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Ixekizumab found superior to ustekinumab in psoriasis at 24 weeks
ORLANDO – The interleukin-17A inhibitor ixekizumab was associated with superior efficacy and safety when compared with ustekinumab at 24 weeks, a head-to-head trial of the two monoclonal antibodies in plaque psoriasis has shown.
The 24-week data from the IXORA-S trial were presented during a late-breaking clinical trial session at the annual meeting of the American Academy of Dermatology by Kristian Reich, MD, PhD, a founder of SCIderm in Hamburg, Germany.
At 24 weeks, 49% in the ixekizumab arm achieved a Psoriasis Area and Severity Index (PASI) 100 level of skin clearance, compared with 24% in the ustekinumab arm (P = .001). Ixekizumab treatment also reached significantly higher skin clearances than ustekinumab at 24 weeks at the level of PASI 90 (83% vs. 59%; P less than .001) and PASI 75 (91% vs. 82%; P = .015).
Treatment with ixekizumab produced a Static Physician’s Global Assessment (sPGA) score of 0 in 54% at 24 weeks, compared with 24% with ustekinumab (P less than .001). A sPGA score of 0 or 1 occurred in 87% of patients who took ixekizumab and in 59% of the ustekinumab group.
An improvement of 4 or more points in the pruritus Numeric Rating Scale was reported by 86% of ixekizumab patients at 24 weeks, compared with 72% of those who took ustekinumab (P = .018).
Dr. Reich reported that there were no deaths or any significant differences in overall treatment-related adverse events across both arms, although he cautioned against putting too much stock in 24-week safety data. “I hesitate to show safety data for only 300 patients at 24 weeks, but it’s good to see here that there doesn’t seem to be a difference. I still would want to see larger patient numbers and more long-term data,” he said.
Dr. Reich had numerous disclosures, including honoraria for serving as a speaker for Eli Lilly, the sponsor of this trial.
ORLANDO – The interleukin-17A inhibitor ixekizumab was associated with superior efficacy and safety when compared with ustekinumab at 24 weeks, a head-to-head trial of the two monoclonal antibodies in plaque psoriasis has shown.
The 24-week data from the IXORA-S trial were presented during a late-breaking clinical trial session at the annual meeting of the American Academy of Dermatology by Kristian Reich, MD, PhD, a founder of SCIderm in Hamburg, Germany.
At 24 weeks, 49% in the ixekizumab arm achieved a Psoriasis Area and Severity Index (PASI) 100 level of skin clearance, compared with 24% in the ustekinumab arm (P = .001). Ixekizumab treatment also reached significantly higher skin clearances than ustekinumab at 24 weeks at the level of PASI 90 (83% vs. 59%; P less than .001) and PASI 75 (91% vs. 82%; P = .015).
Treatment with ixekizumab produced a Static Physician’s Global Assessment (sPGA) score of 0 in 54% at 24 weeks, compared with 24% with ustekinumab (P less than .001). A sPGA score of 0 or 1 occurred in 87% of patients who took ixekizumab and in 59% of the ustekinumab group.
An improvement of 4 or more points in the pruritus Numeric Rating Scale was reported by 86% of ixekizumab patients at 24 weeks, compared with 72% of those who took ustekinumab (P = .018).
Dr. Reich reported that there were no deaths or any significant differences in overall treatment-related adverse events across both arms, although he cautioned against putting too much stock in 24-week safety data. “I hesitate to show safety data for only 300 patients at 24 weeks, but it’s good to see here that there doesn’t seem to be a difference. I still would want to see larger patient numbers and more long-term data,” he said.
Dr. Reich had numerous disclosures, including honoraria for serving as a speaker for Eli Lilly, the sponsor of this trial.
ORLANDO – The interleukin-17A inhibitor ixekizumab was associated with superior efficacy and safety when compared with ustekinumab at 24 weeks, a head-to-head trial of the two monoclonal antibodies in plaque psoriasis has shown.
The 24-week data from the IXORA-S trial were presented during a late-breaking clinical trial session at the annual meeting of the American Academy of Dermatology by Kristian Reich, MD, PhD, a founder of SCIderm in Hamburg, Germany.
At 24 weeks, 49% in the ixekizumab arm achieved a Psoriasis Area and Severity Index (PASI) 100 level of skin clearance, compared with 24% in the ustekinumab arm (P = .001). Ixekizumab treatment also reached significantly higher skin clearances than ustekinumab at 24 weeks at the level of PASI 90 (83% vs. 59%; P less than .001) and PASI 75 (91% vs. 82%; P = .015).
Treatment with ixekizumab produced a Static Physician’s Global Assessment (sPGA) score of 0 in 54% at 24 weeks, compared with 24% with ustekinumab (P less than .001). A sPGA score of 0 or 1 occurred in 87% of patients who took ixekizumab and in 59% of the ustekinumab group.
An improvement of 4 or more points in the pruritus Numeric Rating Scale was reported by 86% of ixekizumab patients at 24 weeks, compared with 72% of those who took ustekinumab (P = .018).
Dr. Reich reported that there were no deaths or any significant differences in overall treatment-related adverse events across both arms, although he cautioned against putting too much stock in 24-week safety data. “I hesitate to show safety data for only 300 patients at 24 weeks, but it’s good to see here that there doesn’t seem to be a difference. I still would want to see larger patient numbers and more long-term data,” he said.
Dr. Reich had numerous disclosures, including honoraria for serving as a speaker for Eli Lilly, the sponsor of this trial.
AT AAD 2017
Key clinical point:
Major finding: At 24 weeks, ixekizumab was associated with significantly better PASI response rates and reduction in itch than ustekinumab in patients with moderate to severe plaque psoriasis.
Data source: Head-to-head trial of 302 adults with moderate to severe plaque psoriasis treated with either ixekizumab or ustekinumab.
Disclosures: Dr. Reich had numerous disclosures, including honoraria for serving as a speaker for Eli Lilly, the sponsor of this trial.
FDA approves safinamide to treat Parkinson’s disease
The U.S. Food and Drug Administration approved safinamide tablets on March 21 as an add-on treatment for patients with Parkinson’s disease who are currently taking levodopa/carbidopa and experiencing “off” episodes.
Newron Pharmaceuticals will market safinamide under the brand name Xadago.
The most common adverse reactions observed in patients taking safinamide were uncontrolled involuntary movement, falls, nausea, and insomnia.
In its announcement of the approval, the FDA noted that patients should not take safinamide if they have severe liver problems, take dextromethorphan, or take a monoamine oxidase inhibitor, because the two together may cause a sudden severe increase in blood pressure. Safinamide also should not be taken by patients who use a opioid drug, St. John’s wort, certain antidepressants (such as serotonin-norepinephrine reuptake inhibitors, tricyclics, tetracyclics, and triazolopyridines), or cyclobenzaprine, because it may cause a life-threatening reaction called serotonin syndrome.
The U.S. Food and Drug Administration approved safinamide tablets on March 21 as an add-on treatment for patients with Parkinson’s disease who are currently taking levodopa/carbidopa and experiencing “off” episodes.
Newron Pharmaceuticals will market safinamide under the brand name Xadago.
The most common adverse reactions observed in patients taking safinamide were uncontrolled involuntary movement, falls, nausea, and insomnia.
In its announcement of the approval, the FDA noted that patients should not take safinamide if they have severe liver problems, take dextromethorphan, or take a monoamine oxidase inhibitor, because the two together may cause a sudden severe increase in blood pressure. Safinamide also should not be taken by patients who use a opioid drug, St. John’s wort, certain antidepressants (such as serotonin-norepinephrine reuptake inhibitors, tricyclics, tetracyclics, and triazolopyridines), or cyclobenzaprine, because it may cause a life-threatening reaction called serotonin syndrome.
The U.S. Food and Drug Administration approved safinamide tablets on March 21 as an add-on treatment for patients with Parkinson’s disease who are currently taking levodopa/carbidopa and experiencing “off” episodes.
Newron Pharmaceuticals will market safinamide under the brand name Xadago.
The most common adverse reactions observed in patients taking safinamide were uncontrolled involuntary movement, falls, nausea, and insomnia.
In its announcement of the approval, the FDA noted that patients should not take safinamide if they have severe liver problems, take dextromethorphan, or take a monoamine oxidase inhibitor, because the two together may cause a sudden severe increase in blood pressure. Safinamide also should not be taken by patients who use a opioid drug, St. John’s wort, certain antidepressants (such as serotonin-norepinephrine reuptake inhibitors, tricyclics, tetracyclics, and triazolopyridines), or cyclobenzaprine, because it may cause a life-threatening reaction called serotonin syndrome.
Trump’s promise to rein in drug prices could open floodgate to importation laws
With prescription drug prices soaring and President Donald Trump vowing to take action, an old idea is gaining fresh traction: allowing Americans to buy medicines from foreign pharmacies at far lower prices. A new bill in Congress to allow the practice would modify previous safety standards and remove a barrier that proved insurmountable in past attempts to enable progress.
Congress came close to allowing importation through the Medicare Modernization Act in 2003 but added one firm precondition that has proved a nonstarter. The secretary of Health & Human Services had to guarantee that imported medications posed no additional risk to public safety and would save money.
“That is a fairly absolute standard and a high bar to cross,” said Elizabeth Jungman, director of public health at the Pew Charitable Trusts. Such an exacting standard – guaranteeing that no imported prescriptions posed a threat – has kept any secretary of HHS from condoning it.
In an open letter to Congress, four former commissioners of the Food and Drug Administration argue consumer drug importation remains too risky to permit. “It could lead to a host of unintended consequences and undesirable effects, including serious harm stemming from the use of adulterated, substandard, or counterfeit drugs,” they said in the letter distributed to media organizations. It was signed by Robert Califf, Margaret Hamburg, Mark McClellan, and Andrew von Eschenbach, who each headed the FDA at various times during 2002 through 2016.
The recent proposal, from senators Bernie Sanders (I-Vt.) and Cory Booker (D-N.J.) and Bob Casey (D-Pa.) drops that requirement. Instead, it sets up a regulatory system in which Canadian pharmacies that purchase supplies from manufacturers inspected by the FDA would be licensed to sell to customers across the border. The bill allows not only individuals but also drug wholesalers and pharmacies to buy from Canada.
After 2 years, HHS could allow importation from other countries that meet standards comparable to those of the United States.
Another bill in Congress, proposed in January by senators John McCain (R-Ariz.) and Amy Klobuchar (D-Minn.), focuses solely on allowing individuals to purchase drugs from such pharmacies.
President Trump has promised that “pricing for the American people will come way down.” Last week, he had a high-profile meeting at the White House with congressmen Elijah Cummings (D-Md.) and Peter Welch (D-Vt.) and the president of Johns Hopkins Hospital, Baltimore, Redonda Miller, MD, to discuss allowing Medicare to negotiate prices on outpatient medicines. Cong. Cummings told reporters later that President Trump said he supports Medicare price negotiation as well as the Sanders bill.
PhRMA, the drug industry’s trade group, has denounced Sanders’ proposal as it has others that enabled imports in the past.
“The bill lacks sufficient safety controls [and] would exacerbate threats to public health from counterfeit, adulterated, or diverted medicines, and increase the burden on law enforcement to prevent unregulated medicines and other dangerous products from harming consumers,” said PhRMA spokeswoman Nicole Longo.
Surveys indicate that up to 8% of Americans have bought medicines outside the United States, even though the practice is technically illegal and imported pills are subject to confiscation.
Around 45 million Americans – 18% of the adult population – said last year that they did not fill a prescription because of cost, according to an analysis of data from the Commonwealth Fund by Gabe Levitt, president of pharmacychecker.com, whose company helps Americans buy medications online by vetting overseas pharmacies and comparing prices for different drugs. Data compiled by the company compare Canadian prescription prices with those offered in New York and show drugs that frequently are three or more times as expensive in the United States as across the border.
For example, a simple Proventil asthma inhaler costs $73.19 in the United States vs. $21.66 in Canada. Crestor, the cholesterol-lowering drug, is $6.82 per pill in U.S. pharmacies but $2.58 in Canada. Abilify, a psychiatric medicine, is $29.88 vs. $7.58, according to pharmacychecker.com.
Many previous bills that permitted importation or that allowed Medicare to negotiate prices for its beneficiaries have failed in the face of $1.9 billion in congressional lobbying by the pharmaceutical industry since 2003, according to Open Secrets. But Americans may be reaching a tipping point of intolerance. In polling just before the election by the Kaiser Family Foundation, 77% of Americans called drug prices “unreasonable” and well over half favored a variety of proposals to address them.
To address safety concerns, the Sanders bill institutes several new strategies. Canadian pharmacies that want to be registered to sell to Americans would have to pay a fee to pay for additional FDA monitoring. A Government Accountability Office study would be required within 18 months of the final rule to address outcomes related to importation processes, drug safety, consumer savings, and regulatory expenses.
Allowing people to legally import medications would not completely solve the problem of high prescription drugs prices, advocates say, but would be a step in the right direction. Said Mr. Levitt, “the best way for Americans to afford their meds is to enact policies here to bring the prices down here.”
Kaiser Health News is a national health policy news service that is part of the nonpartisan Henry J. Kaiser Family Foundation. KHN’s coverage of prescription drug development, costs and pricing is supported in part by the Laura and John Arnold Foundation.
With prescription drug prices soaring and President Donald Trump vowing to take action, an old idea is gaining fresh traction: allowing Americans to buy medicines from foreign pharmacies at far lower prices. A new bill in Congress to allow the practice would modify previous safety standards and remove a barrier that proved insurmountable in past attempts to enable progress.
Congress came close to allowing importation through the Medicare Modernization Act in 2003 but added one firm precondition that has proved a nonstarter. The secretary of Health & Human Services had to guarantee that imported medications posed no additional risk to public safety and would save money.
“That is a fairly absolute standard and a high bar to cross,” said Elizabeth Jungman, director of public health at the Pew Charitable Trusts. Such an exacting standard – guaranteeing that no imported prescriptions posed a threat – has kept any secretary of HHS from condoning it.
In an open letter to Congress, four former commissioners of the Food and Drug Administration argue consumer drug importation remains too risky to permit. “It could lead to a host of unintended consequences and undesirable effects, including serious harm stemming from the use of adulterated, substandard, or counterfeit drugs,” they said in the letter distributed to media organizations. It was signed by Robert Califf, Margaret Hamburg, Mark McClellan, and Andrew von Eschenbach, who each headed the FDA at various times during 2002 through 2016.
The recent proposal, from senators Bernie Sanders (I-Vt.) and Cory Booker (D-N.J.) and Bob Casey (D-Pa.) drops that requirement. Instead, it sets up a regulatory system in which Canadian pharmacies that purchase supplies from manufacturers inspected by the FDA would be licensed to sell to customers across the border. The bill allows not only individuals but also drug wholesalers and pharmacies to buy from Canada.
After 2 years, HHS could allow importation from other countries that meet standards comparable to those of the United States.
Another bill in Congress, proposed in January by senators John McCain (R-Ariz.) and Amy Klobuchar (D-Minn.), focuses solely on allowing individuals to purchase drugs from such pharmacies.
President Trump has promised that “pricing for the American people will come way down.” Last week, he had a high-profile meeting at the White House with congressmen Elijah Cummings (D-Md.) and Peter Welch (D-Vt.) and the president of Johns Hopkins Hospital, Baltimore, Redonda Miller, MD, to discuss allowing Medicare to negotiate prices on outpatient medicines. Cong. Cummings told reporters later that President Trump said he supports Medicare price negotiation as well as the Sanders bill.
PhRMA, the drug industry’s trade group, has denounced Sanders’ proposal as it has others that enabled imports in the past.
“The bill lacks sufficient safety controls [and] would exacerbate threats to public health from counterfeit, adulterated, or diverted medicines, and increase the burden on law enforcement to prevent unregulated medicines and other dangerous products from harming consumers,” said PhRMA spokeswoman Nicole Longo.
Surveys indicate that up to 8% of Americans have bought medicines outside the United States, even though the practice is technically illegal and imported pills are subject to confiscation.
Around 45 million Americans – 18% of the adult population – said last year that they did not fill a prescription because of cost, according to an analysis of data from the Commonwealth Fund by Gabe Levitt, president of pharmacychecker.com, whose company helps Americans buy medications online by vetting overseas pharmacies and comparing prices for different drugs. Data compiled by the company compare Canadian prescription prices with those offered in New York and show drugs that frequently are three or more times as expensive in the United States as across the border.
For example, a simple Proventil asthma inhaler costs $73.19 in the United States vs. $21.66 in Canada. Crestor, the cholesterol-lowering drug, is $6.82 per pill in U.S. pharmacies but $2.58 in Canada. Abilify, a psychiatric medicine, is $29.88 vs. $7.58, according to pharmacychecker.com.
Many previous bills that permitted importation or that allowed Medicare to negotiate prices for its beneficiaries have failed in the face of $1.9 billion in congressional lobbying by the pharmaceutical industry since 2003, according to Open Secrets. But Americans may be reaching a tipping point of intolerance. In polling just before the election by the Kaiser Family Foundation, 77% of Americans called drug prices “unreasonable” and well over half favored a variety of proposals to address them.
To address safety concerns, the Sanders bill institutes several new strategies. Canadian pharmacies that want to be registered to sell to Americans would have to pay a fee to pay for additional FDA monitoring. A Government Accountability Office study would be required within 18 months of the final rule to address outcomes related to importation processes, drug safety, consumer savings, and regulatory expenses.
Allowing people to legally import medications would not completely solve the problem of high prescription drugs prices, advocates say, but would be a step in the right direction. Said Mr. Levitt, “the best way for Americans to afford their meds is to enact policies here to bring the prices down here.”
Kaiser Health News is a national health policy news service that is part of the nonpartisan Henry J. Kaiser Family Foundation. KHN’s coverage of prescription drug development, costs and pricing is supported in part by the Laura and John Arnold Foundation.
With prescription drug prices soaring and President Donald Trump vowing to take action, an old idea is gaining fresh traction: allowing Americans to buy medicines from foreign pharmacies at far lower prices. A new bill in Congress to allow the practice would modify previous safety standards and remove a barrier that proved insurmountable in past attempts to enable progress.
Congress came close to allowing importation through the Medicare Modernization Act in 2003 but added one firm precondition that has proved a nonstarter. The secretary of Health & Human Services had to guarantee that imported medications posed no additional risk to public safety and would save money.
“That is a fairly absolute standard and a high bar to cross,” said Elizabeth Jungman, director of public health at the Pew Charitable Trusts. Such an exacting standard – guaranteeing that no imported prescriptions posed a threat – has kept any secretary of HHS from condoning it.
In an open letter to Congress, four former commissioners of the Food and Drug Administration argue consumer drug importation remains too risky to permit. “It could lead to a host of unintended consequences and undesirable effects, including serious harm stemming from the use of adulterated, substandard, or counterfeit drugs,” they said in the letter distributed to media organizations. It was signed by Robert Califf, Margaret Hamburg, Mark McClellan, and Andrew von Eschenbach, who each headed the FDA at various times during 2002 through 2016.
The recent proposal, from senators Bernie Sanders (I-Vt.) and Cory Booker (D-N.J.) and Bob Casey (D-Pa.) drops that requirement. Instead, it sets up a regulatory system in which Canadian pharmacies that purchase supplies from manufacturers inspected by the FDA would be licensed to sell to customers across the border. The bill allows not only individuals but also drug wholesalers and pharmacies to buy from Canada.
After 2 years, HHS could allow importation from other countries that meet standards comparable to those of the United States.
Another bill in Congress, proposed in January by senators John McCain (R-Ariz.) and Amy Klobuchar (D-Minn.), focuses solely on allowing individuals to purchase drugs from such pharmacies.
President Trump has promised that “pricing for the American people will come way down.” Last week, he had a high-profile meeting at the White House with congressmen Elijah Cummings (D-Md.) and Peter Welch (D-Vt.) and the president of Johns Hopkins Hospital, Baltimore, Redonda Miller, MD, to discuss allowing Medicare to negotiate prices on outpatient medicines. Cong. Cummings told reporters later that President Trump said he supports Medicare price negotiation as well as the Sanders bill.
PhRMA, the drug industry’s trade group, has denounced Sanders’ proposal as it has others that enabled imports in the past.
“The bill lacks sufficient safety controls [and] would exacerbate threats to public health from counterfeit, adulterated, or diverted medicines, and increase the burden on law enforcement to prevent unregulated medicines and other dangerous products from harming consumers,” said PhRMA spokeswoman Nicole Longo.
Surveys indicate that up to 8% of Americans have bought medicines outside the United States, even though the practice is technically illegal and imported pills are subject to confiscation.
Around 45 million Americans – 18% of the adult population – said last year that they did not fill a prescription because of cost, according to an analysis of data from the Commonwealth Fund by Gabe Levitt, president of pharmacychecker.com, whose company helps Americans buy medications online by vetting overseas pharmacies and comparing prices for different drugs. Data compiled by the company compare Canadian prescription prices with those offered in New York and show drugs that frequently are three or more times as expensive in the United States as across the border.
For example, a simple Proventil asthma inhaler costs $73.19 in the United States vs. $21.66 in Canada. Crestor, the cholesterol-lowering drug, is $6.82 per pill in U.S. pharmacies but $2.58 in Canada. Abilify, a psychiatric medicine, is $29.88 vs. $7.58, according to pharmacychecker.com.
Many previous bills that permitted importation or that allowed Medicare to negotiate prices for its beneficiaries have failed in the face of $1.9 billion in congressional lobbying by the pharmaceutical industry since 2003, according to Open Secrets. But Americans may be reaching a tipping point of intolerance. In polling just before the election by the Kaiser Family Foundation, 77% of Americans called drug prices “unreasonable” and well over half favored a variety of proposals to address them.
To address safety concerns, the Sanders bill institutes several new strategies. Canadian pharmacies that want to be registered to sell to Americans would have to pay a fee to pay for additional FDA monitoring. A Government Accountability Office study would be required within 18 months of the final rule to address outcomes related to importation processes, drug safety, consumer savings, and regulatory expenses.
Allowing people to legally import medications would not completely solve the problem of high prescription drugs prices, advocates say, but would be a step in the right direction. Said Mr. Levitt, “the best way for Americans to afford their meds is to enact policies here to bring the prices down here.”
Kaiser Health News is a national health policy news service that is part of the nonpartisan Henry J. Kaiser Family Foundation. KHN’s coverage of prescription drug development, costs and pricing is supported in part by the Laura and John Arnold Foundation.
Disappointment in article on NP, PA roles in HM groups
Editor’s note: The following “Letter to the Editor” was first emailed to the Society of Hospital Medicine, its board president, and John Nelson, MD, MHM, the author of the article, “Hospitalist Roles for NPs and PAs,” which published in the January 2017 issue. All parties agreed to publish the email exchange in The Hospitalist.
Sent: Sunday, February 12, 2017 9:59 AM
Subject: Offensive article on hospitalist roles for NPs, PAs
All,
I have been a hospitalist NP (nurse practitioner) for a decade and found the article in the January issue of The Hospitalist, Volume 21, Number 1, on the Hospitalist Roles for NPs and PAs, offensive and uninformed, with an intolerable amount of personal opinion not backed by research.
I am disappointed that The Hospitalist would publish such a low-class article. Your [magazine] promotes membership to all APPs (advanced practice providers), yet you publish articles that show a study with a positive finding yet allow and highlight an incredibly negative and offensive snippet. The highlighted box states that “Any group that thinks this study is evidence that adding more APPs and having them manage a high number of patients relatively independently will go well in any setting is MISTAKEN ... But it does offer a STORY of one place where, with careful planning and execution, it went OK.”
I can only say that the physicians, APPs, and hospital group who did this study would likely also be offended for taking their study and turning it into a “story.”
EDUCATE yourselves. There are numerous studies out there showing care by APP’s is cost effective, efficient, and with excellent care outcomes. There is a national group, APPex (Advanced Practice Provider Executives), that can give you all the studies you would want showing this information. Or contact the national NP or PA groups.
I am a working hospitalist NP and appreciate my physician colleagues and have their respect. This “John” person obviously doesn’t respect APPs and to publish him is just disheartening.
This publication could have and should have done better. You have one APP on your editorial advisory board – it appears you need more.
Marci Harris, MSN, FNP, ACNP
Acute Care Nurse Practitioner
Hospitalist/Internal Medicine
McKee Medical Center, Loveland, Colo.
Dr. Nelson responds:
Thanks for your message, Marci. It seems clear you’ve thought a lot about NPs and PAs in hospitalist practices and have arrived at conclusions that differ from what I wrote. Your voice and views are welcome.
I certainly didn’t intend to offend anyone, including those who might see all of this very differently from me.
As I mention in the first paragraph, I’m very supportive of NPs and PAs in hospitalist practices. And I wanted to write about this particular study precisely because it provides data that is very supportive of their contributions.
The point I was trying to make in the column is that there is value in careful planning around roles and who does what. A sports team could recruit the most talented players but still won’t perform well if they don’t develop and execute a good plan around who does what and how they work together. Simply having talented people on the team isn’t enough. I think the same is true of hospitalist teams.
The hospitalist group in the study has an impressively detailed plan for new provider (APC and MD alike) orientation and has a lot of operating processes that help ensure the PAs and MDs work effectively together. My experience is that many hospitalists groups have never developed such a plan.
John Nelson, MD, MHM
Partner, Nelson Flores Hospital Medicine Consultants, Bellevue, Wash.
Editor’s note: The following “Letter to the Editor” was first emailed to the Society of Hospital Medicine, its board president, and John Nelson, MD, MHM, the author of the article, “Hospitalist Roles for NPs and PAs,” which published in the January 2017 issue. All parties agreed to publish the email exchange in The Hospitalist.
Sent: Sunday, February 12, 2017 9:59 AM
Subject: Offensive article on hospitalist roles for NPs, PAs
All,
I have been a hospitalist NP (nurse practitioner) for a decade and found the article in the January issue of The Hospitalist, Volume 21, Number 1, on the Hospitalist Roles for NPs and PAs, offensive and uninformed, with an intolerable amount of personal opinion not backed by research.
I am disappointed that The Hospitalist would publish such a low-class article. Your [magazine] promotes membership to all APPs (advanced practice providers), yet you publish articles that show a study with a positive finding yet allow and highlight an incredibly negative and offensive snippet. The highlighted box states that “Any group that thinks this study is evidence that adding more APPs and having them manage a high number of patients relatively independently will go well in any setting is MISTAKEN ... But it does offer a STORY of one place where, with careful planning and execution, it went OK.”
I can only say that the physicians, APPs, and hospital group who did this study would likely also be offended for taking their study and turning it into a “story.”
EDUCATE yourselves. There are numerous studies out there showing care by APP’s is cost effective, efficient, and with excellent care outcomes. There is a national group, APPex (Advanced Practice Provider Executives), that can give you all the studies you would want showing this information. Or contact the national NP or PA groups.
I am a working hospitalist NP and appreciate my physician colleagues and have their respect. This “John” person obviously doesn’t respect APPs and to publish him is just disheartening.
This publication could have and should have done better. You have one APP on your editorial advisory board – it appears you need more.
Marci Harris, MSN, FNP, ACNP
Acute Care Nurse Practitioner
Hospitalist/Internal Medicine
McKee Medical Center, Loveland, Colo.
Dr. Nelson responds:
Thanks for your message, Marci. It seems clear you’ve thought a lot about NPs and PAs in hospitalist practices and have arrived at conclusions that differ from what I wrote. Your voice and views are welcome.
I certainly didn’t intend to offend anyone, including those who might see all of this very differently from me.
As I mention in the first paragraph, I’m very supportive of NPs and PAs in hospitalist practices. And I wanted to write about this particular study precisely because it provides data that is very supportive of their contributions.
The point I was trying to make in the column is that there is value in careful planning around roles and who does what. A sports team could recruit the most talented players but still won’t perform well if they don’t develop and execute a good plan around who does what and how they work together. Simply having talented people on the team isn’t enough. I think the same is true of hospitalist teams.
The hospitalist group in the study has an impressively detailed plan for new provider (APC and MD alike) orientation and has a lot of operating processes that help ensure the PAs and MDs work effectively together. My experience is that many hospitalists groups have never developed such a plan.
John Nelson, MD, MHM
Partner, Nelson Flores Hospital Medicine Consultants, Bellevue, Wash.
Editor’s note: The following “Letter to the Editor” was first emailed to the Society of Hospital Medicine, its board president, and John Nelson, MD, MHM, the author of the article, “Hospitalist Roles for NPs and PAs,” which published in the January 2017 issue. All parties agreed to publish the email exchange in The Hospitalist.
Sent: Sunday, February 12, 2017 9:59 AM
Subject: Offensive article on hospitalist roles for NPs, PAs
All,
I have been a hospitalist NP (nurse practitioner) for a decade and found the article in the January issue of The Hospitalist, Volume 21, Number 1, on the Hospitalist Roles for NPs and PAs, offensive and uninformed, with an intolerable amount of personal opinion not backed by research.
I am disappointed that The Hospitalist would publish such a low-class article. Your [magazine] promotes membership to all APPs (advanced practice providers), yet you publish articles that show a study with a positive finding yet allow and highlight an incredibly negative and offensive snippet. The highlighted box states that “Any group that thinks this study is evidence that adding more APPs and having them manage a high number of patients relatively independently will go well in any setting is MISTAKEN ... But it does offer a STORY of one place where, with careful planning and execution, it went OK.”
I can only say that the physicians, APPs, and hospital group who did this study would likely also be offended for taking their study and turning it into a “story.”
EDUCATE yourselves. There are numerous studies out there showing care by APP’s is cost effective, efficient, and with excellent care outcomes. There is a national group, APPex (Advanced Practice Provider Executives), that can give you all the studies you would want showing this information. Or contact the national NP or PA groups.
I am a working hospitalist NP and appreciate my physician colleagues and have their respect. This “John” person obviously doesn’t respect APPs and to publish him is just disheartening.
This publication could have and should have done better. You have one APP on your editorial advisory board – it appears you need more.
Marci Harris, MSN, FNP, ACNP
Acute Care Nurse Practitioner
Hospitalist/Internal Medicine
McKee Medical Center, Loveland, Colo.
Dr. Nelson responds:
Thanks for your message, Marci. It seems clear you’ve thought a lot about NPs and PAs in hospitalist practices and have arrived at conclusions that differ from what I wrote. Your voice and views are welcome.
I certainly didn’t intend to offend anyone, including those who might see all of this very differently from me.
As I mention in the first paragraph, I’m very supportive of NPs and PAs in hospitalist practices. And I wanted to write about this particular study precisely because it provides data that is very supportive of their contributions.
The point I was trying to make in the column is that there is value in careful planning around roles and who does what. A sports team could recruit the most talented players but still won’t perform well if they don’t develop and execute a good plan around who does what and how they work together. Simply having talented people on the team isn’t enough. I think the same is true of hospitalist teams.
The hospitalist group in the study has an impressively detailed plan for new provider (APC and MD alike) orientation and has a lot of operating processes that help ensure the PAs and MDs work effectively together. My experience is that many hospitalists groups have never developed such a plan.
John Nelson, MD, MHM
Partner, Nelson Flores Hospital Medicine Consultants, Bellevue, Wash.
Create hospitalist-patient partnerships for safety and quality
Hospitalists can help enlist patients in the movement toward improved patient safety, and they can begin simply by sharing their notes.
OpenNotes offers a new platform to do that, according to a BMJ Quality & Safety article, “A patient feedback reporting tool for OpenNotes: implications for patient-clinician safety and quality partnerships.”1
In their study, the researchers invited 6,225 patients to read clinicians’ notes and, through a patient portal, provide feedback. Forty-four percent of patients read the notes; nearly all (96%) respondents reported understanding the notes; 1 in 12 submitted feedback.
“Patients can [and did] find documentation errors in their notes and were willing to report them without any apparent negative effect on the patient-clinician relationship,” Dr. Bell says. “The majority of patients also wanted to share positive feedback with their providers. Sharing notes can also facilitate information transfer across care settings.”
Investigators also reported on feedback from patients that hearing the notes helped them to remember next steps.
“Reading discharge summaries and visit notes from follow-up visits after a hospitalization may prove particularly important,” Dr. Bell says. “Providing patients with access to their notes may help them to adhere to the care plan, better remember recommended follow up tests or visits, and potentially stem preventable readmissions.”
What hospitalists can do now, Dr. Bell adds, is:
- Share their notes with patients and families (by printing the discharge summaries if they are not available on the portal and/or sharing notes from post-discharge follow-up visits).
- Emphasize for patients and families the important role they play as safety partners.
- Ask patients who receive care in other healthcare centers if they have OpenNotes, which can help hospitalists obtain medical records quickly and efficiently.
- Encourage patients to sign up for the patient portal and ask for their notes, for ambulatory visits to begin with and for in-patient notes when they become available.
Suzanne Bopp is a freelance medical writer in New York City.
Reference
1. Bell SK, Gerard M, Fossa A, et al. A patient feedback reporting tool for OpenNotes: implications for patient-clinician safety and quality partnerships [published online ahead of print, Dec. 13, 2016]. BMJ Qual Saf. doi: 10.1136/bmjqs-2016-006020.
Hospitalists can help enlist patients in the movement toward improved patient safety, and they can begin simply by sharing their notes.
OpenNotes offers a new platform to do that, according to a BMJ Quality & Safety article, “A patient feedback reporting tool for OpenNotes: implications for patient-clinician safety and quality partnerships.”1
In their study, the researchers invited 6,225 patients to read clinicians’ notes and, through a patient portal, provide feedback. Forty-four percent of patients read the notes; nearly all (96%) respondents reported understanding the notes; 1 in 12 submitted feedback.
“Patients can [and did] find documentation errors in their notes and were willing to report them without any apparent negative effect on the patient-clinician relationship,” Dr. Bell says. “The majority of patients also wanted to share positive feedback with their providers. Sharing notes can also facilitate information transfer across care settings.”
Investigators also reported on feedback from patients that hearing the notes helped them to remember next steps.
“Reading discharge summaries and visit notes from follow-up visits after a hospitalization may prove particularly important,” Dr. Bell says. “Providing patients with access to their notes may help them to adhere to the care plan, better remember recommended follow up tests or visits, and potentially stem preventable readmissions.”
What hospitalists can do now, Dr. Bell adds, is:
- Share their notes with patients and families (by printing the discharge summaries if they are not available on the portal and/or sharing notes from post-discharge follow-up visits).
- Emphasize for patients and families the important role they play as safety partners.
- Ask patients who receive care in other healthcare centers if they have OpenNotes, which can help hospitalists obtain medical records quickly and efficiently.
- Encourage patients to sign up for the patient portal and ask for their notes, for ambulatory visits to begin with and for in-patient notes when they become available.
Suzanne Bopp is a freelance medical writer in New York City.
Reference
1. Bell SK, Gerard M, Fossa A, et al. A patient feedback reporting tool for OpenNotes: implications for patient-clinician safety and quality partnerships [published online ahead of print, Dec. 13, 2016]. BMJ Qual Saf. doi: 10.1136/bmjqs-2016-006020.
Hospitalists can help enlist patients in the movement toward improved patient safety, and they can begin simply by sharing their notes.
OpenNotes offers a new platform to do that, according to a BMJ Quality & Safety article, “A patient feedback reporting tool for OpenNotes: implications for patient-clinician safety and quality partnerships.”1
In their study, the researchers invited 6,225 patients to read clinicians’ notes and, through a patient portal, provide feedback. Forty-four percent of patients read the notes; nearly all (96%) respondents reported understanding the notes; 1 in 12 submitted feedback.
“Patients can [and did] find documentation errors in their notes and were willing to report them without any apparent negative effect on the patient-clinician relationship,” Dr. Bell says. “The majority of patients also wanted to share positive feedback with their providers. Sharing notes can also facilitate information transfer across care settings.”
Investigators also reported on feedback from patients that hearing the notes helped them to remember next steps.
“Reading discharge summaries and visit notes from follow-up visits after a hospitalization may prove particularly important,” Dr. Bell says. “Providing patients with access to their notes may help them to adhere to the care plan, better remember recommended follow up tests or visits, and potentially stem preventable readmissions.”
What hospitalists can do now, Dr. Bell adds, is:
- Share their notes with patients and families (by printing the discharge summaries if they are not available on the portal and/or sharing notes from post-discharge follow-up visits).
- Emphasize for patients and families the important role they play as safety partners.
- Ask patients who receive care in other healthcare centers if they have OpenNotes, which can help hospitalists obtain medical records quickly and efficiently.
- Encourage patients to sign up for the patient portal and ask for their notes, for ambulatory visits to begin with and for in-patient notes when they become available.
Suzanne Bopp is a freelance medical writer in New York City.
Reference
1. Bell SK, Gerard M, Fossa A, et al. A patient feedback reporting tool for OpenNotes: implications for patient-clinician safety and quality partnerships [published online ahead of print, Dec. 13, 2016]. BMJ Qual Saf. doi: 10.1136/bmjqs-2016-006020.
GOP health plan clears first hurdle; opposition lines up
The Republican plan to replace the Affordable Care Act cleared the first legislative hurdle when two house committees passed language that would repeal revenue provisions of the Affordable Care Act and lay the foundation for replacing the health care reform law.
The House Ways and Means Committee–approved legislation would eliminate the individual mandate in favor of allowing insurance companies to penalize individuals by up to 30% of premiums for lapses in coverage and would repeal taxes on high-cost health plans (Cadillac tax), over-the-counter and prescription medications, health savings accounts, tanning, investment, and on health insurers.
The language passed with a party-line vote March 9 with 23 Republicans voting for and 16 Democrats voting against after nearly 18 hours of debate and amendments.
The House Energy and Commerce Committee, after 27 hours of debate that started March 8, also passed its language along party lines with 31 Republicans voting for and 23 Democrats voting against. Their bill would end Medicaid expansion and reset the program’s funding to a per capita allotment based on population indicators, along with block grants, to provide states more flexibility to better manage its population.
In both committees, Democrats introduced a wide range of amendments, including guarantees there would be no impact from the reduction of Medicaid expansion and on funding to support coverage for mental health, women, children, seniors, and veterans, all of which were voted down. Ways and Means members also offered an amendment to require President Trump to release his income tax filings.
Rep. Frank Pallone (D-N.J.), lead Democrat on the Energy and Commerce Committee, voiced his colleagues’ objections to the bill and the process. The bill “would rip health care away from millions of Americans, raise costs for working families and seniors, and lead to the rationing of care for 76 million Americans who receive Medicaid.
The pace of action in the House even drew criticism from some in the GOP. Sen. Tom Cotton (R-Ark.) took to Twitter with a stern warning to the House. “House health-care bill can’t pass w/o major changes,” Sen. Cotton tweeted. “To my friends in House: pause, start over. Get it right, don’t get it fast.”
He followed up with two more tweets: “GOP shouldn’t act like Dems did in O’care. No excuse to release bill Mon night, start voting Wed. With no budget estimate!” He added: “What matters in long run is better, more affordable health care for Americans, NOT house leaders’ arbitrary legislative calendar.”
Four Republican senators – Rob Portman (Ohio), Shelley Moore Capito (W.Va.), Cory Gardner (Colo.), and Lisa Murkowski (Alaska) – also expressed concerns regarding how Medicaid will be changed under the repeal/replace effort and vowed not to support any plan “that does not include stability for Medicaid expansion populations or flexibility for states.”
Republicans hold a slim 52-seat majority in the Senate and need only 50 votes to pass any legislation that uses the budget reconciliation process. If those four senators voted with Democrats, who are expected to vote as a party against the repeal effort, the current House Republican legislation would not clear the Senate.
Physicians’ groups also have voiced their opposition. American Medical Association President Andrew Gurman, MD, said in a statement that it is “not legislation we can support. The replacement bill, as written, would reverse the coverage gains of the ACA, causing many Americans to lose the health coverage they have come to depend on.” He added that the proposed changes to Medicaid “would limit states’ ability to respond to changes in service demands and threaten coverage for people with low incomes.”
Likewise, a joint statement issued by the American Academy of Family Physicians, American Academy of Pediatricians, American College of Physicians, American Congress of Obstetricians and Gynecologists and the American Osteopathic Association, expressed concern that the proposal “will likely result in less access to coverage and higher costs for millions of patients.”
AGA is closely monitoring the process to ensure that patients are still able to receive coverage for preventive screenings without cost-sharing, such as colorectal cancer screenings, and they continue to advocate that this section remain. They are concerned that patients will not have access to specialty care. A repeal will result in millions of patients being uninsured and millions of dollars in uncompensated care to providers like gastroenterologists. AGA will continue to monitor the legislative process and voice its concerns. Learn more about how you can get involved through the AGA Political Action Committee.
The Republican plan to replace the Affordable Care Act cleared the first legislative hurdle when two house committees passed language that would repeal revenue provisions of the Affordable Care Act and lay the foundation for replacing the health care reform law.
The House Ways and Means Committee–approved legislation would eliminate the individual mandate in favor of allowing insurance companies to penalize individuals by up to 30% of premiums for lapses in coverage and would repeal taxes on high-cost health plans (Cadillac tax), over-the-counter and prescription medications, health savings accounts, tanning, investment, and on health insurers.
The language passed with a party-line vote March 9 with 23 Republicans voting for and 16 Democrats voting against after nearly 18 hours of debate and amendments.
The House Energy and Commerce Committee, after 27 hours of debate that started March 8, also passed its language along party lines with 31 Republicans voting for and 23 Democrats voting against. Their bill would end Medicaid expansion and reset the program’s funding to a per capita allotment based on population indicators, along with block grants, to provide states more flexibility to better manage its population.
In both committees, Democrats introduced a wide range of amendments, including guarantees there would be no impact from the reduction of Medicaid expansion and on funding to support coverage for mental health, women, children, seniors, and veterans, all of which were voted down. Ways and Means members also offered an amendment to require President Trump to release his income tax filings.
Rep. Frank Pallone (D-N.J.), lead Democrat on the Energy and Commerce Committee, voiced his colleagues’ objections to the bill and the process. The bill “would rip health care away from millions of Americans, raise costs for working families and seniors, and lead to the rationing of care for 76 million Americans who receive Medicaid.
The pace of action in the House even drew criticism from some in the GOP. Sen. Tom Cotton (R-Ark.) took to Twitter with a stern warning to the House. “House health-care bill can’t pass w/o major changes,” Sen. Cotton tweeted. “To my friends in House: pause, start over. Get it right, don’t get it fast.”
He followed up with two more tweets: “GOP shouldn’t act like Dems did in O’care. No excuse to release bill Mon night, start voting Wed. With no budget estimate!” He added: “What matters in long run is better, more affordable health care for Americans, NOT house leaders’ arbitrary legislative calendar.”
Four Republican senators – Rob Portman (Ohio), Shelley Moore Capito (W.Va.), Cory Gardner (Colo.), and Lisa Murkowski (Alaska) – also expressed concerns regarding how Medicaid will be changed under the repeal/replace effort and vowed not to support any plan “that does not include stability for Medicaid expansion populations or flexibility for states.”
Republicans hold a slim 52-seat majority in the Senate and need only 50 votes to pass any legislation that uses the budget reconciliation process. If those four senators voted with Democrats, who are expected to vote as a party against the repeal effort, the current House Republican legislation would not clear the Senate.
Physicians’ groups also have voiced their opposition. American Medical Association President Andrew Gurman, MD, said in a statement that it is “not legislation we can support. The replacement bill, as written, would reverse the coverage gains of the ACA, causing many Americans to lose the health coverage they have come to depend on.” He added that the proposed changes to Medicaid “would limit states’ ability to respond to changes in service demands and threaten coverage for people with low incomes.”
Likewise, a joint statement issued by the American Academy of Family Physicians, American Academy of Pediatricians, American College of Physicians, American Congress of Obstetricians and Gynecologists and the American Osteopathic Association, expressed concern that the proposal “will likely result in less access to coverage and higher costs for millions of patients.”
AGA is closely monitoring the process to ensure that patients are still able to receive coverage for preventive screenings without cost-sharing, such as colorectal cancer screenings, and they continue to advocate that this section remain. They are concerned that patients will not have access to specialty care. A repeal will result in millions of patients being uninsured and millions of dollars in uncompensated care to providers like gastroenterologists. AGA will continue to monitor the legislative process and voice its concerns. Learn more about how you can get involved through the AGA Political Action Committee.
The Republican plan to replace the Affordable Care Act cleared the first legislative hurdle when two house committees passed language that would repeal revenue provisions of the Affordable Care Act and lay the foundation for replacing the health care reform law.
The House Ways and Means Committee–approved legislation would eliminate the individual mandate in favor of allowing insurance companies to penalize individuals by up to 30% of premiums for lapses in coverage and would repeal taxes on high-cost health plans (Cadillac tax), over-the-counter and prescription medications, health savings accounts, tanning, investment, and on health insurers.
The language passed with a party-line vote March 9 with 23 Republicans voting for and 16 Democrats voting against after nearly 18 hours of debate and amendments.
The House Energy and Commerce Committee, after 27 hours of debate that started March 8, also passed its language along party lines with 31 Republicans voting for and 23 Democrats voting against. Their bill would end Medicaid expansion and reset the program’s funding to a per capita allotment based on population indicators, along with block grants, to provide states more flexibility to better manage its population.
In both committees, Democrats introduced a wide range of amendments, including guarantees there would be no impact from the reduction of Medicaid expansion and on funding to support coverage for mental health, women, children, seniors, and veterans, all of which were voted down. Ways and Means members also offered an amendment to require President Trump to release his income tax filings.
Rep. Frank Pallone (D-N.J.), lead Democrat on the Energy and Commerce Committee, voiced his colleagues’ objections to the bill and the process. The bill “would rip health care away from millions of Americans, raise costs for working families and seniors, and lead to the rationing of care for 76 million Americans who receive Medicaid.
The pace of action in the House even drew criticism from some in the GOP. Sen. Tom Cotton (R-Ark.) took to Twitter with a stern warning to the House. “House health-care bill can’t pass w/o major changes,” Sen. Cotton tweeted. “To my friends in House: pause, start over. Get it right, don’t get it fast.”
He followed up with two more tweets: “GOP shouldn’t act like Dems did in O’care. No excuse to release bill Mon night, start voting Wed. With no budget estimate!” He added: “What matters in long run is better, more affordable health care for Americans, NOT house leaders’ arbitrary legislative calendar.”
Four Republican senators – Rob Portman (Ohio), Shelley Moore Capito (W.Va.), Cory Gardner (Colo.), and Lisa Murkowski (Alaska) – also expressed concerns regarding how Medicaid will be changed under the repeal/replace effort and vowed not to support any plan “that does not include stability for Medicaid expansion populations or flexibility for states.”
Republicans hold a slim 52-seat majority in the Senate and need only 50 votes to pass any legislation that uses the budget reconciliation process. If those four senators voted with Democrats, who are expected to vote as a party against the repeal effort, the current House Republican legislation would not clear the Senate.
Physicians’ groups also have voiced their opposition. American Medical Association President Andrew Gurman, MD, said in a statement that it is “not legislation we can support. The replacement bill, as written, would reverse the coverage gains of the ACA, causing many Americans to lose the health coverage they have come to depend on.” He added that the proposed changes to Medicaid “would limit states’ ability to respond to changes in service demands and threaten coverage for people with low incomes.”
Likewise, a joint statement issued by the American Academy of Family Physicians, American Academy of Pediatricians, American College of Physicians, American Congress of Obstetricians and Gynecologists and the American Osteopathic Association, expressed concern that the proposal “will likely result in less access to coverage and higher costs for millions of patients.”
AGA is closely monitoring the process to ensure that patients are still able to receive coverage for preventive screenings without cost-sharing, such as colorectal cancer screenings, and they continue to advocate that this section remain. They are concerned that patients will not have access to specialty care. A repeal will result in millions of patients being uninsured and millions of dollars in uncompensated care to providers like gastroenterologists. AGA will continue to monitor the legislative process and voice its concerns. Learn more about how you can get involved through the AGA Political Action Committee.
How you can help avoid catastrophic cuts to dermatology
It seems like only yesterday we were celebrating the elimination of the Medicare sustainable growth rate and the continuation of “global periods.” Now we are facing the elimination of the global payment periods again, and if we don’t bill the proper CPT code (99024) for our follow-up visits, during an upcoming survey period, it will indeed be a challenge for the specialty.
You may not know it, but there is payment for follow-up visits – global periods – built into codes dermatologists frequently use. As you can see, a large part of our specialty is vulnerable, from destruction of actinics and warts, to malignant and benign excisions, to destructions, to reconstructive surgery. This is real money, about a billion (yes, with a “b”) paid to dermatologists every year in Medicare alone. 
These embedded visits vary from one (actinic destruction) to five (full thickness graft of the nose) and make up a major part of your reimbursement. As part of MACRA (Medicare Access and CHIP Reauthorization Act), the CMS was directed to investigate the validity of these embedded visits.1
The CMS has decided to complete this data gathering by how often the CPT code 99024 is billed.
I am not worried that we don’t provide these visits. I know we do, but I am terribly worried that we won’t correctly report these visits and won’t get credit for them.
The problem is that 99024 pays nothing, it is simply a notation to indicate that the patient was seen in follow up. Since it pays nothing, and since billing anything has an inherent expense, and since 30% of dermatologists are still on paper claims, most dermatologists have never used this code and may not start. In addition, groups of under 10 physicians are not required to report, but can, and you must! Seventy percent of our members are in groups of under 10. That means there will be no data collected on most of these codes, which are almost all performed by dermatologists, the great majority of the time.
Let me say it clearly here: If you do not start filing 99024 every time you see a patient in follow-up (and perhaps for telephone follow-ups), the amount you are paid to perform the original procedure will be cut by 30%-75%. Since the CMS will erroneously think you are not seeing these follow-up patients, they will pull these embedded payments out of the codes. You will have to start billing patients (think additional copays and deductibles) for every suture removal and wound check visit.
Data on 99024 will be collected in only nine states (Florida, Kentucky, Louisiana, Nevada, New Jersey, North Dakota, Ohio, Oregon, and Rhode Island). It will start July 1 and no one knows how long it will continue.
So, start preparing. You will not be penalized for adding this nonpaying code to every follow-up when you do not bill an evaluation and management code. I note that one electronic medical record vendor (Modernizing Medicine) has already started populating its bills with 99024. Good for them! You must report follow-up visits no matter the size of your practice. Report early and report often. Your future depends on it.
Common procedures on which the CMS is collecting postoperative visit data
10040 Acne surgery
10060 Drainage of skin abscess
10061 Drainage of skin abscess
10120 Remove foreign body
10140 Drainage of hematoma/fluid
10160 Puncture drainage of lesion
10180 Complex drainage wound
11200 Removal of skin tags <w/15
11400 Exc tr-ext b9+marg 0.5 cm<
11401 Exc tr-ext b9+marg 0.6-1 cm
11402 Exc tr-ext b9+marg 1.1-2 cm
11403 Exc tr-ext b9+marg 2.1-3cm/<
11404 Exc tr-ext b9+marg 3.1-4 cm
11406 Exc tr-ext b9+marg >4.0 cm
11420 Exc h-f-nk-sp b9+marg 0.5/<
11421 Exc h-f-nk-sp b9+marg 0.6-1
11422 Exc h-f-nk-sp b9+marg 1.1-2
11423 Exc h-f-nk-sp b9+marg 2.1-3
11440 Exc face-mm b9+marg 0.5 cm/<
11441 Exc face-mm b9+marg 0.6-1 cm
11442 Exc face-mm b9+marg 1.1-2 cm
11443 Exc face-mm b9+marg 2.1-3 cm
11601 Exc tr-ext mal+marg 0.6-1 cm
11602 Exc tr-ext mal+marg 1.1-2 cm
11603 Exc tr-ext mal+marg 2.1-3 cm
11604 Exc tr-ext mal+marg 3.1-4 cm
11606 Exc tr-ext mal+marg >4 cm
11621 Exc s/n/h/f/g mal+mrg 0.6-1
11622 Exc s/n/h/f/g mal+mrg 1.1-2
11623 Exc s/n/h/f/g mal+mrg 2.1-3
11640 Exc f/e/e/n/l mal+mrg 0.5cm<
11641 Exc f/e/e/n/l mal+mrg 0.6-1
11642 Exc f/e/e/n/l mal+mrg 1.1-2
11643 Exc f/e/e/n/l mal+mrg 2.1-3
11644 Exc f/e/e/n/l mal+mrg 3.1-4
11646 Exc f/e/e/n/l mal+mrg >4 cm
11750 Removal of nail bed
11765 Excision of nail fold toe
12031 Intmd rpr s/a/t/ext 2.5 cm/<
12032 Intmd rpr s/a/t/ext 2.6-7.5
12034 Intmd rpr s/tr/ext 7.6-12.5
12041 Intmd rpr n-hf/genit 2.5cm/<
12042 Intmd rpr n-hf/genit2.6-7.5
12051 Intmd rpr face/mm 2.5 cm/<
12052 Intmd rpr face/mm 2.6-5.0 cm
13101 Cmplx rpr trunk 2.6-7.5 cm
13121 Cmplx rpr s/a/l 2.6-7.5 cm
13131 Cmplx rpr f/c/c/m/n/ax/g/h/f
13132 Cmplx rpr f/c/c/m/n/ax/g/h/f
13151 Cmplx rpr e/n/e/l 1.1-2.5 cm
13152 Cmplx rpr e/n/e/l 2.6-7.5 cm
13160 Late closure of wound
14020 Tis trnfr s/a/l 10 sq cm/<
14021 Tis trnfr s/a/l 10.1-30 sqcm
14040 Tis trnfr f/c/c/m/n/a/g/h/f
14041 Tis trnfr f/c/c/m/n/a/g/h/f
14060 Tis trnfr e/n/e/l 10 sq cm/<
14061 Tis trnfr e/n/e/l10.1-30sqcm
14301 Tis trnfr any 30.1-60 sq cm
15100 Skin splt grft trnk/arm/leg
15120 Skn splt a-grft fac/nck/hf/g
15240 Skin full grft face/genit/hf
15260 Skin full graft een & lips
15732 Muscle-skin graft head/neck
15734 Muscle-skin graft trunk
15823 Revision of upper eyelid
17000 Destruct premalg lesion
17004 Destroy premal lesions 15/>
17110 Destruct b9 lesion 1-14
17111 Destruct lesion 15 or more
17260 Destruction of skin lesions
17261 Destruction of skin lesions
17262 Destruction of skin lesions
17263 Destruction of skin lesions
17270 Destruction of skin lesions
17271 Destruction of skin lesions
17272 Destruction of skin lesions
17273 Destruction of skin lesions
17280 Destruction of skin lesions
17281 Destruction of skin lesions
17282 Destruction of skin lesions
Dr. Coldiron is a past president of the American Academy of Dermatology. He is currently in private practice, but maintains a clinical assistant professorship at the University of Cincinnati. He cares for patients, teaches medical students and residents, and has several active clinical research projects. Dr. Coldiron is the author of more than 80 scientific letters, papers, and several book chapters, and he speaks frequently on a variety of topics. Write to him at dermnews@frontlinemedcom.com.
References
1. Medicare Access and CHIP Reauthorization Act of 2015, HR 2, 114th Cong, 1st Sess (2015).
It seems like only yesterday we were celebrating the elimination of the Medicare sustainable growth rate and the continuation of “global periods.” Now we are facing the elimination of the global payment periods again, and if we don’t bill the proper CPT code (99024) for our follow-up visits, during an upcoming survey period, it will indeed be a challenge for the specialty.
You may not know it, but there is payment for follow-up visits – global periods – built into codes dermatologists frequently use. As you can see, a large part of our specialty is vulnerable, from destruction of actinics and warts, to malignant and benign excisions, to destructions, to reconstructive surgery. This is real money, about a billion (yes, with a “b”) paid to dermatologists every year in Medicare alone.
These embedded visits vary from one (actinic destruction) to five (full thickness graft of the nose) and make up a major part of your reimbursement. As part of MACRA (Medicare Access and CHIP Reauthorization Act), the CMS was directed to investigate the validity of these embedded visits.1
The CMS has decided to complete this data gathering by how often the CPT code 99024 is billed.
I am not worried that we don’t provide these visits. I know we do, but I am terribly worried that we won’t correctly report these visits and won’t get credit for them.
The problem is that 99024 pays nothing, it is simply a notation to indicate that the patient was seen in follow up. Since it pays nothing, and since billing anything has an inherent expense, and since 30% of dermatologists are still on paper claims, most dermatologists have never used this code and may not start. In addition, groups of under 10 physicians are not required to report, but can, and you must! Seventy percent of our members are in groups of under 10. That means there will be no data collected on most of these codes, which are almost all performed by dermatologists, the great majority of the time.
Let me say it clearly here: If you do not start filing 99024 every time you see a patient in follow-up (and perhaps for telephone follow-ups), the amount you are paid to perform the original procedure will be cut by 30%-75%. Since the CMS will erroneously think you are not seeing these follow-up patients, they will pull these embedded payments out of the codes. You will have to start billing patients (think additional copays and deductibles) for every suture removal and wound check visit.
Data on 99024 will be collected in only nine states (Florida, Kentucky, Louisiana, Nevada, New Jersey, North Dakota, Ohio, Oregon, and Rhode Island). It will start July 1 and no one knows how long it will continue.
So, start preparing. You will not be penalized for adding this nonpaying code to every follow-up when you do not bill an evaluation and management code. I note that one electronic medical record vendor (Modernizing Medicine) has already started populating its bills with 99024. Good for them! You must report follow-up visits no matter the size of your practice. Report early and report often. Your future depends on it.
Common procedures on which the CMS is collecting postoperative visit data
10040 Acne surgery
10060 Drainage of skin abscess
10061 Drainage of skin abscess
10120 Remove foreign body
10140 Drainage of hematoma/fluid
10160 Puncture drainage of lesion
10180 Complex drainage wound
11200 Removal of skin tags <w/15
11400 Exc tr-ext b9+marg 0.5 cm<
11401 Exc tr-ext b9+marg 0.6-1 cm
11402 Exc tr-ext b9+marg 1.1-2 cm
11403 Exc tr-ext b9+marg 2.1-3cm/<
11404 Exc tr-ext b9+marg 3.1-4 cm
11406 Exc tr-ext b9+marg >4.0 cm
11420 Exc h-f-nk-sp b9+marg 0.5/<
11421 Exc h-f-nk-sp b9+marg 0.6-1
11422 Exc h-f-nk-sp b9+marg 1.1-2
11423 Exc h-f-nk-sp b9+marg 2.1-3
11440 Exc face-mm b9+marg 0.5 cm/<
11441 Exc face-mm b9+marg 0.6-1 cm
11442 Exc face-mm b9+marg 1.1-2 cm
11443 Exc face-mm b9+marg 2.1-3 cm
11601 Exc tr-ext mal+marg 0.6-1 cm
11602 Exc tr-ext mal+marg 1.1-2 cm
11603 Exc tr-ext mal+marg 2.1-3 cm
11604 Exc tr-ext mal+marg 3.1-4 cm
11606 Exc tr-ext mal+marg >4 cm
11621 Exc s/n/h/f/g mal+mrg 0.6-1
11622 Exc s/n/h/f/g mal+mrg 1.1-2
11623 Exc s/n/h/f/g mal+mrg 2.1-3
11640 Exc f/e/e/n/l mal+mrg 0.5cm<
11641 Exc f/e/e/n/l mal+mrg 0.6-1
11642 Exc f/e/e/n/l mal+mrg 1.1-2
11643 Exc f/e/e/n/l mal+mrg 2.1-3
11644 Exc f/e/e/n/l mal+mrg 3.1-4
11646 Exc f/e/e/n/l mal+mrg >4 cm
11750 Removal of nail bed
11765 Excision of nail fold toe
12031 Intmd rpr s/a/t/ext 2.5 cm/<
12032 Intmd rpr s/a/t/ext 2.6-7.5
12034 Intmd rpr s/tr/ext 7.6-12.5
12041 Intmd rpr n-hf/genit 2.5cm/<
12042 Intmd rpr n-hf/genit2.6-7.5
12051 Intmd rpr face/mm 2.5 cm/<
12052 Intmd rpr face/mm 2.6-5.0 cm
13101 Cmplx rpr trunk 2.6-7.5 cm
13121 Cmplx rpr s/a/l 2.6-7.5 cm
13131 Cmplx rpr f/c/c/m/n/ax/g/h/f
13132 Cmplx rpr f/c/c/m/n/ax/g/h/f
13151 Cmplx rpr e/n/e/l 1.1-2.5 cm
13152 Cmplx rpr e/n/e/l 2.6-7.5 cm
13160 Late closure of wound
14020 Tis trnfr s/a/l 10 sq cm/<
14021 Tis trnfr s/a/l 10.1-30 sqcm
14040 Tis trnfr f/c/c/m/n/a/g/h/f
14041 Tis trnfr f/c/c/m/n/a/g/h/f
14060 Tis trnfr e/n/e/l 10 sq cm/<
14061 Tis trnfr e/n/e/l10.1-30sqcm
14301 Tis trnfr any 30.1-60 sq cm
15100 Skin splt grft trnk/arm/leg
15120 Skn splt a-grft fac/nck/hf/g
15240 Skin full grft face/genit/hf
15260 Skin full graft een & lips
15732 Muscle-skin graft head/neck
15734 Muscle-skin graft trunk
15823 Revision of upper eyelid
17000 Destruct premalg lesion
17004 Destroy premal lesions 15/>
17110 Destruct b9 lesion 1-14
17111 Destruct lesion 15 or more
17260 Destruction of skin lesions
17261 Destruction of skin lesions
17262 Destruction of skin lesions
17263 Destruction of skin lesions
17270 Destruction of skin lesions
17271 Destruction of skin lesions
17272 Destruction of skin lesions
17273 Destruction of skin lesions
17280 Destruction of skin lesions
17281 Destruction of skin lesions
17282 Destruction of skin lesions
Dr. Coldiron is a past president of the American Academy of Dermatology. He is currently in private practice, but maintains a clinical assistant professorship at the University of Cincinnati. He cares for patients, teaches medical students and residents, and has several active clinical research projects. Dr. Coldiron is the author of more than 80 scientific letters, papers, and several book chapters, and he speaks frequently on a variety of topics. Write to him at dermnews@frontlinemedcom.com.
References
1. Medicare Access and CHIP Reauthorization Act of 2015, HR 2, 114th Cong, 1st Sess (2015).
It seems like only yesterday we were celebrating the elimination of the Medicare sustainable growth rate and the continuation of “global periods.” Now we are facing the elimination of the global payment periods again, and if we don’t bill the proper CPT code (99024) for our follow-up visits, during an upcoming survey period, it will indeed be a challenge for the specialty.
You may not know it, but there is payment for follow-up visits – global periods – built into codes dermatologists frequently use. As you can see, a large part of our specialty is vulnerable, from destruction of actinics and warts, to malignant and benign excisions, to destructions, to reconstructive surgery. This is real money, about a billion (yes, with a “b”) paid to dermatologists every year in Medicare alone.
These embedded visits vary from one (actinic destruction) to five (full thickness graft of the nose) and make up a major part of your reimbursement. As part of MACRA (Medicare Access and CHIP Reauthorization Act), the CMS was directed to investigate the validity of these embedded visits.1
The CMS has decided to complete this data gathering by how often the CPT code 99024 is billed.
I am not worried that we don’t provide these visits. I know we do, but I am terribly worried that we won’t correctly report these visits and won’t get credit for them.
The problem is that 99024 pays nothing, it is simply a notation to indicate that the patient was seen in follow up. Since it pays nothing, and since billing anything has an inherent expense, and since 30% of dermatologists are still on paper claims, most dermatologists have never used this code and may not start. In addition, groups of under 10 physicians are not required to report, but can, and you must! Seventy percent of our members are in groups of under 10. That means there will be no data collected on most of these codes, which are almost all performed by dermatologists, the great majority of the time.
Let me say it clearly here: If you do not start filing 99024 every time you see a patient in follow-up (and perhaps for telephone follow-ups), the amount you are paid to perform the original procedure will be cut by 30%-75%. Since the CMS will erroneously think you are not seeing these follow-up patients, they will pull these embedded payments out of the codes. You will have to start billing patients (think additional copays and deductibles) for every suture removal and wound check visit.
Data on 99024 will be collected in only nine states (Florida, Kentucky, Louisiana, Nevada, New Jersey, North Dakota, Ohio, Oregon, and Rhode Island). It will start July 1 and no one knows how long it will continue.
So, start preparing. You will not be penalized for adding this nonpaying code to every follow-up when you do not bill an evaluation and management code. I note that one electronic medical record vendor (Modernizing Medicine) has already started populating its bills with 99024. Good for them! You must report follow-up visits no matter the size of your practice. Report early and report often. Your future depends on it.
Common procedures on which the CMS is collecting postoperative visit data
10040 Acne surgery
10060 Drainage of skin abscess
10061 Drainage of skin abscess
10120 Remove foreign body
10140 Drainage of hematoma/fluid
10160 Puncture drainage of lesion
10180 Complex drainage wound
11200 Removal of skin tags <w/15
11400 Exc tr-ext b9+marg 0.5 cm<
11401 Exc tr-ext b9+marg 0.6-1 cm
11402 Exc tr-ext b9+marg 1.1-2 cm
11403 Exc tr-ext b9+marg 2.1-3cm/<
11404 Exc tr-ext b9+marg 3.1-4 cm
11406 Exc tr-ext b9+marg >4.0 cm
11420 Exc h-f-nk-sp b9+marg 0.5/<
11421 Exc h-f-nk-sp b9+marg 0.6-1
11422 Exc h-f-nk-sp b9+marg 1.1-2
11423 Exc h-f-nk-sp b9+marg 2.1-3
11440 Exc face-mm b9+marg 0.5 cm/<
11441 Exc face-mm b9+marg 0.6-1 cm
11442 Exc face-mm b9+marg 1.1-2 cm
11443 Exc face-mm b9+marg 2.1-3 cm
11601 Exc tr-ext mal+marg 0.6-1 cm
11602 Exc tr-ext mal+marg 1.1-2 cm
11603 Exc tr-ext mal+marg 2.1-3 cm
11604 Exc tr-ext mal+marg 3.1-4 cm
11606 Exc tr-ext mal+marg >4 cm
11621 Exc s/n/h/f/g mal+mrg 0.6-1
11622 Exc s/n/h/f/g mal+mrg 1.1-2
11623 Exc s/n/h/f/g mal+mrg 2.1-3
11640 Exc f/e/e/n/l mal+mrg 0.5cm<
11641 Exc f/e/e/n/l mal+mrg 0.6-1
11642 Exc f/e/e/n/l mal+mrg 1.1-2
11643 Exc f/e/e/n/l mal+mrg 2.1-3
11644 Exc f/e/e/n/l mal+mrg 3.1-4
11646 Exc f/e/e/n/l mal+mrg >4 cm
11750 Removal of nail bed
11765 Excision of nail fold toe
12031 Intmd rpr s/a/t/ext 2.5 cm/<
12032 Intmd rpr s/a/t/ext 2.6-7.5
12034 Intmd rpr s/tr/ext 7.6-12.5
12041 Intmd rpr n-hf/genit 2.5cm/<
12042 Intmd rpr n-hf/genit2.6-7.5
12051 Intmd rpr face/mm 2.5 cm/<
12052 Intmd rpr face/mm 2.6-5.0 cm
13101 Cmplx rpr trunk 2.6-7.5 cm
13121 Cmplx rpr s/a/l 2.6-7.5 cm
13131 Cmplx rpr f/c/c/m/n/ax/g/h/f
13132 Cmplx rpr f/c/c/m/n/ax/g/h/f
13151 Cmplx rpr e/n/e/l 1.1-2.5 cm
13152 Cmplx rpr e/n/e/l 2.6-7.5 cm
13160 Late closure of wound
14020 Tis trnfr s/a/l 10 sq cm/<
14021 Tis trnfr s/a/l 10.1-30 sqcm
14040 Tis trnfr f/c/c/m/n/a/g/h/f
14041 Tis trnfr f/c/c/m/n/a/g/h/f
14060 Tis trnfr e/n/e/l 10 sq cm/<
14061 Tis trnfr e/n/e/l10.1-30sqcm
14301 Tis trnfr any 30.1-60 sq cm
15100 Skin splt grft trnk/arm/leg
15120 Skn splt a-grft fac/nck/hf/g
15240 Skin full grft face/genit/hf
15260 Skin full graft een & lips
15732 Muscle-skin graft head/neck
15734 Muscle-skin graft trunk
15823 Revision of upper eyelid
17000 Destruct premalg lesion
17004 Destroy premal lesions 15/>
17110 Destruct b9 lesion 1-14
17111 Destruct lesion 15 or more
17260 Destruction of skin lesions
17261 Destruction of skin lesions
17262 Destruction of skin lesions
17263 Destruction of skin lesions
17270 Destruction of skin lesions
17271 Destruction of skin lesions
17272 Destruction of skin lesions
17273 Destruction of skin lesions
17280 Destruction of skin lesions
17281 Destruction of skin lesions
17282 Destruction of skin lesions
Dr. Coldiron is a past president of the American Academy of Dermatology. He is currently in private practice, but maintains a clinical assistant professorship at the University of Cincinnati. He cares for patients, teaches medical students and residents, and has several active clinical research projects. Dr. Coldiron is the author of more than 80 scientific letters, papers, and several book chapters, and he speaks frequently on a variety of topics. Write to him at dermnews@frontlinemedcom.com.
References
1. Medicare Access and CHIP Reauthorization Act of 2015, HR 2, 114th Cong, 1st Sess (2015).
People often think functional neurological symptoms are feigned
Clinicians, other caregivers, and even patients often think that functional neurological symptoms and movement disorders are feigned or somewhat amenable to the patient’s control, according to two separate survey studies published online in the Journal of Neurology, Neurosurgery & Psychiatry.
In the first study, Sandra M. A. van der Salm, MD, and her associates reported their assessments of clinicians’ and patients’ views about “free will” pertaining to three movement disorders: functional (“psychogenic”) movement disorders, myoclonus, and tics. They administered survey questionnaires to 39 expert clinicians, 28 patients with functional movement disorders, 15 patients with myoclonus, 17 patients with tics, and 22 healthy control subjects.
Clinicians differed markedly from patients in their perceptions of patient control over movements and symptoms. The majority rated “raising one’s hand to vote” as completely voluntary, functional movement disorders as largely involuntary, tics as slightly more involuntary than voluntary, and myoclonus as completely involuntary. In contrast, most patients (other than some who said they were sometimes able to suppress tics) felt their movements and symptoms were well beyond their control, reported Dr. van der Salm of the department of neurology and clinical neurophysiology, Academic Medical Center, Amsterdam, and her associates (J Neurol Neurosurg Psychiatry. 2017 March 11. doi: 10.1136/jnnp-2016-315152).
“For clinicians, it may be helpful to realize that doctors and patients may have different views of voluntariness in movement disorders, in particular regarding tics and functional movement disorders. Keeping this gap in mind during consultation could prevent misunderstandings that might jeopardize the doctor-patient relationship,” the investigators wrote.
“Our results suggest that patients with functional movement disorders probably require different cognitive behavioral techniques than those used for tics, because patients with functional movement disorders experience less behavioral control” of their symptoms, they wrote.
In the second study, Richard A. A. Kanaan, MD, and Juen Mei Ding, MD, both in the department of psychiatry at the University of Melbourne, reported the results of their survey of 172 “people waiting in a general hospital outpatient department,” including patients, family members, and caregivers.
The questionnaire presented a hypothetical scenario to the respondent in which he or she had “leg weakness” for which all tests had come back negative. A doctor presented seven possible terms for the symptoms and then asked respondents whether such patients would be imagining their symptoms, faking their symptoms, mentally ill, or having a medical condition. The seven diagnoses were functional weakness, psychogenic weakness, medically unexplained weakness, somatic symptom disorder, dissociative disorder, conversion disorder, and stroke.
A total of 26% of the respondents said that at least one of the diagnoses connoted feigning, “confirming that suspicions of feigning in functional neurological symptoms remain a problem among patients and the public,” wrote Dr. Kanaan and Dr. Ding (J Neurol Neurosurg Psychiatry. 2017 March 9. doi: 10.1136/jnnp-2016-315224).
There was a strong correlation between the respondents’ opinions of “faking” and their level of education. Study participants with only a primary-school education were the most likely to think symptoms were feigned (32 of 94), while those with a tertiary education were very unlikely to think so (9 of 73), the investigators said.
It was encouraging that this correlation disappeared after a “simple remedy” was applied: briefly explaining the meaning of each diagnosis. Thus, “the problem appears to be largely one of public ignorance, rather than some inherent stigmatization of mental health,” Dr. Kanaan and Dr. Ding wrote.
Dr. van der Salm’s study was funded by the Academic Medical Center graduate school. No funding source was cited for the study by Dr. Kanaan and Dr. Ding. Both research groups reported having no relevant financial disclosures.
These two studies make interesting and worthwhile observations. They do make it clear that both the public and many physicians consider that many functional movement disorder patients have some voluntariness and hence are faking it. This is a stigma. A number of us have been trying to educate at least the physicians that almost all these patients do have involuntary movements. It is a problem for doctor-patient relationships and for patients to accept their diagnosis. We still have work to do!
Mark Hallett, MD, is chief of the National Institute of Neurological Disorders and Stroke’s Medical Neurology Branch and chief of its Human Motor Control Section. He is now president of the International Federation of Clinical Neurophysiology. He has been president of the Movement Disorder Society and vice president of the American Academy of Neurology.
These two studies make interesting and worthwhile observations. They do make it clear that both the public and many physicians consider that many functional movement disorder patients have some voluntariness and hence are faking it. This is a stigma. A number of us have been trying to educate at least the physicians that almost all these patients do have involuntary movements. It is a problem for doctor-patient relationships and for patients to accept their diagnosis. We still have work to do!
Mark Hallett, MD, is chief of the National Institute of Neurological Disorders and Stroke’s Medical Neurology Branch and chief of its Human Motor Control Section. He is now president of the International Federation of Clinical Neurophysiology. He has been president of the Movement Disorder Society and vice president of the American Academy of Neurology.
These two studies make interesting and worthwhile observations. They do make it clear that both the public and many physicians consider that many functional movement disorder patients have some voluntariness and hence are faking it. This is a stigma. A number of us have been trying to educate at least the physicians that almost all these patients do have involuntary movements. It is a problem for doctor-patient relationships and for patients to accept their diagnosis. We still have work to do!
Mark Hallett, MD, is chief of the National Institute of Neurological Disorders and Stroke’s Medical Neurology Branch and chief of its Human Motor Control Section. He is now president of the International Federation of Clinical Neurophysiology. He has been president of the Movement Disorder Society and vice president of the American Academy of Neurology.
Clinicians, other caregivers, and even patients often think that functional neurological symptoms and movement disorders are feigned or somewhat amenable to the patient’s control, according to two separate survey studies published online in the Journal of Neurology, Neurosurgery & Psychiatry.
In the first study, Sandra M. A. van der Salm, MD, and her associates reported their assessments of clinicians’ and patients’ views about “free will” pertaining to three movement disorders: functional (“psychogenic”) movement disorders, myoclonus, and tics. They administered survey questionnaires to 39 expert clinicians, 28 patients with functional movement disorders, 15 patients with myoclonus, 17 patients with tics, and 22 healthy control subjects.
Clinicians differed markedly from patients in their perceptions of patient control over movements and symptoms. The majority rated “raising one’s hand to vote” as completely voluntary, functional movement disorders as largely involuntary, tics as slightly more involuntary than voluntary, and myoclonus as completely involuntary. In contrast, most patients (other than some who said they were sometimes able to suppress tics) felt their movements and symptoms were well beyond their control, reported Dr. van der Salm of the department of neurology and clinical neurophysiology, Academic Medical Center, Amsterdam, and her associates (J Neurol Neurosurg Psychiatry. 2017 March 11. doi: 10.1136/jnnp-2016-315152).
“For clinicians, it may be helpful to realize that doctors and patients may have different views of voluntariness in movement disorders, in particular regarding tics and functional movement disorders. Keeping this gap in mind during consultation could prevent misunderstandings that might jeopardize the doctor-patient relationship,” the investigators wrote.
“Our results suggest that patients with functional movement disorders probably require different cognitive behavioral techniques than those used for tics, because patients with functional movement disorders experience less behavioral control” of their symptoms, they wrote.
In the second study, Richard A. A. Kanaan, MD, and Juen Mei Ding, MD, both in the department of psychiatry at the University of Melbourne, reported the results of their survey of 172 “people waiting in a general hospital outpatient department,” including patients, family members, and caregivers.
The questionnaire presented a hypothetical scenario to the respondent in which he or she had “leg weakness” for which all tests had come back negative. A doctor presented seven possible terms for the symptoms and then asked respondents whether such patients would be imagining their symptoms, faking their symptoms, mentally ill, or having a medical condition. The seven diagnoses were functional weakness, psychogenic weakness, medically unexplained weakness, somatic symptom disorder, dissociative disorder, conversion disorder, and stroke.
A total of 26% of the respondents said that at least one of the diagnoses connoted feigning, “confirming that suspicions of feigning in functional neurological symptoms remain a problem among patients and the public,” wrote Dr. Kanaan and Dr. Ding (J Neurol Neurosurg Psychiatry. 2017 March 9. doi: 10.1136/jnnp-2016-315224).
There was a strong correlation between the respondents’ opinions of “faking” and their level of education. Study participants with only a primary-school education were the most likely to think symptoms were feigned (32 of 94), while those with a tertiary education were very unlikely to think so (9 of 73), the investigators said.
It was encouraging that this correlation disappeared after a “simple remedy” was applied: briefly explaining the meaning of each diagnosis. Thus, “the problem appears to be largely one of public ignorance, rather than some inherent stigmatization of mental health,” Dr. Kanaan and Dr. Ding wrote.
Dr. van der Salm’s study was funded by the Academic Medical Center graduate school. No funding source was cited for the study by Dr. Kanaan and Dr. Ding. Both research groups reported having no relevant financial disclosures.
Clinicians, other caregivers, and even patients often think that functional neurological symptoms and movement disorders are feigned or somewhat amenable to the patient’s control, according to two separate survey studies published online in the Journal of Neurology, Neurosurgery & Psychiatry.
In the first study, Sandra M. A. van der Salm, MD, and her associates reported their assessments of clinicians’ and patients’ views about “free will” pertaining to three movement disorders: functional (“psychogenic”) movement disorders, myoclonus, and tics. They administered survey questionnaires to 39 expert clinicians, 28 patients with functional movement disorders, 15 patients with myoclonus, 17 patients with tics, and 22 healthy control subjects.
Clinicians differed markedly from patients in their perceptions of patient control over movements and symptoms. The majority rated “raising one’s hand to vote” as completely voluntary, functional movement disorders as largely involuntary, tics as slightly more involuntary than voluntary, and myoclonus as completely involuntary. In contrast, most patients (other than some who said they were sometimes able to suppress tics) felt their movements and symptoms were well beyond their control, reported Dr. van der Salm of the department of neurology and clinical neurophysiology, Academic Medical Center, Amsterdam, and her associates (J Neurol Neurosurg Psychiatry. 2017 March 11. doi: 10.1136/jnnp-2016-315152).
“For clinicians, it may be helpful to realize that doctors and patients may have different views of voluntariness in movement disorders, in particular regarding tics and functional movement disorders. Keeping this gap in mind during consultation could prevent misunderstandings that might jeopardize the doctor-patient relationship,” the investigators wrote.
“Our results suggest that patients with functional movement disorders probably require different cognitive behavioral techniques than those used for tics, because patients with functional movement disorders experience less behavioral control” of their symptoms, they wrote.
In the second study, Richard A. A. Kanaan, MD, and Juen Mei Ding, MD, both in the department of psychiatry at the University of Melbourne, reported the results of their survey of 172 “people waiting in a general hospital outpatient department,” including patients, family members, and caregivers.
The questionnaire presented a hypothetical scenario to the respondent in which he or she had “leg weakness” for which all tests had come back negative. A doctor presented seven possible terms for the symptoms and then asked respondents whether such patients would be imagining their symptoms, faking their symptoms, mentally ill, or having a medical condition. The seven diagnoses were functional weakness, psychogenic weakness, medically unexplained weakness, somatic symptom disorder, dissociative disorder, conversion disorder, and stroke.
A total of 26% of the respondents said that at least one of the diagnoses connoted feigning, “confirming that suspicions of feigning in functional neurological symptoms remain a problem among patients and the public,” wrote Dr. Kanaan and Dr. Ding (J Neurol Neurosurg Psychiatry. 2017 March 9. doi: 10.1136/jnnp-2016-315224).
There was a strong correlation between the respondents’ opinions of “faking” and their level of education. Study participants with only a primary-school education were the most likely to think symptoms were feigned (32 of 94), while those with a tertiary education were very unlikely to think so (9 of 73), the investigators said.
It was encouraging that this correlation disappeared after a “simple remedy” was applied: briefly explaining the meaning of each diagnosis. Thus, “the problem appears to be largely one of public ignorance, rather than some inherent stigmatization of mental health,” Dr. Kanaan and Dr. Ding wrote.
Dr. van der Salm’s study was funded by the Academic Medical Center graduate school. No funding source was cited for the study by Dr. Kanaan and Dr. Ding. Both research groups reported having no relevant financial disclosures.
FROM JOURNAL OF NEUROLOGY, NEUROSURGERY & PSYCHIATRY
Key clinical point:
Major finding: Most clinicians rated “raising one’s hand to vote” as completely voluntary, functional movement disorders as largely voluntary, tics as slightly more involuntary than voluntary, and myoclonus as completely involuntary.
Data source: Two separate survey questionnaires involving 172 respondents and 121 respondents, respectively.
Disclosures: Dr. van der Salm’s study was funded by the Academic Medical Center graduate school. No funding source was cited for the study by Dr. Kanaan and Dr. Ding. Both research groups reported having no relevant financial disclosures.
A Rare Case of Spontaneous Fusion of the Knee
Take-Home Points
- Post-infectious or post-inflammatory pathological knee arthrodesis is one of the most challenging complications in orthopedics.
- It can result in significant patient distress with some struggling to maintain any range of motion for functionality.
- TKA for the correction of knee ankylosis is an option, but not without significant morbidity and failure rates.
Spontaneous knee fusion is an unusual and rarely reported phenomenon. Progressive stiffness is commonly experienced by patients with arthritis. However, most patients maintain some range of knee motion, which may be enhanced with medical treatment, rehabilitation with physiotherapy, and ambulation devices. To our knowledge, this article is the first report of a case of spontaneous and progressive bony fusion of a knee joint without a prior diagnosis of inflammatory or septic arthritis or surgical arthrodesis. The patient provided written informed consent for print and electronic publication of this case report.
Case Report
In 2015, a 51-year-old woman presented to the orthopedics department with a 13-year history of complete loss of left knee flexion. She denied a history of trauma to or surgical intervention for the knee and denied a medical history of inflammatory or septic arthritis.
On initial referral to the department, in 2002, the patient, age 38 years at the time, had a 1-year history of progressive left knee stiffness and reduced range of motion (ROM). At the time, she recalled injuring the knee during an aerobics class 2 months prior. A physiotherapy trial (ROM actively and passively assessed 10°-90°) failed. All movement was painful, and 2 crutches were needed for ambulation. The patient was treated nonoperatively with analgesia and was advised to return to physiotherapy. Plain radiographs showed a small effusion but no bony abnormalities or fractures (Figures 1A, 1B). 
Four months after the initial referral, the patient returned to the outpatient department with persistent knee pain and ROM of 5° to 20°. A repeat radiograph showed extensive left knee joint destruction, cortical irregularity, and narrowing of the joint space (Figures 3A, 3B). 
At the latest presentation (2015), the patient had a painless fixed extension deformity of the left knee joint and poor quality of life and wanted surgical intervention. 
Discussion
We have reported a rare case of spontaneous knee fusion in a middle-aged patient with no significant predisposing factors and no clear diagnosis. Serologic results were normal and not significant, but imaging was highly suggestive of an inflammatory process and provided a probable diagnosis of an underlying inflammatory condition and/or infection.
In the literature, there are no other reports of similar cases of spontaneous knee joint fusion, though there are some rare cases of the phenomenon in other joints. In 2005, Budoff and Lichtman1 reported a case of spontaneous wrist fusion in an 18-year-old patient with a background of Kienböck disease, which may have predisposed the patient to an underlying synovitis progressing to autofusion of the joint. In 2014, Lui2 described the case of a 64-year-old woman with spontaneous subtalar fusion complicating a subtalar arthroereisis. Although an extensive literature review on the topic is difficult owing to the rarity of the condition, these few cases, unlike our case, appear to describe a predisposing factor or inciting event.
The reversibility of knee arthrodesis remains an issue in our patient’s case and in other cases, and total knee arthroplasty (TKA) may be the most obvious operative intervention. Cameron and Hu3 reported 17 cases of knee fusion take-down with conversion to TKA, and Kim and colleagues4 reported 16 TKAs performed after spontaneous osseous ankylosis and 14 performed after formal knee fusion take-down. Although functional improvements were found in both studies, complication rates were relatively high, at least 53%. Other authors have used TKAs in cases of knee ankylosis after infectious or inflammatory arthritis, but results were suboptimal and unpredictable, and complication rates were 27% and 53.3%.5,6In this difficult scenario, our middle-aged patient’s fixed extension deformity of the knee, likely the result of an idiopathic process, led to severe debilitation and poor quality of life. To perform a TKA in a 51-year-old patient is far from ideal. The reversibility of formally fused and spontaneously fused knees is still in question, and, though there are reports of relatively satisfactory results, most operative options are fraught with complications.
Am J Orthop. 2017;46(2):E83-E85. Copyright Frontline Medical Communications Inc. 2017. All rights reserved.
1. Budoff JE, Lichtman DM. Spontaneous wrist fusion: an unusual complication of Kienböck’s disease. J Hand Surg Am. 2005;30(1):59-64.
2. Lui TH. Spontaneous subtalar fusion: an irreversible complication of subtalar arthroereisis. J Foot Ankle Surg. 2014;53(5):652-656.
3. Cameron HU, Hu C. Results of total knee arthroplasty following takedown of formal knee fusion. J Arthroplasty. 1996;11(6):732-737.
4. Kim YH, Kim JS, Cho SH. Total knee arthroplasty after spontaneous osseous ankylosis and takedown of formal knee fusion. J Arthroplasty. 2000;15(4):453-460.
5. Rajgopal A, Ahuja N, Dolai B. Total knee arthroplasty in stiff and ankylosed knees. J Arthroplasty. 2005;20(5):585-590.
6. Kim YH, Cho SH, Kim JS. Total knee arthroplasty in bony ankylosis in gross flexion. J Bone Joint Surg Br. 1999;81(2):296-300.
Take-Home Points
- Post-infectious or post-inflammatory pathological knee arthrodesis is one of the most challenging complications in orthopedics.
- It can result in significant patient distress with some struggling to maintain any range of motion for functionality.
- TKA for the correction of knee ankylosis is an option, but not without significant morbidity and failure rates.
Spontaneous knee fusion is an unusual and rarely reported phenomenon. Progressive stiffness is commonly experienced by patients with arthritis. However, most patients maintain some range of knee motion, which may be enhanced with medical treatment, rehabilitation with physiotherapy, and ambulation devices. To our knowledge, this article is the first report of a case of spontaneous and progressive bony fusion of a knee joint without a prior diagnosis of inflammatory or septic arthritis or surgical arthrodesis. The patient provided written informed consent for print and electronic publication of this case report.
Case Report
In 2015, a 51-year-old woman presented to the orthopedics department with a 13-year history of complete loss of left knee flexion. She denied a history of trauma to or surgical intervention for the knee and denied a medical history of inflammatory or septic arthritis.
On initial referral to the department, in 2002, the patient, age 38 years at the time, had a 1-year history of progressive left knee stiffness and reduced range of motion (ROM). At the time, she recalled injuring the knee during an aerobics class 2 months prior. A physiotherapy trial (ROM actively and passively assessed 10°-90°) failed. All movement was painful, and 2 crutches were needed for ambulation. The patient was treated nonoperatively with analgesia and was advised to return to physiotherapy. Plain radiographs showed a small effusion but no bony abnormalities or fractures (Figures 1A, 1B).
Four months after the initial referral, the patient returned to the outpatient department with persistent knee pain and ROM of 5° to 20°. A repeat radiograph showed extensive left knee joint destruction, cortical irregularity, and narrowing of the joint space (Figures 3A, 3B).
At the latest presentation (2015), the patient had a painless fixed extension deformity of the left knee joint and poor quality of life and wanted surgical intervention.
Discussion
We have reported a rare case of spontaneous knee fusion in a middle-aged patient with no significant predisposing factors and no clear diagnosis. Serologic results were normal and not significant, but imaging was highly suggestive of an inflammatory process and provided a probable diagnosis of an underlying inflammatory condition and/or infection.
In the literature, there are no other reports of similar cases of spontaneous knee joint fusion, though there are some rare cases of the phenomenon in other joints. In 2005, Budoff and Lichtman1 reported a case of spontaneous wrist fusion in an 18-year-old patient with a background of Kienböck disease, which may have predisposed the patient to an underlying synovitis progressing to autofusion of the joint. In 2014, Lui2 described the case of a 64-year-old woman with spontaneous subtalar fusion complicating a subtalar arthroereisis. Although an extensive literature review on the topic is difficult owing to the rarity of the condition, these few cases, unlike our case, appear to describe a predisposing factor or inciting event.
The reversibility of knee arthrodesis remains an issue in our patient’s case and in other cases, and total knee arthroplasty (TKA) may be the most obvious operative intervention. Cameron and Hu3 reported 17 cases of knee fusion take-down with conversion to TKA, and Kim and colleagues4 reported 16 TKAs performed after spontaneous osseous ankylosis and 14 performed after formal knee fusion take-down. Although functional improvements were found in both studies, complication rates were relatively high, at least 53%. Other authors have used TKAs in cases of knee ankylosis after infectious or inflammatory arthritis, but results were suboptimal and unpredictable, and complication rates were 27% and 53.3%.5,6In this difficult scenario, our middle-aged patient’s fixed extension deformity of the knee, likely the result of an idiopathic process, led to severe debilitation and poor quality of life. To perform a TKA in a 51-year-old patient is far from ideal. The reversibility of formally fused and spontaneously fused knees is still in question, and, though there are reports of relatively satisfactory results, most operative options are fraught with complications.
Am J Orthop. 2017;46(2):E83-E85. Copyright Frontline Medical Communications Inc. 2017. All rights reserved.
Take-Home Points
- Post-infectious or post-inflammatory pathological knee arthrodesis is one of the most challenging complications in orthopedics.
- It can result in significant patient distress with some struggling to maintain any range of motion for functionality.
- TKA for the correction of knee ankylosis is an option, but not without significant morbidity and failure rates.
Spontaneous knee fusion is an unusual and rarely reported phenomenon. Progressive stiffness is commonly experienced by patients with arthritis. However, most patients maintain some range of knee motion, which may be enhanced with medical treatment, rehabilitation with physiotherapy, and ambulation devices. To our knowledge, this article is the first report of a case of spontaneous and progressive bony fusion of a knee joint without a prior diagnosis of inflammatory or septic arthritis or surgical arthrodesis. The patient provided written informed consent for print and electronic publication of this case report.
Case Report
In 2015, a 51-year-old woman presented to the orthopedics department with a 13-year history of complete loss of left knee flexion. She denied a history of trauma to or surgical intervention for the knee and denied a medical history of inflammatory or septic arthritis.
On initial referral to the department, in 2002, the patient, age 38 years at the time, had a 1-year history of progressive left knee stiffness and reduced range of motion (ROM). At the time, she recalled injuring the knee during an aerobics class 2 months prior. A physiotherapy trial (ROM actively and passively assessed 10°-90°) failed. All movement was painful, and 2 crutches were needed for ambulation. The patient was treated nonoperatively with analgesia and was advised to return to physiotherapy. Plain radiographs showed a small effusion but no bony abnormalities or fractures (Figures 1A, 1B).
Four months after the initial referral, the patient returned to the outpatient department with persistent knee pain and ROM of 5° to 20°. A repeat radiograph showed extensive left knee joint destruction, cortical irregularity, and narrowing of the joint space (Figures 3A, 3B).
At the latest presentation (2015), the patient had a painless fixed extension deformity of the left knee joint and poor quality of life and wanted surgical intervention.
Discussion
We have reported a rare case of spontaneous knee fusion in a middle-aged patient with no significant predisposing factors and no clear diagnosis. Serologic results were normal and not significant, but imaging was highly suggestive of an inflammatory process and provided a probable diagnosis of an underlying inflammatory condition and/or infection.
In the literature, there are no other reports of similar cases of spontaneous knee joint fusion, though there are some rare cases of the phenomenon in other joints. In 2005, Budoff and Lichtman1 reported a case of spontaneous wrist fusion in an 18-year-old patient with a background of Kienböck disease, which may have predisposed the patient to an underlying synovitis progressing to autofusion of the joint. In 2014, Lui2 described the case of a 64-year-old woman with spontaneous subtalar fusion complicating a subtalar arthroereisis. Although an extensive literature review on the topic is difficult owing to the rarity of the condition, these few cases, unlike our case, appear to describe a predisposing factor or inciting event.
The reversibility of knee arthrodesis remains an issue in our patient’s case and in other cases, and total knee arthroplasty (TKA) may be the most obvious operative intervention. Cameron and Hu3 reported 17 cases of knee fusion take-down with conversion to TKA, and Kim and colleagues4 reported 16 TKAs performed after spontaneous osseous ankylosis and 14 performed after formal knee fusion take-down. Although functional improvements were found in both studies, complication rates were relatively high, at least 53%. Other authors have used TKAs in cases of knee ankylosis after infectious or inflammatory arthritis, but results were suboptimal and unpredictable, and complication rates were 27% and 53.3%.5,6In this difficult scenario, our middle-aged patient’s fixed extension deformity of the knee, likely the result of an idiopathic process, led to severe debilitation and poor quality of life. To perform a TKA in a 51-year-old patient is far from ideal. The reversibility of formally fused and spontaneously fused knees is still in question, and, though there are reports of relatively satisfactory results, most operative options are fraught with complications.
Am J Orthop. 2017;46(2):E83-E85. Copyright Frontline Medical Communications Inc. 2017. All rights reserved.
1. Budoff JE, Lichtman DM. Spontaneous wrist fusion: an unusual complication of Kienböck’s disease. J Hand Surg Am. 2005;30(1):59-64.
2. Lui TH. Spontaneous subtalar fusion: an irreversible complication of subtalar arthroereisis. J Foot Ankle Surg. 2014;53(5):652-656.
3. Cameron HU, Hu C. Results of total knee arthroplasty following takedown of formal knee fusion. J Arthroplasty. 1996;11(6):732-737.
4. Kim YH, Kim JS, Cho SH. Total knee arthroplasty after spontaneous osseous ankylosis and takedown of formal knee fusion. J Arthroplasty. 2000;15(4):453-460.
5. Rajgopal A, Ahuja N, Dolai B. Total knee arthroplasty in stiff and ankylosed knees. J Arthroplasty. 2005;20(5):585-590.
6. Kim YH, Cho SH, Kim JS. Total knee arthroplasty in bony ankylosis in gross flexion. J Bone Joint Surg Br. 1999;81(2):296-300.
1. Budoff JE, Lichtman DM. Spontaneous wrist fusion: an unusual complication of Kienböck’s disease. J Hand Surg Am. 2005;30(1):59-64.
2. Lui TH. Spontaneous subtalar fusion: an irreversible complication of subtalar arthroereisis. J Foot Ankle Surg. 2014;53(5):652-656.
3. Cameron HU, Hu C. Results of total knee arthroplasty following takedown of formal knee fusion. J Arthroplasty. 1996;11(6):732-737.
4. Kim YH, Kim JS, Cho SH. Total knee arthroplasty after spontaneous osseous ankylosis and takedown of formal knee fusion. J Arthroplasty. 2000;15(4):453-460.
5. Rajgopal A, Ahuja N, Dolai B. Total knee arthroplasty in stiff and ankylosed knees. J Arthroplasty. 2005;20(5):585-590.
6. Kim YH, Cho SH, Kim JS. Total knee arthroplasty in bony ankylosis in gross flexion. J Bone Joint Surg Br. 1999;81(2):296-300.
Lasers for Latino skin – A balance of gentleness and strength
ORLANDO – With its unique tendency to develop postinflammatory hyperpigmentation (PIH), Latino skin needs a gentle touch from powerful lasers, according to Eduardo Weiss, MD.
“It’s often best to use a lower power, even though you trade off some efficacy for safety,” said Dr. Weiss, a dermatologist in Miami. “In general, it’s better to go with less aggressive treatment and more sessions, than to risk getting too aggressive and having a bad outcome.”
Dr. Weiss stressed that there are no “one size fits all” recommendations about laser treatment in typical Latino skin, because there’s no such thing as typical Latino skin. The group comprises all Fitzpatrick phototypes. But, in general, he said, the darker the skin, the greater the chance of an acute laser-induced burn, postinflammatory hyperpigmentation, and scarring.
Although general skin tone can provide a good first guess about the potential for hyperreaction to lasers, Dr. Weiss bolsters his judgments with a very simple – but effective – screen: palmar and digital crease pigmentation. First suggested by Hector G. Leal-Silva, MD, of the Institute of Dermatology and Cosmetic Surgery, Monterrey, Mexico, the screen divides patients into four groups, depending on the concentration of pigment present in palmar creases. A score of 0 means no pigment is visible, and the risk of PIH is negligible; a score of 3 means the creases are highly pigmented, and that the risk of PIH is very high.
But, with some adjustments in delivery – including using longer wavelengths and pulse duration, lower fluence and density, and smaller spot sizes – lasers can be used safely and effectively in these at-risk patients, Dr. Weiss said.
Safe treatment starts with pretreatment. It’s best to avoid laser procedures during the summer, when skin is at its darkest. Dr. Weiss also recommends a 6-week regimen aimed at lightening the area to be treated. This can include:
- Sun avoidance and the regular use of a high SPF sunscreen.
- Hydroquinone 4%-8%.
- A “Miami peel,” which is a modified Jessner’s peel with kojic acid and hydroquinone.
- Kligman’s formula of hydroquinone, tretinoin, and a corticosteroid.
- Heliocare, an oral extract of the Polypodium leucotomos fern.
About a month before the procedure, he performs a test spot with the intended laser and its planned settings, in the preauricular area. Any PIH will be obvious within 2-4 weeks. He also carefully screens patients or any photosensitizing condition, like lupus or herpes simplex, or a history of any photosensitizing drugs, such as tetracycline.
Dr. Weiss made specific suggestions for laser treatment of some common Latino skin issues:
Pigmented lesions
The high density of epidermal melanin in Fitzpatrick types IV-VI acts as a competitive chromophore against hemoglobin and oxyhemoglobin. This makes it quite challenging to treat vascular lesions such as port wine stains and telangiectasias, he said. The pulsed dye laser is a good choice, with wavelengths of 585-590 nm especially effective. “The longer 595-nm wavelength allows for a slightly deeper penetration,” Dr. Weiss said. “However, the absorption coefficient of oxyhemoglobin is three times higher at 585 nm than [at] 590 nm.”
Longer pulses are generally safer in dark-skinned patients, he noted. “It will be much less effective than the 585, but for darker-skinned patients, we must sacrifice a little efficacy for safety.”
For rosacea and telangiectasias, Dr. Weiss suggests a 515-nm intense pulsed light with pulse duration of 12-15/ms for these lesions, or pigmentation, he also uses 540 nm or 500-600 nm with pulse duration of 12-15/ms.
Melasma, a very common condition in dark-skinned Latinos, is also “one of the most difficult and frustrating conditions to manage,” he pointed out. He turns to a laser only when the case is resistant to more conservative treatment, which typically includes Kligman’s formula, sunscreen, light peels, and azelaic or kojic acid.
“Lasers are still controversial and, in my opinion, a last resort for melasma. I wouldn’t start unless everything else fails. I reserve them for the deep nonresponding melasmas.”
The Q-switched Nd:YAG is the most widely used for melasma. The fluence used is less than 5 J/cm2, with a 6-mm spot size and a frequency of 10 Hz. The number of treatment sessions varies from 5 to 10 at 1-week intervals, Dr. Weiss said. “Keep in mind that rebound hyperpigmentation could be due to the multiple subthreshold exposures that can stimulate melanogenesis in some areas.”
Skin rejuvenation
Ablative lasers – long the gold standard for skin rejuvenation in those with light skin – can be problematic for darker-skinned patients, Dr. Weiss said.
“These lasers, like the CO2 and Erbium:YAG, can cause several unwanted side effects in Latino skin.” These can include hyperpigmentation, which occurs in 50% of Fitzpatrick III or higher phototypes; erythema that can last for months; and delayed-onset hypopigmentation.
“I think better options for our darker-skinned patients are nonablative infrared, microneedling, and radiofrequency devices,” Dr. Weiss said. “There are, however, newer microablative resurfacing lasers. Fractional CO2, fractional Erbium, and the 2,790-nm yttrium scandium gallium garnet, offer a safer modality with which to treat skin types IV and above. Compared with the older-generation resurfacing lasers, the microablative lasers minimize the amount and duration of erythema and edema, which can last just 3-4 days.”
Dr. Weiss had no relevant financial disclosures.
ORLANDO – With its unique tendency to develop postinflammatory hyperpigmentation (PIH), Latino skin needs a gentle touch from powerful lasers, according to Eduardo Weiss, MD.
“It’s often best to use a lower power, even though you trade off some efficacy for safety,” said Dr. Weiss, a dermatologist in Miami. “In general, it’s better to go with less aggressive treatment and more sessions, than to risk getting too aggressive and having a bad outcome.”
Dr. Weiss stressed that there are no “one size fits all” recommendations about laser treatment in typical Latino skin, because there’s no such thing as typical Latino skin. The group comprises all Fitzpatrick phototypes. But, in general, he said, the darker the skin, the greater the chance of an acute laser-induced burn, postinflammatory hyperpigmentation, and scarring.
Although general skin tone can provide a good first guess about the potential for hyperreaction to lasers, Dr. Weiss bolsters his judgments with a very simple – but effective – screen: palmar and digital crease pigmentation. First suggested by Hector G. Leal-Silva, MD, of the Institute of Dermatology and Cosmetic Surgery, Monterrey, Mexico, the screen divides patients into four groups, depending on the concentration of pigment present in palmar creases. A score of 0 means no pigment is visible, and the risk of PIH is negligible; a score of 3 means the creases are highly pigmented, and that the risk of PIH is very high.
But, with some adjustments in delivery – including using longer wavelengths and pulse duration, lower fluence and density, and smaller spot sizes – lasers can be used safely and effectively in these at-risk patients, Dr. Weiss said.
Safe treatment starts with pretreatment. It’s best to avoid laser procedures during the summer, when skin is at its darkest. Dr. Weiss also recommends a 6-week regimen aimed at lightening the area to be treated. This can include:
- Sun avoidance and the regular use of a high SPF sunscreen.
- Hydroquinone 4%-8%.
- A “Miami peel,” which is a modified Jessner’s peel with kojic acid and hydroquinone.
- Kligman’s formula of hydroquinone, tretinoin, and a corticosteroid.
- Heliocare, an oral extract of the Polypodium leucotomos fern.
About a month before the procedure, he performs a test spot with the intended laser and its planned settings, in the preauricular area. Any PIH will be obvious within 2-4 weeks. He also carefully screens patients or any photosensitizing condition, like lupus or herpes simplex, or a history of any photosensitizing drugs, such as tetracycline.
Dr. Weiss made specific suggestions for laser treatment of some common Latino skin issues:
Pigmented lesions
The high density of epidermal melanin in Fitzpatrick types IV-VI acts as a competitive chromophore against hemoglobin and oxyhemoglobin. This makes it quite challenging to treat vascular lesions such as port wine stains and telangiectasias, he said. The pulsed dye laser is a good choice, with wavelengths of 585-590 nm especially effective. “The longer 595-nm wavelength allows for a slightly deeper penetration,” Dr. Weiss said. “However, the absorption coefficient of oxyhemoglobin is three times higher at 585 nm than [at] 590 nm.”
Longer pulses are generally safer in dark-skinned patients, he noted. “It will be much less effective than the 585, but for darker-skinned patients, we must sacrifice a little efficacy for safety.”
For rosacea and telangiectasias, Dr. Weiss suggests a 515-nm intense pulsed light with pulse duration of 12-15/ms for these lesions, or pigmentation, he also uses 540 nm or 500-600 nm with pulse duration of 12-15/ms.
Melasma, a very common condition in dark-skinned Latinos, is also “one of the most difficult and frustrating conditions to manage,” he pointed out. He turns to a laser only when the case is resistant to more conservative treatment, which typically includes Kligman’s formula, sunscreen, light peels, and azelaic or kojic acid.
“Lasers are still controversial and, in my opinion, a last resort for melasma. I wouldn’t start unless everything else fails. I reserve them for the deep nonresponding melasmas.”
The Q-switched Nd:YAG is the most widely used for melasma. The fluence used is less than 5 J/cm2, with a 6-mm spot size and a frequency of 10 Hz. The number of treatment sessions varies from 5 to 10 at 1-week intervals, Dr. Weiss said. “Keep in mind that rebound hyperpigmentation could be due to the multiple subthreshold exposures that can stimulate melanogenesis in some areas.”
Skin rejuvenation
Ablative lasers – long the gold standard for skin rejuvenation in those with light skin – can be problematic for darker-skinned patients, Dr. Weiss said.
“These lasers, like the CO2 and Erbium:YAG, can cause several unwanted side effects in Latino skin.” These can include hyperpigmentation, which occurs in 50% of Fitzpatrick III or higher phototypes; erythema that can last for months; and delayed-onset hypopigmentation.
“I think better options for our darker-skinned patients are nonablative infrared, microneedling, and radiofrequency devices,” Dr. Weiss said. “There are, however, newer microablative resurfacing lasers. Fractional CO2, fractional Erbium, and the 2,790-nm yttrium scandium gallium garnet, offer a safer modality with which to treat skin types IV and above. Compared with the older-generation resurfacing lasers, the microablative lasers minimize the amount and duration of erythema and edema, which can last just 3-4 days.”
Dr. Weiss had no relevant financial disclosures.
ORLANDO – With its unique tendency to develop postinflammatory hyperpigmentation (PIH), Latino skin needs a gentle touch from powerful lasers, according to Eduardo Weiss, MD.
“It’s often best to use a lower power, even though you trade off some efficacy for safety,” said Dr. Weiss, a dermatologist in Miami. “In general, it’s better to go with less aggressive treatment and more sessions, than to risk getting too aggressive and having a bad outcome.”
Dr. Weiss stressed that there are no “one size fits all” recommendations about laser treatment in typical Latino skin, because there’s no such thing as typical Latino skin. The group comprises all Fitzpatrick phototypes. But, in general, he said, the darker the skin, the greater the chance of an acute laser-induced burn, postinflammatory hyperpigmentation, and scarring.
Although general skin tone can provide a good first guess about the potential for hyperreaction to lasers, Dr. Weiss bolsters his judgments with a very simple – but effective – screen: palmar and digital crease pigmentation. First suggested by Hector G. Leal-Silva, MD, of the Institute of Dermatology and Cosmetic Surgery, Monterrey, Mexico, the screen divides patients into four groups, depending on the concentration of pigment present in palmar creases. A score of 0 means no pigment is visible, and the risk of PIH is negligible; a score of 3 means the creases are highly pigmented, and that the risk of PIH is very high.
But, with some adjustments in delivery – including using longer wavelengths and pulse duration, lower fluence and density, and smaller spot sizes – lasers can be used safely and effectively in these at-risk patients, Dr. Weiss said.
Safe treatment starts with pretreatment. It’s best to avoid laser procedures during the summer, when skin is at its darkest. Dr. Weiss also recommends a 6-week regimen aimed at lightening the area to be treated. This can include:
- Sun avoidance and the regular use of a high SPF sunscreen.
- Hydroquinone 4%-8%.
- A “Miami peel,” which is a modified Jessner’s peel with kojic acid and hydroquinone.
- Kligman’s formula of hydroquinone, tretinoin, and a corticosteroid.
- Heliocare, an oral extract of the Polypodium leucotomos fern.
About a month before the procedure, he performs a test spot with the intended laser and its planned settings, in the preauricular area. Any PIH will be obvious within 2-4 weeks. He also carefully screens patients or any photosensitizing condition, like lupus or herpes simplex, or a history of any photosensitizing drugs, such as tetracycline.
Dr. Weiss made specific suggestions for laser treatment of some common Latino skin issues:
Pigmented lesions
The high density of epidermal melanin in Fitzpatrick types IV-VI acts as a competitive chromophore against hemoglobin and oxyhemoglobin. This makes it quite challenging to treat vascular lesions such as port wine stains and telangiectasias, he said. The pulsed dye laser is a good choice, with wavelengths of 585-590 nm especially effective. “The longer 595-nm wavelength allows for a slightly deeper penetration,” Dr. Weiss said. “However, the absorption coefficient of oxyhemoglobin is three times higher at 585 nm than [at] 590 nm.”
Longer pulses are generally safer in dark-skinned patients, he noted. “It will be much less effective than the 585, but for darker-skinned patients, we must sacrifice a little efficacy for safety.”
For rosacea and telangiectasias, Dr. Weiss suggests a 515-nm intense pulsed light with pulse duration of 12-15/ms for these lesions, or pigmentation, he also uses 540 nm or 500-600 nm with pulse duration of 12-15/ms.
Melasma, a very common condition in dark-skinned Latinos, is also “one of the most difficult and frustrating conditions to manage,” he pointed out. He turns to a laser only when the case is resistant to more conservative treatment, which typically includes Kligman’s formula, sunscreen, light peels, and azelaic or kojic acid.
“Lasers are still controversial and, in my opinion, a last resort for melasma. I wouldn’t start unless everything else fails. I reserve them for the deep nonresponding melasmas.”
The Q-switched Nd:YAG is the most widely used for melasma. The fluence used is less than 5 J/cm2, with a 6-mm spot size and a frequency of 10 Hz. The number of treatment sessions varies from 5 to 10 at 1-week intervals, Dr. Weiss said. “Keep in mind that rebound hyperpigmentation could be due to the multiple subthreshold exposures that can stimulate melanogenesis in some areas.”
Skin rejuvenation
Ablative lasers – long the gold standard for skin rejuvenation in those with light skin – can be problematic for darker-skinned patients, Dr. Weiss said.
“These lasers, like the CO2 and Erbium:YAG, can cause several unwanted side effects in Latino skin.” These can include hyperpigmentation, which occurs in 50% of Fitzpatrick III or higher phototypes; erythema that can last for months; and delayed-onset hypopigmentation.
“I think better options for our darker-skinned patients are nonablative infrared, microneedling, and radiofrequency devices,” Dr. Weiss said. “There are, however, newer microablative resurfacing lasers. Fractional CO2, fractional Erbium, and the 2,790-nm yttrium scandium gallium garnet, offer a safer modality with which to treat skin types IV and above. Compared with the older-generation resurfacing lasers, the microablative lasers minimize the amount and duration of erythema and edema, which can last just 3-4 days.”
Dr. Weiss had no relevant financial disclosures.
EXPERT ANALYSIS FROM AAD 17