods occurring from 2002 to 2017.

The reasons for this less frequent contact and the ramifications for patients and doctors practicing primary care are unclear, according to various experts. But some offered possible explanations for the changes, with patients’ increased participation in high deductible plans and shortages in primary care physicians (PCPs) being among the most often cited.

The findings, which were published online Jan. 11 in Annals of Family Medicine, were derived from researchers using a repeated cross-sectional study of the 2002-2017 Medical Expenditure Panel Survey to characterize trends in primary care use. This survey, which collected information about medical care utilization from individuals and families, included 243,919 participants who were interviewed five times over 2 years. The authors defined primary care physician contact as “in-person visit or contact with a primary care physician (primarily telephone calls) with a reported specialty of family medicine, general internal medicine, geriatrics, general pediatrics, or general practice physician.” According to the paper, “the proportion of individuals with any primary care physician contact was determined for both the population and by age group using logistic regression models,” and negative binomial regression models were used to determine the number of contacts among people with visits during 2-year periods.

The study authors, Michael E. Johansen, MD, MS, and Joshua D. Niforatos, MD, MTS, said their study suggests that previously reported decreases in primary care contact was caused by fewer contacts per patient “as opposed to an absolute decrease in the number of patients in contact with primary care.”

Harold B. Betton, MD, PhD, who practices family medicine in Little Rock, Ark., questioned this claim.

"The paper draws observational conclusions and I fail to see the merit in the observation without knowing what the respondents were asked and not asked," he added. 

Other primary care physicians suggested patients’ participation in alternative pay models and high-deductible plans have played a factor in the declines.

Courtesy of Ada Stewart, MD

“Most of us have gone from fee-for-service, volume-based care to more value-based care,” Ada D. Stewart, MD, president of the American Academy of Family Physicians, said in an interview. The data reflect that trend, “whereas we were rewarded more for the number of people we were seeing, now we are trying to get towards more of the value that we provide,” suggested Dr. Stewart, who also practices family medicine with Cooperative Health in Columbia, S.C.

“Given the rise of high-deductible plans and copays, it is not surprising that younger patients, a generally healthier population, might well decrease their visits to a primary care physician. I would suspect that data for patients over 50 might well be different,” William E. Golden, MD, who is medical director at the Arkansas Department of Health & Human Services, noted in an interview.

Eileen Barrett, MD, MPH, also cited greater participation in high-deductible plans as a possible factor that could be leading some patients to forgo visits, as well as increased financial insecurity, rendering it expensive to have the visit and also to take time from work for the visit.

“I would wonder if some of this is also due to how overloaded most primary care offices are so that instead of stopping accepting new patients or shedding patients, it is just harder for existing patients to be seen,” said Dr. Barrett, who is a general internist and associate professor in the division of hospital medicine, department of internal medicine, at the University of New Mexico, Albuquerque. “Some of this could be from administrative burden – 2 hours per hour of clinic – and consequently reducing clinical time,” continued Dr. Barrett, who also serves on the editorial advisory board of Internal Medicine News, which is affiliated with Family Practice News.

Other experts pointed to data showing an insufficient supply of PCPs as a potential explanation for the new study’s findings. The Health Resources and Services Organization, for example, reported that 83 million Americans live in primary care “health professional shortage areas,” as of Jan. 24, 2021, on their website.
 

New data

“The rate of any contact with a [PCP] for patients in the population over multiple 2-year periods decreased by 2.5% over the study period (adjusted odds ratio, 0.99 per panel; 95% [confidence interval], 0.98-0.99; P < .001),” wrote Dr. Johansen and Dr. Niforatos. The rate of contact for patients aged 18-39 years (aOR, 0.99 per panel; 95% CI, 0.98-0.99; P < .001) and patients aged 40-64 years (aOR, 0.99 per panel; 95% CI, 0.99-1.00; P = .002), specifically, also fell. These decreased contact rates correspond “to a predicted cumulative 5% absolute decrease for the younger group and a 2% absolute decrease for the older group,” the authors added.

“The number of contacts with a [PCP] decreased among individuals with any contact by 0.5 contacts over 2 years (P < .001). A decrease in the number of [PCP] contacts was observed across all age groups (P < .001 for all), with the largest absolute decrease among individuals with higher contact rates (aged less than 4 years and aged greater than 64 years),” according to the paper.

Outlook for PCPs

Physicians questioned about how concerning these data are for the future of PCPs and their ability to keep their practices running were hesitant to speculate, because of uncertainty about the causes of the study findings.

“A quote from the paper indicates that the respondents were interviewed five times over 2 years; however, without a copy of the questionnaire it is impossible to know what they were asked and not asked,” said Dr. Betton, who also serves on the editorial advisory board of Family Practice News and runs his own private practice. “In addition, it is impossible for the reader to know whether they understood what a primary care physician was to do.

“To draw a conclusion that PCP visits are falling off per patient per provider is only helpful if patients are opting out of the primary care model of practice and opting in for point-of-care [urgent] care,” Dr. Betton added.

Internist Alan Nelson, MD, said he was also undecided about whether the findings of the study are good or bad news for the physician specialty of primary care.

“Similar findings have been reported by the Medicare Payment Advisory Commission. They certainly merit further investigation,” noted Dr. Nelson, who is a member of the editorial advisory board of Internal Medicine News. “Is it because primary care physicians are too busy to see additional patients? Is it because nonphysician practitioners seem to be more caring? Should residency training be modified, and if so, how? In the meantime, I would not be surprised if the trend continues, at least in the short term.”

Ann Greiner, president and CEO of the Primary Care Collaborative, a nonprofit organization that advocates to strengthen primary care and make it more responsive to patient needs and preferences, on the other hand, reacted with a concerned outlook for primary care.

This study and others show that “the U.S. health care system is moving away from a primary care orientation, and that is concerning,” Ms. Greiner said in an interview. “Health systems that are more oriented toward primary care have better population health outcomes, do better on measures of equity across different population groups, and are less costly.”
 

Authors’ take

“Future research is needed to determine whether fewer contacts per patient resulted in clinically meaningful differences in outcomes across disease processes,” wrote Dr. Johansen, who is a family medicine doctor affiliated with OhioHealth Family Medicine Grant in Columbus and with the Heritage College of Osteopathic Medicine at Ohio University, Dublin, and Dr. Niforatos, who is affiliated with the department of emergency medicine at Johns Hopkins University, Baltimore.

The study’s limitations included reliance on self-reported categorization of PCP versus specialty care physician contact, insufficient accounting for nurse practitioner and physician assistant contact, and improved contact reporting having started in 2013, they said.
 

How to grow patient contact

For those PCPs looking to grow their visits and patient contact, Dr. Golden suggested they strengthen their medical home model in their practice.

“Medical home models help and transform practice operations. The Arkansas model is a multipayer model – private, Medicaid and CPC+ (Medicare),” said Dr. Golden, who also serves on the editorial advisory board of Internal Medicine News. It includes community-based doctors, not Federally Qualified Health Centers, and “requires 24/7 live voice access that promotes regular contact with patients and can reduce dependency on ER and urgent care center visits.”

“Greater use of patient portals and email communications facilitate access and patient engagement with their PCP,” Dr. Golden explained.

 “Over the last 6 years, the Arkansas [patient-centered medical home] initiatives have altered culture and made our practice sites stronger to withstand COVID and other challenges. As our sites became more patient centered and incorporated behavioral health options, patients perceived greater value in the functionality of primary care” he said.

Dr. Barrett proposed PCPs participate in team-based care “for professional sustainability and also for patients to continue to experience high-quality, person-centered care.” She added that “telemedicine can also help practices maintain and increase patients, as it can lessen burden on patients and clinicians – if it is done right.”

“More flexible clinic hours is also key – after usual business hours and on weekends – but I would recommend in lieu of usual weekday hours and for those who can make it work with their family and other duties,” Dr. Barrett said. “Evening or Saturday morning clinic isn’t an option for everyone, but it is an option for many some of the time, and it would be great for access to care if it were available in more locations.”
 

Pandemic effect

The data examined by Dr. Johansen and Dr. Niforatos predates the pandemic, but PCPs interviewed by this news organization have seen declining patient contact occur in 2020 as well.

In fact, a survey of 1,485 mostly physician primary care practitioners that began after the pandemic onset found that 43% of participants have fewer in-person visits, motivated largely by patient preferences (66%) and safety concerns (74%). This ongoing survey, which was conducted by the Larry Green Center in partnership with the Primary Care Collaborative, also indicated that, while 25% of participants saw a total increase in patient volume, more than half of primary care practitioners reported that chronic and wellness visits are down, 53% and 55%, respectively.

“Sometimes we have to go looking for our patients when we have not seen them in a while,” Dr. Stewart noted. “We saw that with COVID because people were fearful of coming into our offices, and we had to have some outreach.”

The study authors had no conflicts of interest. Dr. Barrett, Dr. Betton, Dr. Golden, Dr. Nelson, and Dr. Stewart had no relevant disclosures.

Jake Remaly contributed to this article.

klennon@mdedge.com

Fully half of patients with moderate to severe psoriasis who achieve complete clearance after their first four doses of guselkumab (Tremfya) continue to maintain a PASI 90 response nearly 6 months after withdrawal of the biologic, according to a post hoc analysis of the pivotal phase 3 VOYAGE 2 trial.

“That’s impressive maintenance of efficacy,” said Curdin Conrad, MD, who presented the data at the virtual annual congress of the European Academy of Dermatology and Venereology.

“These findings are reassuring when you have to interrupt guselkumab therapy: For example, due to acute infection, pregnancy, or surgery. But it might also help when considering in the future a flexible dosing interval, particularly for patients who had complete clearance,” added Dr. Conrad, professor of dermatology and head of the polyclinic and the Center of Excellence for Psoriasis at Lausanne (Switzerland) University Hospital.

The intriguing implication from VOYAGE 2 that guselkumab might lend itself to flexible dosing featuring lengthy drug-free intervals is being prospectively examined in the ongoing phase 3b GUIDE trial. This is a double-blind, placebo-controlled trial including 888 French and German patients with moderate to severe psoriasis and a study hypothesis that those who have a Psoriasis Area and Severity Index score of 0 at weeks 20 and 28 in response to on-label dosing – the so-called ‘super responders’ – will maintain disease control until week 68 if their dosing is reduced to 100 mg of guselkumab every 16 weeks instead of the standard 8-week intervals.

Dr. Conrad reported that in VOYAGE 2, 106 patients on standard-dose guselkumab who had a PASI score of 0 at weeks 20 and 28 were randomized to discontinue the interleukin-23 inhibitor after receiving their fourth dose at week 20. It took 25 weeks for 50% of them to lose their PASI 90 response as defined by regression to a PASI score of 1 or greater. Using a less stringent definition of maintenance of efficacy, the super responders’ median time off guselkumab until reaching a PASI score of 3 or more was 30.7 weeks, with a median of 35.4 weeks to a PASI score of 5 or more.

In addition, 34 other VOYAGE 2 participants who were almost clear on guselkumab at weeks 20 and 28, with a PASI score of more than 0 but less than 1, were randomized to guselkumab withdrawal after their week-20 dose. Median time to loss of their PASI 90 response was shorter than that of the super responders – not surprising since their mean PASI score when the biologic was halted was 0.5, rather than 0 as for the super responders. But Dr. Conrad said the maintenance of response was still impressive: A median of 16.2 weeks to reach a PASI score of 1 or more, 27.2 weeks for a PASI 3, and 33.7 weeks for a PASI score of 5.

He reported receiving research funding from and serving as a scientific adviser to Janssen, the study sponsor, as well as to more than a dozen other pharmaceutical companies.

bjancin@mdedge.com

Fully half of patients with moderate to severe psoriasis who achieve complete clearance after their first four doses of guselkumab (Tremfya) continue to maintain a PASI 90 response nearly 6 months after withdrawal of the biologic, according to a post hoc analysis of the pivotal phase 3 VOYAGE 2 trial.

“That’s impressive maintenance of efficacy,” said Curdin Conrad, MD, who presented the data at the virtual annual congress of the European Academy of Dermatology and Venereology.

“These findings are reassuring when you have to interrupt guselkumab therapy: For example, due to acute infection, pregnancy, or surgery. But it might also help when considering in the future a flexible dosing interval, particularly for patients who had complete clearance,” added Dr. Conrad, professor of dermatology and head of the polyclinic and the Center of Excellence for Psoriasis at Lausanne (Switzerland) University Hospital.

The intriguing implication from VOYAGE 2 that guselkumab might lend itself to flexible dosing featuring lengthy drug-free intervals is being prospectively examined in the ongoing phase 3b GUIDE trial. This is a double-blind, placebo-controlled trial including 888 French and German patients with moderate to severe psoriasis and a study hypothesis that those who have a Psoriasis Area and Severity Index score of 0 at weeks 20 and 28 in response to on-label dosing – the so-called ‘super responders’ – will maintain disease control until week 68 if their dosing is reduced to 100 mg of guselkumab every 16 weeks instead of the standard 8-week intervals.

Dr. Conrad reported that in VOYAGE 2, 106 patients on standard-dose guselkumab who had a PASI score of 0 at weeks 20 and 28 were randomized to discontinue the interleukin-23 inhibitor after receiving their fourth dose at week 20. It took 25 weeks for 50% of them to lose their PASI 90 response as defined by regression to a PASI score of 1 or greater. Using a less stringent definition of maintenance of efficacy, the super responders’ median time off guselkumab until reaching a PASI score of 3 or more was 30.7 weeks, with a median of 35.4 weeks to a PASI score of 5 or more.

In addition, 34 other VOYAGE 2 participants who were almost clear on guselkumab at weeks 20 and 28, with a PASI score of more than 0 but less than 1, were randomized to guselkumab withdrawal after their week-20 dose. Median time to loss of their PASI 90 response was shorter than that of the super responders – not surprising since their mean PASI score when the biologic was halted was 0.5, rather than 0 as for the super responders. But Dr. Conrad said the maintenance of response was still impressive: A median of 16.2 weeks to reach a PASI score of 1 or more, 27.2 weeks for a PASI 3, and 33.7 weeks for a PASI score of 5.

He reported receiving research funding from and serving as a scientific adviser to Janssen, the study sponsor, as well as to more than a dozen other pharmaceutical companies.

bjancin@mdedge.com

Fully half of patients with moderate to severe psoriasis who achieve complete clearance after their first four doses of guselkumab (Tremfya) continue to maintain a PASI 90 response nearly 6 months after withdrawal of the biologic, according to a post hoc analysis of the pivotal phase 3 VOYAGE 2 trial.

“That’s impressive maintenance of efficacy,” said Curdin Conrad, MD, who presented the data at the virtual annual congress of the European Academy of Dermatology and Venereology.

“These findings are reassuring when you have to interrupt guselkumab therapy: For example, due to acute infection, pregnancy, or surgery. But it might also help when considering in the future a flexible dosing interval, particularly for patients who had complete clearance,” added Dr. Conrad, professor of dermatology and head of the polyclinic and the Center of Excellence for Psoriasis at Lausanne (Switzerland) University Hospital.

The intriguing implication from VOYAGE 2 that guselkumab might lend itself to flexible dosing featuring lengthy drug-free intervals is being prospectively examined in the ongoing phase 3b GUIDE trial. This is a double-blind, placebo-controlled trial including 888 French and German patients with moderate to severe psoriasis and a study hypothesis that those who have a Psoriasis Area and Severity Index score of 0 at weeks 20 and 28 in response to on-label dosing – the so-called ‘super responders’ – will maintain disease control until week 68 if their dosing is reduced to 100 mg of guselkumab every 16 weeks instead of the standard 8-week intervals.

Dr. Conrad reported that in VOYAGE 2, 106 patients on standard-dose guselkumab who had a PASI score of 0 at weeks 20 and 28 were randomized to discontinue the interleukin-23 inhibitor after receiving their fourth dose at week 20. It took 25 weeks for 50% of them to lose their PASI 90 response as defined by regression to a PASI score of 1 or greater. Using a less stringent definition of maintenance of efficacy, the super responders’ median time off guselkumab until reaching a PASI score of 3 or more was 30.7 weeks, with a median of 35.4 weeks to a PASI score of 5 or more.

In addition, 34 other VOYAGE 2 participants who were almost clear on guselkumab at weeks 20 and 28, with a PASI score of more than 0 but less than 1, were randomized to guselkumab withdrawal after their week-20 dose. Median time to loss of their PASI 90 response was shorter than that of the super responders – not surprising since their mean PASI score when the biologic was halted was 0.5, rather than 0 as for the super responders. But Dr. Conrad said the maintenance of response was still impressive: A median of 16.2 weeks to reach a PASI score of 1 or more, 27.2 weeks for a PASI 3, and 33.7 weeks for a PASI score of 5.

He reported receiving research funding from and serving as a scientific adviser to Janssen, the study sponsor, as well as to more than a dozen other pharmaceutical companies.

bjancin@mdedge.com

The Food and Drug Administration has approved voclosporin (Lupkynis) for the treatment of lupus nephritis, according to a Jan. 22 press release from manufacturer Aurinia Pharmaceuticals.

Lupkynis is a calcineurin-inhibitor immunosuppressant, and is the first oral medication to show effectiveness in lupus nephritis, according to the company. The drug is indicated for the treatment of adult patients with active lupus nephritis in combination with a background immunosuppressive therapy regimen, according to the drug label, which also has a boxed warning describing the increased risk of infections and malignancies, including lymphoma.

The approval of voclosporin was based on data from two studies, the AURORA phase 3 study and the AURA-LV phase 2 study. The studies included 533 adults with lupus nephritis who were randomized to 23.7 mg or placebo of voclosporin twice daily in the form of oral capsules, or placebo capsules, in addition to standard of care (mycophenolate mofetil plus low-dose glucocorticoids).

In the AURORA phase 3 study of 357 patients, close to twice as many patients in the treatment group showed a complete renal response, compared with the placebo group after 1 year (40.8% vs. 22.5%). In addition, patients treated with voclosporin more quickly achieved a significant reduction in urine protein to creatinine ratio, compared with the placebo patients (169 days vs. 372 days).

Severe adverse events were similar between the groups, including the most common complication of infection (10.1% and 11.2% for voclosporin and control groups, respectively). Other adverse reactions reported in at least 3% of the study participants included a decrease in glomerular filtration rate, hypertension, diarrhea, headache, anemia, cough, urinary tract infection, upper abdominal pain, dyspepsia, alopecia, renal impairment, abdominal pain, mouth ulceration, fatigue, tremor, acute kidney injury, and decreased appetite, according to the company press release.

Full clinical trial information for the AURORA study is available here.

The Food and Drug Administration has approved voclosporin (Lupkynis) for the treatment of lupus nephritis, according to a Jan. 22 press release from manufacturer Aurinia Pharmaceuticals.

Lupkynis is a calcineurin-inhibitor immunosuppressant, and is the first oral medication to show effectiveness in lupus nephritis, according to the company. The drug is indicated for the treatment of adult patients with active lupus nephritis in combination with a background immunosuppressive therapy regimen, according to the drug label, which also has a boxed warning describing the increased risk of infections and malignancies, including lymphoma.

The approval of voclosporin was based on data from two studies, the AURORA phase 3 study and the AURA-LV phase 2 study. The studies included 533 adults with lupus nephritis who were randomized to 23.7 mg or placebo of voclosporin twice daily in the form of oral capsules, or placebo capsules, in addition to standard of care (mycophenolate mofetil plus low-dose glucocorticoids).

In the AURORA phase 3 study of 357 patients, close to twice as many patients in the treatment group showed a complete renal response, compared with the placebo group after 1 year (40.8% vs. 22.5%). In addition, patients treated with voclosporin more quickly achieved a significant reduction in urine protein to creatinine ratio, compared with the placebo patients (169 days vs. 372 days).

Severe adverse events were similar between the groups, including the most common complication of infection (10.1% and 11.2% for voclosporin and control groups, respectively). Other adverse reactions reported in at least 3% of the study participants included a decrease in glomerular filtration rate, hypertension, diarrhea, headache, anemia, cough, urinary tract infection, upper abdominal pain, dyspepsia, alopecia, renal impairment, abdominal pain, mouth ulceration, fatigue, tremor, acute kidney injury, and decreased appetite, according to the company press release.

Full clinical trial information for the AURORA study is available here.

The Food and Drug Administration has approved voclosporin (Lupkynis) for the treatment of lupus nephritis, according to a Jan. 22 press release from manufacturer Aurinia Pharmaceuticals.

Lupkynis is a calcineurin-inhibitor immunosuppressant, and is the first oral medication to show effectiveness in lupus nephritis, according to the company. The drug is indicated for the treatment of adult patients with active lupus nephritis in combination with a background immunosuppressive therapy regimen, according to the drug label, which also has a boxed warning describing the increased risk of infections and malignancies, including lymphoma.

The approval of voclosporin was based on data from two studies, the AURORA phase 3 study and the AURA-LV phase 2 study. The studies included 533 adults with lupus nephritis who were randomized to 23.7 mg or placebo of voclosporin twice daily in the form of oral capsules, or placebo capsules, in addition to standard of care (mycophenolate mofetil plus low-dose glucocorticoids).

In the AURORA phase 3 study of 357 patients, close to twice as many patients in the treatment group showed a complete renal response, compared with the placebo group after 1 year (40.8% vs. 22.5%). In addition, patients treated with voclosporin more quickly achieved a significant reduction in urine protein to creatinine ratio, compared with the placebo patients (169 days vs. 372 days).

Severe adverse events were similar between the groups, including the most common complication of infection (10.1% and 11.2% for voclosporin and control groups, respectively). Other adverse reactions reported in at least 3% of the study participants included a decrease in glomerular filtration rate, hypertension, diarrhea, headache, anemia, cough, urinary tract infection, upper abdominal pain, dyspepsia, alopecia, renal impairment, abdominal pain, mouth ulceration, fatigue, tremor, acute kidney injury, and decreased appetite, according to the company press release.

Full clinical trial information for the AURORA study is available here.

Overutilization and low-value care are important clinical and policy problems. Their measurement is challenging because it requires detailed clinical information. Additionally, there are inherent difficulties in identifying discretionary services likely to be inappropriate or low-value and demonstrating that certain services produce little/no health benefit. Quantifying “ideal” expected testing rates—ones that would reflect minimization of inappropriate/low-value care without excluding essential, high-yield diagnostic services—presents additional challenges. Consequently, of 521 unique measures specified by national measurement programs and professional guidelines, 91.6% targeted underuse, while only 6.5% targeted overuse.¹

The potential for unintended consequences of implementing measures to eliminate overuse are a barrier to incorporating such measures into practice.² For example, measuring, reporting, and penalizing overuse of inappropriate bone scanning may lead to underuse in patients for whom scanning is crucial.² Most overuse measures based on inappropriate or low-value indications relate to imaging and medications.¹ However, there is increasing interest in overutilization measures based on a broad set of health services. Identifying low-value testing or treatments often requires a substantial degree of clinical detail to avoid the damaging inclusion of beneficial services, which may lead to unintended negative outcomes, creating skepticism among clinicians. Ultimately, getting measurement of low-value care wrong would undermine adoption of interventions to reduce overuse.

To reduce low-value care through expansive measures of provider ordering behavior,³ Ellenbogen et al⁴ derived a novel index to identify hospitals with high rates of low-yield diagnostic testing. This index is based on the concept that, in the presence of nonspecific, symptom-based principal diagnoses, a substantial proportion of (apparently) non-diagnostic related studies were probably ordered despite a low pretest probability of serious disease. Since such symptom-based diagnoses reflect the absence of a more specific diagnosis, the examinations observed are markers of physician-driven decisions leading to discretionary utilization likely to be of low-value to patients. This study fills a critical gap in dual measures of appropriateness and yield, rather than simply utilization, to advance the Choosing Wisely campaign.³

Advantages of this overuse index include its derivation from administrative data, obviating the need for electronic health records, and incorporation of diagnostic yield at the inpatient-encounter level. One study selected procedures identifiable solely with claims from a set deemed overused by professional/consumer groups.⁵ However, the yield of physician decisions in specific cases was not measured. In contrast, this novel index is derived from an assessment of diagnostic yield.⁴ Although test results are not known with certainty, the absence of a specific discharge diagnosis serves as a test result proxy. Measurement of diagnostic examination yield at the patient-level (aggregated to the hospital-level) may be applicable across hospitals with varied patient populations, which include large differences in patient and/or family preferences to seek medical attention and engage in shared decision-making. The role that patient preferences play in decisions creates a limitation in this index—while decisions for the candidate diagnostic tests are physician driven, patient demand may be a confounding factor. This index cannot therefore be considered purely a measure of physician-induced intensity of diagnostic services. Patient-reported data would enhance future analyses by more fully capturing all dimensions of care necessary to identify low-value services. Subjective outcomes are critical in completely measuring the aggregate benefits of tests and interventions judged low-value based on objective metrics. Such data would also aid in quantifying the relative contributions of patient and physician preferences in driving discretionary utilization.

Finally, the derived index is restricted to diagnostic decision-making and may not be applicable to treatment-related practice patterns. However, the literature suggests strong correlations between diagnostic and therapeutic intensity. Application of this novel index will play an important role in reducing low-value discretionary utilization.

Overutilization and low-value care are important clinical and policy problems. Their measurement is challenging because it requires detailed clinical information. Additionally, there are inherent difficulties in identifying discretionary services likely to be inappropriate or low-value and demonstrating that certain services produce little/no health benefit. Quantifying “ideal” expected testing rates—ones that would reflect minimization of inappropriate/low-value care without excluding essential, high-yield diagnostic services—presents additional challenges. Consequently, of 521 unique measures specified by national measurement programs and professional guidelines, 91.6% targeted underuse, while only 6.5% targeted overuse.¹

The potential for unintended consequences of implementing measures to eliminate overuse are a barrier to incorporating such measures into practice.² For example, measuring, reporting, and penalizing overuse of inappropriate bone scanning may lead to underuse in patients for whom scanning is crucial.² Most overuse measures based on inappropriate or low-value indications relate to imaging and medications.¹ However, there is increasing interest in overutilization measures based on a broad set of health services. Identifying low-value testing or treatments often requires a substantial degree of clinical detail to avoid the damaging inclusion of beneficial services, which may lead to unintended negative outcomes, creating skepticism among clinicians. Ultimately, getting measurement of low-value care wrong would undermine adoption of interventions to reduce overuse.

To reduce low-value care through expansive measures of provider ordering behavior,³ Ellenbogen et al⁴ derived a novel index to identify hospitals with high rates of low-yield diagnostic testing. This index is based on the concept that, in the presence of nonspecific, symptom-based principal diagnoses, a substantial proportion of (apparently) non-diagnostic related studies were probably ordered despite a low pretest probability of serious disease. Since such symptom-based diagnoses reflect the absence of a more specific diagnosis, the examinations observed are markers of physician-driven decisions leading to discretionary utilization likely to be of low-value to patients. This study fills a critical gap in dual measures of appropriateness and yield, rather than simply utilization, to advance the Choosing Wisely campaign.³

Advantages of this overuse index include its derivation from administrative data, obviating the need for electronic health records, and incorporation of diagnostic yield at the inpatient-encounter level. One study selected procedures identifiable solely with claims from a set deemed overused by professional/consumer groups.⁵ However, the yield of physician decisions in specific cases was not measured. In contrast, this novel index is derived from an assessment of diagnostic yield.⁴ Although test results are not known with certainty, the absence of a specific discharge diagnosis serves as a test result proxy. Measurement of diagnostic examination yield at the patient-level (aggregated to the hospital-level) may be applicable across hospitals with varied patient populations, which include large differences in patient and/or family preferences to seek medical attention and engage in shared decision-making. The role that patient preferences play in decisions creates a limitation in this index—while decisions for the candidate diagnostic tests are physician driven, patient demand may be a confounding factor. This index cannot therefore be considered purely a measure of physician-induced intensity of diagnostic services. Patient-reported data would enhance future analyses by more fully capturing all dimensions of care necessary to identify low-value services. Subjective outcomes are critical in completely measuring the aggregate benefits of tests and interventions judged low-value based on objective metrics. Such data would also aid in quantifying the relative contributions of patient and physician preferences in driving discretionary utilization.

Finally, the derived index is restricted to diagnostic decision-making and may not be applicable to treatment-related practice patterns. However, the literature suggests strong correlations between diagnostic and therapeutic intensity. Application of this novel index will play an important role in reducing low-value discretionary utilization.

Overutilization and low-value care are important clinical and policy problems. Their measurement is challenging because it requires detailed clinical information. Additionally, there are inherent difficulties in identifying discretionary services likely to be inappropriate or low-value and demonstrating that certain services produce little/no health benefit. Quantifying “ideal” expected testing rates—ones that would reflect minimization of inappropriate/low-value care without excluding essential, high-yield diagnostic services—presents additional challenges. Consequently, of 521 unique measures specified by national measurement programs and professional guidelines, 91.6% targeted underuse, while only 6.5% targeted overuse.¹

The potential for unintended consequences of implementing measures to eliminate overuse are a barrier to incorporating such measures into practice.² For example, measuring, reporting, and penalizing overuse of inappropriate bone scanning may lead to underuse in patients for whom scanning is crucial.² Most overuse measures based on inappropriate or low-value indications relate to imaging and medications.¹ However, there is increasing interest in overutilization measures based on a broad set of health services. Identifying low-value testing or treatments often requires a substantial degree of clinical detail to avoid the damaging inclusion of beneficial services, which may lead to unintended negative outcomes, creating skepticism among clinicians. Ultimately, getting measurement of low-value care wrong would undermine adoption of interventions to reduce overuse.

To reduce low-value care through expansive measures of provider ordering behavior,³ Ellenbogen et al⁴ derived a novel index to identify hospitals with high rates of low-yield diagnostic testing. This index is based on the concept that, in the presence of nonspecific, symptom-based principal diagnoses, a substantial proportion of (apparently) non-diagnostic related studies were probably ordered despite a low pretest probability of serious disease. Since such symptom-based diagnoses reflect the absence of a more specific diagnosis, the examinations observed are markers of physician-driven decisions leading to discretionary utilization likely to be of low-value to patients. This study fills a critical gap in dual measures of appropriateness and yield, rather than simply utilization, to advance the Choosing Wisely campaign.³

Advantages of this overuse index include its derivation from administrative data, obviating the need for electronic health records, and incorporation of diagnostic yield at the inpatient-encounter level. One study selected procedures identifiable solely with claims from a set deemed overused by professional/consumer groups.⁵ However, the yield of physician decisions in specific cases was not measured. In contrast, this novel index is derived from an assessment of diagnostic yield.⁴ Although test results are not known with certainty, the absence of a specific discharge diagnosis serves as a test result proxy. Measurement of diagnostic examination yield at the patient-level (aggregated to the hospital-level) may be applicable across hospitals with varied patient populations, which include large differences in patient and/or family preferences to seek medical attention and engage in shared decision-making. The role that patient preferences play in decisions creates a limitation in this index—while decisions for the candidate diagnostic tests are physician driven, patient demand may be a confounding factor. This index cannot therefore be considered purely a measure of physician-induced intensity of diagnostic services. Patient-reported data would enhance future analyses by more fully capturing all dimensions of care necessary to identify low-value services. Subjective outcomes are critical in completely measuring the aggregate benefits of tests and interventions judged low-value based on objective metrics. Such data would also aid in quantifying the relative contributions of patient and physician preferences in driving discretionary utilization.

Finally, the derived index is restricted to diagnostic decision-making and may not be applicable to treatment-related practice patterns. However, the literature suggests strong correlations between diagnostic and therapeutic intensity. Application of this novel index will play an important role in reducing low-value discretionary utilization.

During the early phase of the novel coronavirus disease 2019 (COVID-19) epidemic in the United States, public health strategies focused on “flattening the curve” to ensure that healthcare systems in hard-hit regions had the ability to care for surges of acutely ill patients. Now, COVID-19 cases and hospitalizations are rising sharply throughout the country, and many healthcare systems are facing intense strain due to an influx of patients.

In this issue of JHM, Horwitz et al provide important insights on evolving inpatient care and healthcare system strain for patients with COVID-19. The authors evaluated 5,121 adults hospitalized with SARS-CoV-2 infection at a 3-hospital health system in New York City from March through August 2020,¹ and found that patients hospitalized later during the time period were much younger and had fewer comorbidities. Importantly, the authors observed a marked decline in adjusted in-hospital mortality or hospice rates, from 25.6% in March to 7.6% in August.

What might explain the dramatic improvement in risk-adjusted mortality? The authors’ use of granular data from the electronic health record allowed them to account for temporal changes in demographics and clinical severity of hospitalized patients, indicating that other factors have contributed to the decline in adjusted mortality. One likely explanation is that increasing clinical experience in the management of patients with COVID-19 has resulted in the delivery of better inpatient care, while the use of evidence-based therapies for COVID-19 has also grown. Although important gains have been made in treatment, the care of patients with COVID-19 largely remains supportive. But supportive care requires an adequate number of hospital beds, healthcare staff, and sufficient critical care resources, at minimum.

Healthcare system strain has undoubtedly played a critical role in the outcomes of hospitalized patients. Horwitz et al found that the number of COVID-19 hospitalizations in March and April, when death rates were highest, was more than 10 times greater than in July and August, when death rates were lowest. As noted in the early epidemic in China, COVID-19 death rates partially reflect access to high-quality medical care.² And, in the US, hospitals’ capacity to care for critically ill patients with COVID-19 is an important predictor of death.³

As COVID-19 cases now surge across the country, ensuring that healthcare systems have the resources needed to care for patients will be paramount. Unfortunately, the spread of COVID-19 is exponential, while hospitals’ ability to scale-up surge capacity over a short timeframe is not. Already, reports are emerging across the country of hospitals reaching bed capacity and experiencing shortages of physicians and nurses.

To curtail escalating healthcare system stress in the coming months, we must minimize the cluster-based super-spreading that drives epidemic surges. Approximately 15% to 20% of infected cases account for up to 80% of disease transmission.⁴ Therefore, strategies must address high-risk scenarios that involve crowding, close prolonged contact, and poor ventilation, such as weddings, sporting events, religious gatherings, and indoor dining and bars.

Without adequate testing or tracing capacity during viral surges, employing nonpharmaceutical interventions to mitigate spread is key. Japan, which created the “3 Cs” campaign (avoid close contact, closed spaces, and crowds), utilized a response framework that specifically targeted super-spreading. The US should follow a similar strategy in the coming months to protect healthcare systems, healthcare workers, and most importantly, our patients.

During the early phase of the novel coronavirus disease 2019 (COVID-19) epidemic in the United States, public health strategies focused on “flattening the curve” to ensure that healthcare systems in hard-hit regions had the ability to care for surges of acutely ill patients. Now, COVID-19 cases and hospitalizations are rising sharply throughout the country, and many healthcare systems are facing intense strain due to an influx of patients.

In this issue of JHM, Horwitz et al provide important insights on evolving inpatient care and healthcare system strain for patients with COVID-19. The authors evaluated 5,121 adults hospitalized with SARS-CoV-2 infection at a 3-hospital health system in New York City from March through August 2020,¹ and found that patients hospitalized later during the time period were much younger and had fewer comorbidities. Importantly, the authors observed a marked decline in adjusted in-hospital mortality or hospice rates, from 25.6% in March to 7.6% in August.

What might explain the dramatic improvement in risk-adjusted mortality? The authors’ use of granular data from the electronic health record allowed them to account for temporal changes in demographics and clinical severity of hospitalized patients, indicating that other factors have contributed to the decline in adjusted mortality. One likely explanation is that increasing clinical experience in the management of patients with COVID-19 has resulted in the delivery of better inpatient care, while the use of evidence-based therapies for COVID-19 has also grown. Although important gains have been made in treatment, the care of patients with COVID-19 largely remains supportive. But supportive care requires an adequate number of hospital beds, healthcare staff, and sufficient critical care resources, at minimum.

Healthcare system strain has undoubtedly played a critical role in the outcomes of hospitalized patients. Horwitz et al found that the number of COVID-19 hospitalizations in March and April, when death rates were highest, was more than 10 times greater than in July and August, when death rates were lowest. As noted in the early epidemic in China, COVID-19 death rates partially reflect access to high-quality medical care.² And, in the US, hospitals’ capacity to care for critically ill patients with COVID-19 is an important predictor of death.³

As COVID-19 cases now surge across the country, ensuring that healthcare systems have the resources needed to care for patients will be paramount. Unfortunately, the spread of COVID-19 is exponential, while hospitals’ ability to scale-up surge capacity over a short timeframe is not. Already, reports are emerging across the country of hospitals reaching bed capacity and experiencing shortages of physicians and nurses.

To curtail escalating healthcare system stress in the coming months, we must minimize the cluster-based super-spreading that drives epidemic surges. Approximately 15% to 20% of infected cases account for up to 80% of disease transmission.⁴ Therefore, strategies must address high-risk scenarios that involve crowding, close prolonged contact, and poor ventilation, such as weddings, sporting events, religious gatherings, and indoor dining and bars.

Without adequate testing or tracing capacity during viral surges, employing nonpharmaceutical interventions to mitigate spread is key. Japan, which created the “3 Cs” campaign (avoid close contact, closed spaces, and crowds), utilized a response framework that specifically targeted super-spreading. The US should follow a similar strategy in the coming months to protect healthcare systems, healthcare workers, and most importantly, our patients.

During the early phase of the novel coronavirus disease 2019 (COVID-19) epidemic in the United States, public health strategies focused on “flattening the curve” to ensure that healthcare systems in hard-hit regions had the ability to care for surges of acutely ill patients. Now, COVID-19 cases and hospitalizations are rising sharply throughout the country, and many healthcare systems are facing intense strain due to an influx of patients.

In this issue of JHM, Horwitz et al provide important insights on evolving inpatient care and healthcare system strain for patients with COVID-19. The authors evaluated 5,121 adults hospitalized with SARS-CoV-2 infection at a 3-hospital health system in New York City from March through August 2020,¹ and found that patients hospitalized later during the time period were much younger and had fewer comorbidities. Importantly, the authors observed a marked decline in adjusted in-hospital mortality or hospice rates, from 25.6% in March to 7.6% in August.

What might explain the dramatic improvement in risk-adjusted mortality? The authors’ use of granular data from the electronic health record allowed them to account for temporal changes in demographics and clinical severity of hospitalized patients, indicating that other factors have contributed to the decline in adjusted mortality. One likely explanation is that increasing clinical experience in the management of patients with COVID-19 has resulted in the delivery of better inpatient care, while the use of evidence-based therapies for COVID-19 has also grown. Although important gains have been made in treatment, the care of patients with COVID-19 largely remains supportive. But supportive care requires an adequate number of hospital beds, healthcare staff, and sufficient critical care resources, at minimum.

Healthcare system strain has undoubtedly played a critical role in the outcomes of hospitalized patients. Horwitz et al found that the number of COVID-19 hospitalizations in March and April, when death rates were highest, was more than 10 times greater than in July and August, when death rates were lowest. As noted in the early epidemic in China, COVID-19 death rates partially reflect access to high-quality medical care.² And, in the US, hospitals’ capacity to care for critically ill patients with COVID-19 is an important predictor of death.³

As COVID-19 cases now surge across the country, ensuring that healthcare systems have the resources needed to care for patients will be paramount. Unfortunately, the spread of COVID-19 is exponential, while hospitals’ ability to scale-up surge capacity over a short timeframe is not. Already, reports are emerging across the country of hospitals reaching bed capacity and experiencing shortages of physicians and nurses.

To curtail escalating healthcare system stress in the coming months, we must minimize the cluster-based super-spreading that drives epidemic surges. Approximately 15% to 20% of infected cases account for up to 80% of disease transmission.⁴ Therefore, strategies must address high-risk scenarios that involve crowding, close prolonged contact, and poor ventilation, such as weddings, sporting events, religious gatherings, and indoor dining and bars.

Without adequate testing or tracing capacity during viral surges, employing nonpharmaceutical interventions to mitigate spread is key. Japan, which created the “3 Cs” campaign (avoid close contact, closed spaces, and crowds), utilized a response framework that specifically targeted super-spreading. The US should follow a similar strategy in the coming months to protect healthcare systems, healthcare workers, and most importantly, our patients.

Hospitalists are known as change agents for their fierce patient advocacy and expertise in hospital systems redesign. The field of hospital medicine has claimed numerous successes and the hospitalist model has been embraced by institutions across the country. Yet the lived experiences of hospitalists surveyed by Bhandari et al in this month’s issue of JHM suggest a grim undertone.¹ Hospital medicine is a field with high physician burnout rates, stark gender inequities in pay, leadership, and academic opportunities, and an unacceptably high prevalence of sexual harassment and gender discrimination. Women hospitalists disproportionately bear the brunt of these inequities. All hospitalists, however, can and should be an integral part of the path forward by recognizing the impact of these inequities on colleagues and hospital systems.

The study by Bhandari et al adds to the increasing body of knowledge documenting high levels of sexual harassment and gender discrimination in medicine and highlights important gender differences in these experiences among hospitalists nationally.^1,2 Among 336 respondents across 18 academic institutions, sexual harassment and gender discrimination were both common and highly problematic within the field of hospital medicine, confirming what prior narratives have only anecdotally shared. Both men and women experienced harassment, from patients and colleagues alike, but women endured higher levels compared with men on all the measures studied.¹

Qualitative comments in this study are noteworthy, including one about a hospitalist’s institution allowing potential faculty to be interviewed about plans for pregnancy, childcare, and personal household division of labor. One might argue that this knowledge is necessary for shift-based inpatient work in the context of a worldwide pandemic in which pregnant workers are likely at higher risk of increased morbidity and mortality. It remains illegal, however, to ask such questions, which are representative of the types of characteristics that constitute a toxic workplace environment. Moreover, such practices are particularly problematic given that pregnancy and childbearing for women in medicine come with their own set of well-documented unique challenges.³

The considerable body of research in this field should help guide new research priorities and targets for intervention. Does the experience of sexual harassment impact hospitalists’ intentions to leave their institutions or the career as a whole? Does sexual harassment originating from colleagues or from patients and families affect patient safety or quality of care? Do interventions in other international hospital settings specifically targeting respectfulness translate to American hospitals?⁴ These questions and a host of others merit our attention.

Hospital system leaders should work with hospital medicine leaders to support wholesale institutional cultural transformation. Implementation of antiharassment measures recommended in the 2018 report on sexual harassment from the National Academies of Sciences, Engineering, and Medicine is critical.² This means supporting diverse, inclusive, and respectful environments at all levels within the organization, improving transparency and accountability for how incidents are handled, striving for strong and diverse leadership, providing meaningful support for targets of harassment, measuring prevalence over time, and encouraging professional societies to adopt similar actions. Furthermore, we believe it is critical to adopt a zero-tolerance policy for harassing behaviors and to hold individuals accountable. Encouraging all individuals within health care systems to uphold their ethical obligations to combat harassment and bias on a personal level is important.⁵ If left unaddressed, the unmet needs of those who are subjected to harassment and bias will continue to be problematic for generations to come, with detrimental effects throughout healthcare systems and the broader populations they serve.

Hospitalists are known as change agents for their fierce patient advocacy and expertise in hospital systems redesign. The field of hospital medicine has claimed numerous successes and the hospitalist model has been embraced by institutions across the country. Yet the lived experiences of hospitalists surveyed by Bhandari et al in this month’s issue of JHM suggest a grim undertone.¹ Hospital medicine is a field with high physician burnout rates, stark gender inequities in pay, leadership, and academic opportunities, and an unacceptably high prevalence of sexual harassment and gender discrimination. Women hospitalists disproportionately bear the brunt of these inequities. All hospitalists, however, can and should be an integral part of the path forward by recognizing the impact of these inequities on colleagues and hospital systems.

The study by Bhandari et al adds to the increasing body of knowledge documenting high levels of sexual harassment and gender discrimination in medicine and highlights important gender differences in these experiences among hospitalists nationally.^1,2 Among 336 respondents across 18 academic institutions, sexual harassment and gender discrimination were both common and highly problematic within the field of hospital medicine, confirming what prior narratives have only anecdotally shared. Both men and women experienced harassment, from patients and colleagues alike, but women endured higher levels compared with men on all the measures studied.¹

Qualitative comments in this study are noteworthy, including one about a hospitalist’s institution allowing potential faculty to be interviewed about plans for pregnancy, childcare, and personal household division of labor. One might argue that this knowledge is necessary for shift-based inpatient work in the context of a worldwide pandemic in which pregnant workers are likely at higher risk of increased morbidity and mortality. It remains illegal, however, to ask such questions, which are representative of the types of characteristics that constitute a toxic workplace environment. Moreover, such practices are particularly problematic given that pregnancy and childbearing for women in medicine come with their own set of well-documented unique challenges.³

The considerable body of research in this field should help guide new research priorities and targets for intervention. Does the experience of sexual harassment impact hospitalists’ intentions to leave their institutions or the career as a whole? Does sexual harassment originating from colleagues or from patients and families affect patient safety or quality of care? Do interventions in other international hospital settings specifically targeting respectfulness translate to American hospitals?⁴ These questions and a host of others merit our attention.

Hospital system leaders should work with hospital medicine leaders to support wholesale institutional cultural transformation. Implementation of antiharassment measures recommended in the 2018 report on sexual harassment from the National Academies of Sciences, Engineering, and Medicine is critical.² This means supporting diverse, inclusive, and respectful environments at all levels within the organization, improving transparency and accountability for how incidents are handled, striving for strong and diverse leadership, providing meaningful support for targets of harassment, measuring prevalence over time, and encouraging professional societies to adopt similar actions. Furthermore, we believe it is critical to adopt a zero-tolerance policy for harassing behaviors and to hold individuals accountable. Encouraging all individuals within health care systems to uphold their ethical obligations to combat harassment and bias on a personal level is important.⁵ If left unaddressed, the unmet needs of those who are subjected to harassment and bias will continue to be problematic for generations to come, with detrimental effects throughout healthcare systems and the broader populations they serve.

Hospitalists are known as change agents for their fierce patient advocacy and expertise in hospital systems redesign. The field of hospital medicine has claimed numerous successes and the hospitalist model has been embraced by institutions across the country. Yet the lived experiences of hospitalists surveyed by Bhandari et al in this month’s issue of JHM suggest a grim undertone.¹ Hospital medicine is a field with high physician burnout rates, stark gender inequities in pay, leadership, and academic opportunities, and an unacceptably high prevalence of sexual harassment and gender discrimination. Women hospitalists disproportionately bear the brunt of these inequities. All hospitalists, however, can and should be an integral part of the path forward by recognizing the impact of these inequities on colleagues and hospital systems.

The study by Bhandari et al adds to the increasing body of knowledge documenting high levels of sexual harassment and gender discrimination in medicine and highlights important gender differences in these experiences among hospitalists nationally.^1,2 Among 336 respondents across 18 academic institutions, sexual harassment and gender discrimination were both common and highly problematic within the field of hospital medicine, confirming what prior narratives have only anecdotally shared. Both men and women experienced harassment, from patients and colleagues alike, but women endured higher levels compared with men on all the measures studied.¹

Qualitative comments in this study are noteworthy, including one about a hospitalist’s institution allowing potential faculty to be interviewed about plans for pregnancy, childcare, and personal household division of labor. One might argue that this knowledge is necessary for shift-based inpatient work in the context of a worldwide pandemic in which pregnant workers are likely at higher risk of increased morbidity and mortality. It remains illegal, however, to ask such questions, which are representative of the types of characteristics that constitute a toxic workplace environment. Moreover, such practices are particularly problematic given that pregnancy and childbearing for women in medicine come with their own set of well-documented unique challenges.³

The considerable body of research in this field should help guide new research priorities and targets for intervention. Does the experience of sexual harassment impact hospitalists’ intentions to leave their institutions or the career as a whole? Does sexual harassment originating from colleagues or from patients and families affect patient safety or quality of care? Do interventions in other international hospital settings specifically targeting respectfulness translate to American hospitals?⁴ These questions and a host of others merit our attention.

Hospital system leaders should work with hospital medicine leaders to support wholesale institutional cultural transformation. Implementation of antiharassment measures recommended in the 2018 report on sexual harassment from the National Academies of Sciences, Engineering, and Medicine is critical.² This means supporting diverse, inclusive, and respectful environments at all levels within the organization, improving transparency and accountability for how incidents are handled, striving for strong and diverse leadership, providing meaningful support for targets of harassment, measuring prevalence over time, and encouraging professional societies to adopt similar actions. Furthermore, we believe it is critical to adopt a zero-tolerance policy for harassing behaviors and to hold individuals accountable. Encouraging all individuals within health care systems to uphold their ethical obligations to combat harassment and bias on a personal level is important.⁵ If left unaddressed, the unmet needs of those who are subjected to harassment and bias will continue to be problematic for generations to come, with detrimental effects throughout healthcare systems and the broader populations they serve.

Historically, bacterial infections in hospitalized children were treated with intravenous (IV) antibiotics for the duration of therapy—frequently with placement of a vascular catheter. Risks associated with vascular catheters and the limitations they impose on a child’s quality of life are increasingly being recognized—including thrombi, catheter dislodgement, and secondary infections as catheters provide a portal of entry for bacteria into the bloodstream (ie, catheter-associated bloodstream infections) or along the catheter wall (ie, phlebitis). This potential for harm underscores the importance of transitioning to oral antibiotic therapy whenever possible.

In this issue of the Journal of Hospital Medicine, Cotter et al used an administrative database to investigate opportunities to transition from IV to oral antibiotics for patients across multiple pediatric hospitals.¹ Their novel metric, “percent opportunity,” represents the percent of days that there was the opportunity to transition from IV to oral antibiotics. They found that over 50% of the time, IV antibiotics could have been switched to equivalent oral agents. Furthermore, there was wide variability across institutions in IV-to-oral transitioning practices; 45% of the variation was seemingly attributable to institution-level preferences.

The large sample size and multicenter nature of this study improve its external validity. However, using administrative data to make assumptions about clinical decision-making has limitations. The definition of opportunity days assumes that any day a child receives other enteral medications provides an “opportunity” to prescribe oral antibiotics instead. This does not account for other reasonable indications to continue IV therapy (eg, endocarditis) and may overestimate true opportunities for conversion to oral therapy. Alternatively, their conservative approach of excluding days when a child received both IV and oral antibiotics may underestimate opportunities for oral transition. Regardless of the precision of their estimates, their findings highlight that there is room to improve the culture of transitioning hospitalized children from IV to oral antibiotic therapy.

Admittedly, the evidence for clinically effective conversion to oral therapy in children remains incomplete. Data support oral antibiotics for hospitalized children with pneumonia, cellulitis, pyelonephritis, and osteoarticular infections—even with associated bacteremia.² There is also evidence for successful conversion to oral therapy for complicated appendicitis, retropharyngeal abscesses, mastoiditis, and orbital cellulitis.²

The decision to transition to oral therapy does not need to be delayed until the time of hospital discharge because each additional day of IV therapy poses a cumulative risk. Rather, prescribers should apply a structured approach, such as the “Four Moments of Antibiotic Decision Making,” on a daily basis for every hospitalized child receiving antibiotics to prompt timely decisions about discontinuing IV therapy, narrowing IV therapy, or transitioning from IV to oral antibiotic therapy.³ We applaud Cotter et al for shedding light on an area in need of standardization of care, which could optimize patient outcomes and minimize harm for a large number of children.¹ The “percent opportunity” to switch from IV to oral antibiotic therapy is a promising antibiotic stewardship metric, and its association with clinical outcomes merits further investigation.

Historically, bacterial infections in hospitalized children were treated with intravenous (IV) antibiotics for the duration of therapy—frequently with placement of a vascular catheter. Risks associated with vascular catheters and the limitations they impose on a child’s quality of life are increasingly being recognized—including thrombi, catheter dislodgement, and secondary infections as catheters provide a portal of entry for bacteria into the bloodstream (ie, catheter-associated bloodstream infections) or along the catheter wall (ie, phlebitis). This potential for harm underscores the importance of transitioning to oral antibiotic therapy whenever possible.

In this issue of the Journal of Hospital Medicine, Cotter et al used an administrative database to investigate opportunities to transition from IV to oral antibiotics for patients across multiple pediatric hospitals.¹ Their novel metric, “percent opportunity,” represents the percent of days that there was the opportunity to transition from IV to oral antibiotics. They found that over 50% of the time, IV antibiotics could have been switched to equivalent oral agents. Furthermore, there was wide variability across institutions in IV-to-oral transitioning practices; 45% of the variation was seemingly attributable to institution-level preferences.

The large sample size and multicenter nature of this study improve its external validity. However, using administrative data to make assumptions about clinical decision-making has limitations. The definition of opportunity days assumes that any day a child receives other enteral medications provides an “opportunity” to prescribe oral antibiotics instead. This does not account for other reasonable indications to continue IV therapy (eg, endocarditis) and may overestimate true opportunities for conversion to oral therapy. Alternatively, their conservative approach of excluding days when a child received both IV and oral antibiotics may underestimate opportunities for oral transition. Regardless of the precision of their estimates, their findings highlight that there is room to improve the culture of transitioning hospitalized children from IV to oral antibiotic therapy.

Admittedly, the evidence for clinically effective conversion to oral therapy in children remains incomplete. Data support oral antibiotics for hospitalized children with pneumonia, cellulitis, pyelonephritis, and osteoarticular infections—even with associated bacteremia.² There is also evidence for successful conversion to oral therapy for complicated appendicitis, retropharyngeal abscesses, mastoiditis, and orbital cellulitis.²

The decision to transition to oral therapy does not need to be delayed until the time of hospital discharge because each additional day of IV therapy poses a cumulative risk. Rather, prescribers should apply a structured approach, such as the “Four Moments of Antibiotic Decision Making,” on a daily basis for every hospitalized child receiving antibiotics to prompt timely decisions about discontinuing IV therapy, narrowing IV therapy, or transitioning from IV to oral antibiotic therapy.³ We applaud Cotter et al for shedding light on an area in need of standardization of care, which could optimize patient outcomes and minimize harm for a large number of children.¹ The “percent opportunity” to switch from IV to oral antibiotic therapy is a promising antibiotic stewardship metric, and its association with clinical outcomes merits further investigation.

Historically, bacterial infections in hospitalized children were treated with intravenous (IV) antibiotics for the duration of therapy—frequently with placement of a vascular catheter. Risks associated with vascular catheters and the limitations they impose on a child’s quality of life are increasingly being recognized—including thrombi, catheter dislodgement, and secondary infections as catheters provide a portal of entry for bacteria into the bloodstream (ie, catheter-associated bloodstream infections) or along the catheter wall (ie, phlebitis). This potential for harm underscores the importance of transitioning to oral antibiotic therapy whenever possible.

In this issue of the Journal of Hospital Medicine, Cotter et al used an administrative database to investigate opportunities to transition from IV to oral antibiotics for patients across multiple pediatric hospitals.¹ Their novel metric, “percent opportunity,” represents the percent of days that there was the opportunity to transition from IV to oral antibiotics. They found that over 50% of the time, IV antibiotics could have been switched to equivalent oral agents. Furthermore, there was wide variability across institutions in IV-to-oral transitioning practices; 45% of the variation was seemingly attributable to institution-level preferences.

The large sample size and multicenter nature of this study improve its external validity. However, using administrative data to make assumptions about clinical decision-making has limitations. The definition of opportunity days assumes that any day a child receives other enteral medications provides an “opportunity” to prescribe oral antibiotics instead. This does not account for other reasonable indications to continue IV therapy (eg, endocarditis) and may overestimate true opportunities for conversion to oral therapy. Alternatively, their conservative approach of excluding days when a child received both IV and oral antibiotics may underestimate opportunities for oral transition. Regardless of the precision of their estimates, their findings highlight that there is room to improve the culture of transitioning hospitalized children from IV to oral antibiotic therapy.

Admittedly, the evidence for clinically effective conversion to oral therapy in children remains incomplete. Data support oral antibiotics for hospitalized children with pneumonia, cellulitis, pyelonephritis, and osteoarticular infections—even with associated bacteremia.² There is also evidence for successful conversion to oral therapy for complicated appendicitis, retropharyngeal abscesses, mastoiditis, and orbital cellulitis.²

The decision to transition to oral therapy does not need to be delayed until the time of hospital discharge because each additional day of IV therapy poses a cumulative risk. Rather, prescribers should apply a structured approach, such as the “Four Moments of Antibiotic Decision Making,” on a daily basis for every hospitalized child receiving antibiotics to prompt timely decisions about discontinuing IV therapy, narrowing IV therapy, or transitioning from IV to oral antibiotic therapy.³ We applaud Cotter et al for shedding light on an area in need of standardization of care, which could optimize patient outcomes and minimize harm for a large number of children.¹ The “percent opportunity” to switch from IV to oral antibiotic therapy is a promising antibiotic stewardship metric, and its association with clinical outcomes merits further investigation.

“Success starts with saying yes. Saying no maintains it.”

—Anonymous

You have just received an opportunity that seems worthwhile. However, you already have a lot on your plate. What do you do? The balance of when to say “yes” and when to say “no” to opportunities, projects, and collaborations is often challenging, especially for busy clinicians. There is a trend, with good basis, to encourage individuals to say “no” more often. While there is much to be said for that, many good opportunities can be missed that way. As Amy Poehler put it, “Saying ‘yes’ doesn’t mean I don’t know how to say no.”

So how does one arrive at a good balance?

Most importantly, figure out who you are, what you want your “brand” to be and where you envision your career going. This is likely the most difficult step. Start with a roadmap and recalibrate as your career unfolds. Early in your career, seek breadth rather than depth.

As your career progresses, the “yes-no” balance may shift. We recommend you say “yes” frequently early on. Be open to opportunities that come up, even if they do not perfectly align with your goals. Explore opportunities beyond the limits of your job description. After all, opportunities beget more opportunities. Consider “stretch opportunities.” If you are offered an opportunity that you may not have 100% of the skills for—and is, therefore, a “stretch”—but which aligns with your career goals, do not turn it down. Consider saying “yes” and learn on the job. A mentor or coach can help you navigate these decisions.

Sometimes, it is important to say “yes” as part of being a “good citizen” in your department. Examples include mentoring learners, serving on a safety committee, teaching student lectures, or coaching a colleague. Often it is possible to align service with career goals.

Another consideration is the benefit of networking: developing alliances and building bridges. In addition to the service or productivity that come with projects or collaborations, these can be powerful networking opportunities. Networking broadly, both within and beyond your field of practice and within and outside your institution, is an important way to create “bonding capital” and “bridging capital,” ie, relationships based on your commonalities and relationships built across differences, respectively.¹

Remember, when you say “yes,” you must deliver: every time, on time, and with excellence. When saying “yes” to more opportunities starts to impact your ability to deliver for what you have already committed to, it is time to say “no.” This will help you maintain balance, avoid burnout, and stay focused.

When juggling a busy schedule, consider effort vs impact. There are many low-effort opportunities that have relatively high impact. For instance, as a junior faculty member interested in medical education, participating in a grading committee is low effort but can help you understand the process, connect you with educational leaders, and open doors to future opportunities. An effective strategy may be to incorporate a combination of low-effort and high-effort activities at any one time, while considering the impact of each, to help maintain balance. The effort-vs-impact balance may shift as you grow in your career.

Know where you are going, explore the opportunities that may get you there, and recalibrate often. The path to success is typically a circuitous one, so enjoy the journey and give it your all every step of the way.

“Success starts with saying yes. Saying no maintains it.”

—Anonymous

You have just received an opportunity that seems worthwhile. However, you already have a lot on your plate. What do you do? The balance of when to say “yes” and when to say “no” to opportunities, projects, and collaborations is often challenging, especially for busy clinicians. There is a trend, with good basis, to encourage individuals to say “no” more often. While there is much to be said for that, many good opportunities can be missed that way. As Amy Poehler put it, “Saying ‘yes’ doesn’t mean I don’t know how to say no.”

So how does one arrive at a good balance?

Most importantly, figure out who you are, what you want your “brand” to be and where you envision your career going. This is likely the most difficult step. Start with a roadmap and recalibrate as your career unfolds. Early in your career, seek breadth rather than depth.

As your career progresses, the “yes-no” balance may shift. We recommend you say “yes” frequently early on. Be open to opportunities that come up, even if they do not perfectly align with your goals. Explore opportunities beyond the limits of your job description. After all, opportunities beget more opportunities. Consider “stretch opportunities.” If you are offered an opportunity that you may not have 100% of the skills for—and is, therefore, a “stretch”—but which aligns with your career goals, do not turn it down. Consider saying “yes” and learn on the job. A mentor or coach can help you navigate these decisions.

Sometimes, it is important to say “yes” as part of being a “good citizen” in your department. Examples include mentoring learners, serving on a safety committee, teaching student lectures, or coaching a colleague. Often it is possible to align service with career goals.

Another consideration is the benefit of networking: developing alliances and building bridges. In addition to the service or productivity that come with projects or collaborations, these can be powerful networking opportunities. Networking broadly, both within and beyond your field of practice and within and outside your institution, is an important way to create “bonding capital” and “bridging capital,” ie, relationships based on your commonalities and relationships built across differences, respectively.¹

Remember, when you say “yes,” you must deliver: every time, on time, and with excellence. When saying “yes” to more opportunities starts to impact your ability to deliver for what you have already committed to, it is time to say “no.” This will help you maintain balance, avoid burnout, and stay focused.

When juggling a busy schedule, consider effort vs impact. There are many low-effort opportunities that have relatively high impact. For instance, as a junior faculty member interested in medical education, participating in a grading committee is low effort but can help you understand the process, connect you with educational leaders, and open doors to future opportunities. An effective strategy may be to incorporate a combination of low-effort and high-effort activities at any one time, while considering the impact of each, to help maintain balance. The effort-vs-impact balance may shift as you grow in your career.

Know where you are going, explore the opportunities that may get you there, and recalibrate often. The path to success is typically a circuitous one, so enjoy the journey and give it your all every step of the way.

“Success starts with saying yes. Saying no maintains it.”

—Anonymous

You have just received an opportunity that seems worthwhile. However, you already have a lot on your plate. What do you do? The balance of when to say “yes” and when to say “no” to opportunities, projects, and collaborations is often challenging, especially for busy clinicians. There is a trend, with good basis, to encourage individuals to say “no” more often. While there is much to be said for that, many good opportunities can be missed that way. As Amy Poehler put it, “Saying ‘yes’ doesn’t mean I don’t know how to say no.”

So how does one arrive at a good balance?

Most importantly, figure out who you are, what you want your “brand” to be and where you envision your career going. This is likely the most difficult step. Start with a roadmap and recalibrate as your career unfolds. Early in your career, seek breadth rather than depth.

As your career progresses, the “yes-no” balance may shift. We recommend you say “yes” frequently early on. Be open to opportunities that come up, even if they do not perfectly align with your goals. Explore opportunities beyond the limits of your job description. After all, opportunities beget more opportunities. Consider “stretch opportunities.” If you are offered an opportunity that you may not have 100% of the skills for—and is, therefore, a “stretch”—but which aligns with your career goals, do not turn it down. Consider saying “yes” and learn on the job. A mentor or coach can help you navigate these decisions.

Sometimes, it is important to say “yes” as part of being a “good citizen” in your department. Examples include mentoring learners, serving on a safety committee, teaching student lectures, or coaching a colleague. Often it is possible to align service with career goals.

Another consideration is the benefit of networking: developing alliances and building bridges. In addition to the service or productivity that come with projects or collaborations, these can be powerful networking opportunities. Networking broadly, both within and beyond your field of practice and within and outside your institution, is an important way to create “bonding capital” and “bridging capital,” ie, relationships based on your commonalities and relationships built across differences, respectively.¹

Remember, when you say “yes,” you must deliver: every time, on time, and with excellence. When saying “yes” to more opportunities starts to impact your ability to deliver for what you have already committed to, it is time to say “no.” This will help you maintain balance, avoid burnout, and stay focused.

When juggling a busy schedule, consider effort vs impact. There are many low-effort opportunities that have relatively high impact. For instance, as a junior faculty member interested in medical education, participating in a grading committee is low effort but can help you understand the process, connect you with educational leaders, and open doors to future opportunities. An effective strategy may be to incorporate a combination of low-effort and high-effort activities at any one time, while considering the impact of each, to help maintain balance. The effort-vs-impact balance may shift as you grow in your career.

Know where you are going, explore the opportunities that may get you there, and recalibrate often. The path to success is typically a circuitous one, so enjoy the journey and give it your all every step of the way.