Martin et al recently presented a study at the 2015 American Society of Clinical Oncology Annual Meeting (J Clin Oncol. 2015;33[suppl]:9000) that reported on a phase 3 double-blind randomized trial to assess the use of oral nicotinamide to reduce actinic skin cancers, namely basal cell carcinoma (BCC) and squamous cell carcinoma (SCC).

This study was conducted in 2 tertiary treatment centers in Sydney, Australia, from 2012 to 2014, and it included 386 immunocompetent participants with 2 or more histologically confirmed nonmelanoma skin cancers (NMSCs) in the last 5 years. Two groups were randomized (1:1 ratio) to either receive oral nicotinamide 500 mg twice daily or matched placebo for 12 months. The primary end point measured was the number of new NMSCs to 12 months. Other secondary end points included number of SCCs, BCCs, and actinic keratoses to 12 months. Dermatologists performed skin checks every 3 months on the participants.

The results of the study showed that the average NMSC rate was significantly lower for the oral nicotinamide group (1.77) compared to the placebo group (2.42). The estimated relative rate reduction (RRR) was 0.23 (95% confidence interval [CI], 0.04-0.38; P=.02) adjusting for center and NMSC history, and 0.27 (95% CI, 0.05-0.44; P=.02) with no adjustment. The effects for BCC were comparable to SCC: BCC (RRR, 0.20; 95% CI, -0.06 to 0.39; P=.1) and SCC (RRR, 0.30; 95% CI, 0-0.51; P=.05). Additionally, actinic keratosis counts were reduced by 11% at 3 months (P=.01), 14% at 6 months (P<.001), 20% at 9 months (P<.0001), and 13% at 12 months (P<.005) for the oral nicotinamide group compared to the placebo group. There was no difference in the adverse event rates between the 2 groups.

What’s the issue?

This study reported the results of a double-blind randomized study of nicotinamide (vitamin B₃) to reduce actinic cancer, called the ONTRAC (Oral Nicotinamide to Reduce Actinic Cancer) study, with favorable results for the use of oral nicotinamide, an inexpensive vitamin. There was a 20% reduction in BCC and a 30% reduction in SCC in the nicotinamide group compared to the group taking a placebo with no active ingredients. This study was conducted in a heavily sun-damaged group and it is postulated that nicotinamide helps cells repair DNA damage.

The thought of using a vitamin to reduce skin cancer rates is exciting; however, this study is singular, and while it did show promising results, the number of participants is not very large. There also was no evidence that nicotinamide prevents melanoma formation. Also, there was no protective effect seen once the vitamin B₃ treatment was stopped. One must be cognizant that nicotinamide is not interchangeable with other forms of vitamin B₃ such as niacin.

Although this study is promising, more research is needed to determine nicotinamide’s preventative effects. Of course, strict sun protection and skin checks are the first line in the prevention of skin cancer. Will you be prescribing oral nicotinamide to your patients to prevent NMSC?

We want to know your views! Tell us what you think.

Martin et al recently presented a study at the 2015 American Society of Clinical Oncology Annual Meeting (J Clin Oncol. 2015;33[suppl]:9000) that reported on a phase 3 double-blind randomized trial to assess the use of oral nicotinamide to reduce actinic skin cancers, namely basal cell carcinoma (BCC) and squamous cell carcinoma (SCC).

This study was conducted in 2 tertiary treatment centers in Sydney, Australia, from 2012 to 2014, and it included 386 immunocompetent participants with 2 or more histologically confirmed nonmelanoma skin cancers (NMSCs) in the last 5 years. Two groups were randomized (1:1 ratio) to either receive oral nicotinamide 500 mg twice daily or matched placebo for 12 months. The primary end point measured was the number of new NMSCs to 12 months. Other secondary end points included number of SCCs, BCCs, and actinic keratoses to 12 months. Dermatologists performed skin checks every 3 months on the participants.

The results of the study showed that the average NMSC rate was significantly lower for the oral nicotinamide group (1.77) compared to the placebo group (2.42). The estimated relative rate reduction (RRR) was 0.23 (95% confidence interval [CI], 0.04-0.38; P=.02) adjusting for center and NMSC history, and 0.27 (95% CI, 0.05-0.44; P=.02) with no adjustment. The effects for BCC were comparable to SCC: BCC (RRR, 0.20; 95% CI, -0.06 to 0.39; P=.1) and SCC (RRR, 0.30; 95% CI, 0-0.51; P=.05). Additionally, actinic keratosis counts were reduced by 11% at 3 months (P=.01), 14% at 6 months (P<.001), 20% at 9 months (P<.0001), and 13% at 12 months (P<.005) for the oral nicotinamide group compared to the placebo group. There was no difference in the adverse event rates between the 2 groups.

What’s the issue?

This study reported the results of a double-blind randomized study of nicotinamide (vitamin B₃) to reduce actinic cancer, called the ONTRAC (Oral Nicotinamide to Reduce Actinic Cancer) study, with favorable results for the use of oral nicotinamide, an inexpensive vitamin. There was a 20% reduction in BCC and a 30% reduction in SCC in the nicotinamide group compared to the group taking a placebo with no active ingredients. This study was conducted in a heavily sun-damaged group and it is postulated that nicotinamide helps cells repair DNA damage.

The thought of using a vitamin to reduce skin cancer rates is exciting; however, this study is singular, and while it did show promising results, the number of participants is not very large. There also was no evidence that nicotinamide prevents melanoma formation. Also, there was no protective effect seen once the vitamin B₃ treatment was stopped. One must be cognizant that nicotinamide is not interchangeable with other forms of vitamin B₃ such as niacin.

Although this study is promising, more research is needed to determine nicotinamide’s preventative effects. Of course, strict sun protection and skin checks are the first line in the prevention of skin cancer. Will you be prescribing oral nicotinamide to your patients to prevent NMSC?

We want to know your views! Tell us what you think.

Martin et al recently presented a study at the 2015 American Society of Clinical Oncology Annual Meeting (J Clin Oncol. 2015;33[suppl]:9000) that reported on a phase 3 double-blind randomized trial to assess the use of oral nicotinamide to reduce actinic skin cancers, namely basal cell carcinoma (BCC) and squamous cell carcinoma (SCC).

This study was conducted in 2 tertiary treatment centers in Sydney, Australia, from 2012 to 2014, and it included 386 immunocompetent participants with 2 or more histologically confirmed nonmelanoma skin cancers (NMSCs) in the last 5 years. Two groups were randomized (1:1 ratio) to either receive oral nicotinamide 500 mg twice daily or matched placebo for 12 months. The primary end point measured was the number of new NMSCs to 12 months. Other secondary end points included number of SCCs, BCCs, and actinic keratoses to 12 months. Dermatologists performed skin checks every 3 months on the participants.

The results of the study showed that the average NMSC rate was significantly lower for the oral nicotinamide group (1.77) compared to the placebo group (2.42). The estimated relative rate reduction (RRR) was 0.23 (95% confidence interval [CI], 0.04-0.38; P=.02) adjusting for center and NMSC history, and 0.27 (95% CI, 0.05-0.44; P=.02) with no adjustment. The effects for BCC were comparable to SCC: BCC (RRR, 0.20; 95% CI, -0.06 to 0.39; P=.1) and SCC (RRR, 0.30; 95% CI, 0-0.51; P=.05). Additionally, actinic keratosis counts were reduced by 11% at 3 months (P=.01), 14% at 6 months (P<.001), 20% at 9 months (P<.0001), and 13% at 12 months (P<.005) for the oral nicotinamide group compared to the placebo group. There was no difference in the adverse event rates between the 2 groups.

What’s the issue?

This study reported the results of a double-blind randomized study of nicotinamide (vitamin B₃) to reduce actinic cancer, called the ONTRAC (Oral Nicotinamide to Reduce Actinic Cancer) study, with favorable results for the use of oral nicotinamide, an inexpensive vitamin. There was a 20% reduction in BCC and a 30% reduction in SCC in the nicotinamide group compared to the group taking a placebo with no active ingredients. This study was conducted in a heavily sun-damaged group and it is postulated that nicotinamide helps cells repair DNA damage.

The thought of using a vitamin to reduce skin cancer rates is exciting; however, this study is singular, and while it did show promising results, the number of participants is not very large. There also was no evidence that nicotinamide prevents melanoma formation. Also, there was no protective effect seen once the vitamin B₃ treatment was stopped. One must be cognizant that nicotinamide is not interchangeable with other forms of vitamin B₃ such as niacin.

Although this study is promising, more research is needed to determine nicotinamide’s preventative effects. Of course, strict sun protection and skin checks are the first line in the prevention of skin cancer. Will you be prescribing oral nicotinamide to your patients to prevent NMSC?

We want to know your views! Tell us what you think.

Memory loss is prevalent among adult hospitalized patients and can complicate hospitalists' job of teaching them about their conditions and home care, recent research suggests. But just what is behind patients’ memory impairment is not clear.

In a recent study published in the Journal of Hospital Medicine, researchers assessed the memory and in-hospital sleep habits of older adult patients to determine whether the two are linked.

"Since the hospital is considered a 'teachable moment,' and hospitalized patients have to learn about their care but also face sleep loss due to a disruptive environment and their own illness, we thought it would be interesting to see if there was an association," says study co-author Vineet M. Arora, MD, MAPP, a hospitalist and associate professor of medicine at the University of Chicago.

Nearly half of hospitalized patients in the study showed poor memory, based on their recall of word lists and medical vignettes. The results led Dr. Arora to conclude that hospitalists need to rethink the idea of hospitalization as a teachable moment and try reinforcing techniques when teaching patients.

"When trying to teach something that hospitalized patients need to remember, consider adopting strategies that use reminders or tools that people can take home, such as written instructions or video," Dr. Arora says. She also suggests hospitalists consider involving a patient's caregiver during the teaching, to have someone who can serve as a backup for the patient later.

The study also found that patients averaged 5.4 hours of in-hospital sleep per night and below-normal sleep efficiency, with 44% of patients' sleep-quality scores measured in the insomniac range. But they saw no statistically significant association between sleep loss and memory impairment in this study, Dr. Arora says.

"Our study was observational; it may be that everyone was too sleep deprived," she adds. "We may not have enough variation in sleep to detect difference in memory."

In future studies, having some well-rested subjects might make it possible to detect the association between sleep loss and memory impairment, Dr. Arora notes.

"If we did an intervention and tried to improve sleep in half our patients," she says, "then it would be worth seeing if memory was improved because we would have two groups: one that had better sleep and one that had worse sleep." TH

Visit our website for more information on inpatients and memory loss.

Memory loss is prevalent among adult hospitalized patients and can complicate hospitalists' job of teaching them about their conditions and home care, recent research suggests. But just what is behind patients’ memory impairment is not clear.

In a recent study published in the Journal of Hospital Medicine, researchers assessed the memory and in-hospital sleep habits of older adult patients to determine whether the two are linked.

"Since the hospital is considered a 'teachable moment,' and hospitalized patients have to learn about their care but also face sleep loss due to a disruptive environment and their own illness, we thought it would be interesting to see if there was an association," says study co-author Vineet M. Arora, MD, MAPP, a hospitalist and associate professor of medicine at the University of Chicago.

Nearly half of hospitalized patients in the study showed poor memory, based on their recall of word lists and medical vignettes. The results led Dr. Arora to conclude that hospitalists need to rethink the idea of hospitalization as a teachable moment and try reinforcing techniques when teaching patients.

"When trying to teach something that hospitalized patients need to remember, consider adopting strategies that use reminders or tools that people can take home, such as written instructions or video," Dr. Arora says. She also suggests hospitalists consider involving a patient's caregiver during the teaching, to have someone who can serve as a backup for the patient later.

The study also found that patients averaged 5.4 hours of in-hospital sleep per night and below-normal sleep efficiency, with 44% of patients' sleep-quality scores measured in the insomniac range. But they saw no statistically significant association between sleep loss and memory impairment in this study, Dr. Arora says.

"Our study was observational; it may be that everyone was too sleep deprived," she adds. "We may not have enough variation in sleep to detect difference in memory."

In future studies, having some well-rested subjects might make it possible to detect the association between sleep loss and memory impairment, Dr. Arora notes.

"If we did an intervention and tried to improve sleep in half our patients," she says, "then it would be worth seeing if memory was improved because we would have two groups: one that had better sleep and one that had worse sleep." TH

Visit our website for more information on inpatients and memory loss.

Memory loss is prevalent among adult hospitalized patients and can complicate hospitalists' job of teaching them about their conditions and home care, recent research suggests. But just what is behind patients’ memory impairment is not clear.

In a recent study published in the Journal of Hospital Medicine, researchers assessed the memory and in-hospital sleep habits of older adult patients to determine whether the two are linked.

"Since the hospital is considered a 'teachable moment,' and hospitalized patients have to learn about their care but also face sleep loss due to a disruptive environment and their own illness, we thought it would be interesting to see if there was an association," says study co-author Vineet M. Arora, MD, MAPP, a hospitalist and associate professor of medicine at the University of Chicago.

Nearly half of hospitalized patients in the study showed poor memory, based on their recall of word lists and medical vignettes. The results led Dr. Arora to conclude that hospitalists need to rethink the idea of hospitalization as a teachable moment and try reinforcing techniques when teaching patients.

"When trying to teach something that hospitalized patients need to remember, consider adopting strategies that use reminders or tools that people can take home, such as written instructions or video," Dr. Arora says. She also suggests hospitalists consider involving a patient's caregiver during the teaching, to have someone who can serve as a backup for the patient later.

The study also found that patients averaged 5.4 hours of in-hospital sleep per night and below-normal sleep efficiency, with 44% of patients' sleep-quality scores measured in the insomniac range. But they saw no statistically significant association between sleep loss and memory impairment in this study, Dr. Arora says.

"Our study was observational; it may be that everyone was too sleep deprived," she adds. "We may not have enough variation in sleep to detect difference in memory."

In future studies, having some well-rested subjects might make it possible to detect the association between sleep loss and memory impairment, Dr. Arora notes.

"If we did an intervention and tried to improve sleep in half our patients," she says, "then it would be worth seeing if memory was improved because we would have two groups: one that had better sleep and one that had worse sleep." TH

Visit our website for more information on inpatients and memory loss.

STAT. It’s often capitalized, I guess to convey urgency. It shouldn’t be, though, since it’s not an acronym. It’s a shortening of the Latin word “statim” meaning “immediately.”

Everyone in health care says it at one time or another, but I find it unsettling how many have no idea, or simply don’t care, what that really means.

To me, it’s that the test you’re ordering is urgent. You need to make a decision based on its results – STAT – to save life and/or limb. The results may make a significant difference in your treatment plan.

I find a lot of people don’t use this as the meaning anymore. They think STAT means “because I’m trying to get the patient out of here before Monday” or “a family is breathing down my neck” or “this is a VIP hospital board donor and I need to be extra nice.”

I’ve had my share of debates with other docs about those meanings, but I still stand by mine. To me, this is like pulling a fire alarm. When you do it, you want people to know you’re serious, and there’s a problem that needs to be addressed urgently.

Medicine, regrettably, has become a field of immediate gratification. Patients want results NOW. I’ve had people call me for results within 10 minutes of leaving an MRI facility or lab, even though I’d told them in advance that turnaround time would be days. Rather than accepting this, many ask that I call the radiologist or otherwise have their results rushed to make it more convenient for them. Of course, if you refuse, they may threaten to give you a bad review on Yelp or other rate-a-doc sites.

Some doctors are the same way. A syncope patient is stable, but needs to have a STAT EEG over the weekend so they can be sent home within the 24-hour observation window. It might be possible to send the patient out and get the study as an outpatient, but then they might not have it done, or another neurologist might get the billing. So better to pay the EEG tech overtime and have it done STAT.

Like the boy who cried wolf, STAT has become so commonplace at some hospitals as to be meaningless. Which only hurts the patients who legitimately need urgent studies.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

STAT. It’s often capitalized, I guess to convey urgency. It shouldn’t be, though, since it’s not an acronym. It’s a shortening of the Latin word “statim” meaning “immediately.”

Everyone in health care says it at one time or another, but I find it unsettling how many have no idea, or simply don’t care, what that really means.

To me, it’s that the test you’re ordering is urgent. You need to make a decision based on its results – STAT – to save life and/or limb. The results may make a significant difference in your treatment plan.

I find a lot of people don’t use this as the meaning anymore. They think STAT means “because I’m trying to get the patient out of here before Monday” or “a family is breathing down my neck” or “this is a VIP hospital board donor and I need to be extra nice.”

I’ve had my share of debates with other docs about those meanings, but I still stand by mine. To me, this is like pulling a fire alarm. When you do it, you want people to know you’re serious, and there’s a problem that needs to be addressed urgently.

Medicine, regrettably, has become a field of immediate gratification. Patients want results NOW. I’ve had people call me for results within 10 minutes of leaving an MRI facility or lab, even though I’d told them in advance that turnaround time would be days. Rather than accepting this, many ask that I call the radiologist or otherwise have their results rushed to make it more convenient for them. Of course, if you refuse, they may threaten to give you a bad review on Yelp or other rate-a-doc sites.

Some doctors are the same way. A syncope patient is stable, but needs to have a STAT EEG over the weekend so they can be sent home within the 24-hour observation window. It might be possible to send the patient out and get the study as an outpatient, but then they might not have it done, or another neurologist might get the billing. So better to pay the EEG tech overtime and have it done STAT.

Like the boy who cried wolf, STAT has become so commonplace at some hospitals as to be meaningless. Which only hurts the patients who legitimately need urgent studies.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

STAT. It’s often capitalized, I guess to convey urgency. It shouldn’t be, though, since it’s not an acronym. It’s a shortening of the Latin word “statim” meaning “immediately.”

Everyone in health care says it at one time or another, but I find it unsettling how many have no idea, or simply don’t care, what that really means.

To me, it’s that the test you’re ordering is urgent. You need to make a decision based on its results – STAT – to save life and/or limb. The results may make a significant difference in your treatment plan.

I find a lot of people don’t use this as the meaning anymore. They think STAT means “because I’m trying to get the patient out of here before Monday” or “a family is breathing down my neck” or “this is a VIP hospital board donor and I need to be extra nice.”

I’ve had my share of debates with other docs about those meanings, but I still stand by mine. To me, this is like pulling a fire alarm. When you do it, you want people to know you’re serious, and there’s a problem that needs to be addressed urgently.

Medicine, regrettably, has become a field of immediate gratification. Patients want results NOW. I’ve had people call me for results within 10 minutes of leaving an MRI facility or lab, even though I’d told them in advance that turnaround time would be days. Rather than accepting this, many ask that I call the radiologist or otherwise have their results rushed to make it more convenient for them. Of course, if you refuse, they may threaten to give you a bad review on Yelp or other rate-a-doc sites.

Some doctors are the same way. A syncope patient is stable, but needs to have a STAT EEG over the weekend so they can be sent home within the 24-hour observation window. It might be possible to send the patient out and get the study as an outpatient, but then they might not have it done, or another neurologist might get the billing. So better to pay the EEG tech overtime and have it done STAT.

Like the boy who cried wolf, STAT has become so commonplace at some hospitals as to be meaningless. Which only hurts the patients who legitimately need urgent studies.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

Patients often inquire if their diet has caused a dermatologic condition or if their diet makes it worse. Dr. Gary Goldenberg addresses how diet may impact acne, psoriasis, and urticaria. Ultimately, patient education by the dermatologist is needed to ensure patients are not relying on misinformation on the Internet regarding diets they should consider for their particular condition.

Patients often inquire if their diet has caused a dermatologic condition or if their diet makes it worse. Dr. Gary Goldenberg addresses how diet may impact acne, psoriasis, and urticaria. Ultimately, patient education by the dermatologist is needed to ensure patients are not relying on misinformation on the Internet regarding diets they should consider for their particular condition.

Patients often inquire if their diet has caused a dermatologic condition or if their diet makes it worse. Dr. Gary Goldenberg addresses how diet may impact acne, psoriasis, and urticaria. Ultimately, patient education by the dermatologist is needed to ensure patients are not relying on misinformation on the Internet regarding diets they should consider for their particular condition.

Two deals involving hospitalist management firms were announced in the past week, further consolidating the ranks of staffing companies in the specialty.

In the bigger deal, TeamHealth Holdings, Inc., last week agreed to acquire IPC Healthcare Inc. of North Hollywood, Calif., for $1.6 billion. The deal announcement highlighted IPC's stake in both hospital and post-acute care settings as a motivational factor for the acquisition.

"Combining emergency department staffing with hospitalist presence creates the opportunity to effectively manage patients from the emergency department through the inpatient discharge and beyond," the deal announcement notes. "This will allow TeamHealth to lower costs and increase quality, and, as a result, drive better patient experiences."

TeamHealth’s acquisition of IPC Healthcare is the latest deal to combine large hospital management groups, perpetuating a consolidation trend among companies seeking cost efficiencies.

Also last week, private equity firm Onex Corporation announced an agreement to acquire Hospital Physician Partners (HPP) of Hollywood, Fla., which bills itself as the fourth-largest provider of emergency and hospitalist clinical staffing services. Financial terms were not released.

Both deals are expected to close by year's end. They follow 2014's acquisition by Sound Physicians of Cogent Healthcare. The combined entity, which retained the Sound name, created the largest hospital management group in the country.

John Nelson, MD, MHM, a principal in Nelson Flores Hospital Medicine Consultants and regular practice management columnist for The Hospitalist, says consolidation is a double-edged sword.

"They may have the scale to come up with new valuable ways to organize care that can be adopted … by others," Dr. Nelson writes in an email to The Hospitalist. "But a marketplace that moves from multiple competing companies to a few very large ones faces the usual negatives of fewer competitors in the marketplace."

Dr. Nelson compares such deals to the airline industry, where consolidation has shrunk the playing field to a handful of major carriers. While larger HM firms may carry more weight in contract negotiations with institutions, individual practitioners need not worry that consolidation as a trend will negatively impact their daily rounds, he notes.

"Any efficiencies large companies have will likely have little effect on the work life of rank-and-file hospitalists, at least for foreseeable future," he adds. TH

Visit our website for more information on consolidation in hospital medicine.

Two deals involving hospitalist management firms were announced in the past week, further consolidating the ranks of staffing companies in the specialty.

In the bigger deal, TeamHealth Holdings, Inc., last week agreed to acquire IPC Healthcare Inc. of North Hollywood, Calif., for $1.6 billion. The deal announcement highlighted IPC's stake in both hospital and post-acute care settings as a motivational factor for the acquisition.

"Combining emergency department staffing with hospitalist presence creates the opportunity to effectively manage patients from the emergency department through the inpatient discharge and beyond," the deal announcement notes. "This will allow TeamHealth to lower costs and increase quality, and, as a result, drive better patient experiences."

TeamHealth’s acquisition of IPC Healthcare is the latest deal to combine large hospital management groups, perpetuating a consolidation trend among companies seeking cost efficiencies.

Also last week, private equity firm Onex Corporation announced an agreement to acquire Hospital Physician Partners (HPP) of Hollywood, Fla., which bills itself as the fourth-largest provider of emergency and hospitalist clinical staffing services. Financial terms were not released.

Both deals are expected to close by year's end. They follow 2014's acquisition by Sound Physicians of Cogent Healthcare. The combined entity, which retained the Sound name, created the largest hospital management group in the country.

John Nelson, MD, MHM, a principal in Nelson Flores Hospital Medicine Consultants and regular practice management columnist for The Hospitalist, says consolidation is a double-edged sword.

"They may have the scale to come up with new valuable ways to organize care that can be adopted … by others," Dr. Nelson writes in an email to The Hospitalist. "But a marketplace that moves from multiple competing companies to a few very large ones faces the usual negatives of fewer competitors in the marketplace."

Dr. Nelson compares such deals to the airline industry, where consolidation has shrunk the playing field to a handful of major carriers. While larger HM firms may carry more weight in contract negotiations with institutions, individual practitioners need not worry that consolidation as a trend will negatively impact their daily rounds, he notes.

"Any efficiencies large companies have will likely have little effect on the work life of rank-and-file hospitalists, at least for foreseeable future," he adds. TH

Visit our website for more information on consolidation in hospital medicine.

Two deals involving hospitalist management firms were announced in the past week, further consolidating the ranks of staffing companies in the specialty.

In the bigger deal, TeamHealth Holdings, Inc., last week agreed to acquire IPC Healthcare Inc. of North Hollywood, Calif., for $1.6 billion. The deal announcement highlighted IPC's stake in both hospital and post-acute care settings as a motivational factor for the acquisition.

"Combining emergency department staffing with hospitalist presence creates the opportunity to effectively manage patients from the emergency department through the inpatient discharge and beyond," the deal announcement notes. "This will allow TeamHealth to lower costs and increase quality, and, as a result, drive better patient experiences."

TeamHealth’s acquisition of IPC Healthcare is the latest deal to combine large hospital management groups, perpetuating a consolidation trend among companies seeking cost efficiencies.

Also last week, private equity firm Onex Corporation announced an agreement to acquire Hospital Physician Partners (HPP) of Hollywood, Fla., which bills itself as the fourth-largest provider of emergency and hospitalist clinical staffing services. Financial terms were not released.

Both deals are expected to close by year's end. They follow 2014's acquisition by Sound Physicians of Cogent Healthcare. The combined entity, which retained the Sound name, created the largest hospital management group in the country.

John Nelson, MD, MHM, a principal in Nelson Flores Hospital Medicine Consultants and regular practice management columnist for The Hospitalist, says consolidation is a double-edged sword.

"They may have the scale to come up with new valuable ways to organize care that can be adopted … by others," Dr. Nelson writes in an email to The Hospitalist. "But a marketplace that moves from multiple competing companies to a few very large ones faces the usual negatives of fewer competitors in the marketplace."

Dr. Nelson compares such deals to the airline industry, where consolidation has shrunk the playing field to a handful of major carriers. While larger HM firms may carry more weight in contract negotiations with institutions, individual practitioners need not worry that consolidation as a trend will negatively impact their daily rounds, he notes.

"Any efficiencies large companies have will likely have little effect on the work life of rank-and-file hospitalists, at least for foreseeable future," he adds. TH

Visit our website for more information on consolidation in hospital medicine.

NEW YORK (Reuters Health) - The American Board of Internal Medicine (ABIM) maintenance-of-certification (MOC) program could cost $5.7 billion in physicians' time and fees over the next decade, according to a new model study.

"We estimate that physicians will spend 33 million hours over 10 years to fulfill MOC requirements," Dr. Dhruv S. Kazi from the University of California, San Francisco, told Reuters Health by email.

"This is approximately equivalent to the total clinical work load of 1785 physicians over 10 years," Dr. Kazi said. "This demand on physician time comes during a period of expanding insurance coverage and anticipated physician workforce shortfalls; it may therefore adversely affect access to care, particularly elective care."

The ABIM's substantial expansion in 2014 of its MOC requirements for the more than 250,000 board-certified internists, hospitalists and internal medicine subspecialists ignited an intense debate about the societal value of the program, resulting in temporary suspension of some of the new requirements.

Dr. Kazi's team sought to quantify the costs of the 2015 version of the MOC program and compare them with the costs that would have been incurred had the 2013 version remained unchanged.

The new MOC requirements would cost board-certified internal medicine physicians an average of $23,607 over 10 years, including $2,349 in fees to the ABIM and $21,259 in time costs, the researchers report in Annals of Internal Medicine, online July 28.

Average costs would range from $16,725 for general internists to $40,495 for hematologists-oncologists.

The overall program would cost $5.7 billion ($561 million in fees to ABIM and $5.1 billion in time costs) over the next 10 years, an increase of $1.2 billion over the previous MOC program.

"The ABIM has previously suggested that participation in MOC will cost $200 to $400 per year," the researchers note. "This is a substantial underestimate precisely because it overlooks time costs."

"While we had anticipated that physician time would be an important driver of costs of the program, we were surprised to see that 9 out of every 10 dollars in MOC costs were related to the program's demands on physician time," Dr. Kazi said. "In fact, every additional hour spent by physicians on MOC increased the costs of the program by approximately 13 million dollars."

"The internal medicine community has embraced the principle of evidence-based medicine in clinical practice; expensive policy interventions such as MOC should be held to the same evidentiary standards," Dr. Kazi concluded.

"Instead of piecemeal evaluations, the entire MOC program should be compared head-to-head with other policy interventions or health systems interventions that improve healthcare quality, thus providing an empirical basis for choosing MOC over alternative strategies for quality improvement," Dr. Kazi said.

"We hope that the high costs of MOC catalyze future studies examining the impact of MOC on the quality and economics of care delivered by board-certified physicians in the United States," Dr. Kazi added.

Dr. Robert B. Baron from the American Board of Internal Medicine told Reuters Health by email, "Their analysis is less about time and cost of doing MOC than it is about the time physicians take staying up-to-date. They estimate that it is about an hour a month, and about 40 hours to prepare for the exam every decade. While the researchers attribute that time to MOC, I suspect most physicians would be spending this time staying abreast of the latest developments in their field, with or without MOC. What MOC offers them is a structured framework to keep up and a marker for the public that they are."

"Our MOC program already recognizes so much of what physicians are doing in practice to stay up to date," said Dr. Baron, also of the University of California, San Francisco. "We can and should do more in that area. We are getting a lot of feedback from physicians about how we can improve MOC, and this feedback will help us shape what we know will be an evolving program."

"In conversations we have already had with the community, one thing physicians have shared loud and clear is that they deeply value staying current in their field," he added. "They believe they should spend time staying abreast of the latest updates in their discipline. We are talking with the community to assure that MOC gives them a structured way to stay current, and we all agree it is an important marker for patients that they have done so."

"The researchers make some claims about overall costs to the health care system," Dr. Baron said. "If you accept their methodology, which is a stretch, other research that appeared in JAMA in December showed greater overall savings - 30 times as much as the costs reported here - just in Medicare costs for physicians who participated in MOC. So maybe all those hours spent keeping up are worth it, not just for the physicians and the patients we take care of but for our entire health care system."

NEW YORK (Reuters Health) - The American Board of Internal Medicine (ABIM) maintenance-of-certification (MOC) program could cost $5.7 billion in physicians' time and fees over the next decade, according to a new model study.

"We estimate that physicians will spend 33 million hours over 10 years to fulfill MOC requirements," Dr. Dhruv S. Kazi from the University of California, San Francisco, told Reuters Health by email.

"This is approximately equivalent to the total clinical work load of 1785 physicians over 10 years," Dr. Kazi said. "This demand on physician time comes during a period of expanding insurance coverage and anticipated physician workforce shortfalls; it may therefore adversely affect access to care, particularly elective care."

The ABIM's substantial expansion in 2014 of its MOC requirements for the more than 250,000 board-certified internists, hospitalists and internal medicine subspecialists ignited an intense debate about the societal value of the program, resulting in temporary suspension of some of the new requirements.

Dr. Kazi's team sought to quantify the costs of the 2015 version of the MOC program and compare them with the costs that would have been incurred had the 2013 version remained unchanged.

The new MOC requirements would cost board-certified internal medicine physicians an average of $23,607 over 10 years, including $2,349 in fees to the ABIM and $21,259 in time costs, the researchers report in Annals of Internal Medicine, online July 28.

Average costs would range from $16,725 for general internists to $40,495 for hematologists-oncologists.

The overall program would cost $5.7 billion ($561 million in fees to ABIM and $5.1 billion in time costs) over the next 10 years, an increase of $1.2 billion over the previous MOC program.

"The ABIM has previously suggested that participation in MOC will cost $200 to $400 per year," the researchers note. "This is a substantial underestimate precisely because it overlooks time costs."

"While we had anticipated that physician time would be an important driver of costs of the program, we were surprised to see that 9 out of every 10 dollars in MOC costs were related to the program's demands on physician time," Dr. Kazi said. "In fact, every additional hour spent by physicians on MOC increased the costs of the program by approximately 13 million dollars."

"The internal medicine community has embraced the principle of evidence-based medicine in clinical practice; expensive policy interventions such as MOC should be held to the same evidentiary standards," Dr. Kazi concluded.

"Instead of piecemeal evaluations, the entire MOC program should be compared head-to-head with other policy interventions or health systems interventions that improve healthcare quality, thus providing an empirical basis for choosing MOC over alternative strategies for quality improvement," Dr. Kazi said.

"We hope that the high costs of MOC catalyze future studies examining the impact of MOC on the quality and economics of care delivered by board-certified physicians in the United States," Dr. Kazi added.

Dr. Robert B. Baron from the American Board of Internal Medicine told Reuters Health by email, "Their analysis is less about time and cost of doing MOC than it is about the time physicians take staying up-to-date. They estimate that it is about an hour a month, and about 40 hours to prepare for the exam every decade. While the researchers attribute that time to MOC, I suspect most physicians would be spending this time staying abreast of the latest developments in their field, with or without MOC. What MOC offers them is a structured framework to keep up and a marker for the public that they are."

"Our MOC program already recognizes so much of what physicians are doing in practice to stay up to date," said Dr. Baron, also of the University of California, San Francisco. "We can and should do more in that area. We are getting a lot of feedback from physicians about how we can improve MOC, and this feedback will help us shape what we know will be an evolving program."

"In conversations we have already had with the community, one thing physicians have shared loud and clear is that they deeply value staying current in their field," he added. "They believe they should spend time staying abreast of the latest updates in their discipline. We are talking with the community to assure that MOC gives them a structured way to stay current, and we all agree it is an important marker for patients that they have done so."

"The researchers make some claims about overall costs to the health care system," Dr. Baron said. "If you accept their methodology, which is a stretch, other research that appeared in JAMA in December showed greater overall savings - 30 times as much as the costs reported here - just in Medicare costs for physicians who participated in MOC. So maybe all those hours spent keeping up are worth it, not just for the physicians and the patients we take care of but for our entire health care system."

NEW YORK (Reuters Health) - The American Board of Internal Medicine (ABIM) maintenance-of-certification (MOC) program could cost $5.7 billion in physicians' time and fees over the next decade, according to a new model study.

"We estimate that physicians will spend 33 million hours over 10 years to fulfill MOC requirements," Dr. Dhruv S. Kazi from the University of California, San Francisco, told Reuters Health by email.

"This is approximately equivalent to the total clinical work load of 1785 physicians over 10 years," Dr. Kazi said. "This demand on physician time comes during a period of expanding insurance coverage and anticipated physician workforce shortfalls; it may therefore adversely affect access to care, particularly elective care."

The ABIM's substantial expansion in 2014 of its MOC requirements for the more than 250,000 board-certified internists, hospitalists and internal medicine subspecialists ignited an intense debate about the societal value of the program, resulting in temporary suspension of some of the new requirements.

Dr. Kazi's team sought to quantify the costs of the 2015 version of the MOC program and compare them with the costs that would have been incurred had the 2013 version remained unchanged.

The new MOC requirements would cost board-certified internal medicine physicians an average of $23,607 over 10 years, including $2,349 in fees to the ABIM and $21,259 in time costs, the researchers report in Annals of Internal Medicine, online July 28.

Average costs would range from $16,725 for general internists to $40,495 for hematologists-oncologists.

The overall program would cost $5.7 billion ($561 million in fees to ABIM and $5.1 billion in time costs) over the next 10 years, an increase of $1.2 billion over the previous MOC program.

"The ABIM has previously suggested that participation in MOC will cost $200 to $400 per year," the researchers note. "This is a substantial underestimate precisely because it overlooks time costs."

"While we had anticipated that physician time would be an important driver of costs of the program, we were surprised to see that 9 out of every 10 dollars in MOC costs were related to the program's demands on physician time," Dr. Kazi said. "In fact, every additional hour spent by physicians on MOC increased the costs of the program by approximately 13 million dollars."

"The internal medicine community has embraced the principle of evidence-based medicine in clinical practice; expensive policy interventions such as MOC should be held to the same evidentiary standards," Dr. Kazi concluded.

"Instead of piecemeal evaluations, the entire MOC program should be compared head-to-head with other policy interventions or health systems interventions that improve healthcare quality, thus providing an empirical basis for choosing MOC over alternative strategies for quality improvement," Dr. Kazi said.

"We hope that the high costs of MOC catalyze future studies examining the impact of MOC on the quality and economics of care delivered by board-certified physicians in the United States," Dr. Kazi added.

Dr. Robert B. Baron from the American Board of Internal Medicine told Reuters Health by email, "Their analysis is less about time and cost of doing MOC than it is about the time physicians take staying up-to-date. They estimate that it is about an hour a month, and about 40 hours to prepare for the exam every decade. While the researchers attribute that time to MOC, I suspect most physicians would be spending this time staying abreast of the latest developments in their field, with or without MOC. What MOC offers them is a structured framework to keep up and a marker for the public that they are."

"Our MOC program already recognizes so much of what physicians are doing in practice to stay up to date," said Dr. Baron, also of the University of California, San Francisco. "We can and should do more in that area. We are getting a lot of feedback from physicians about how we can improve MOC, and this feedback will help us shape what we know will be an evolving program."

"In conversations we have already had with the community, one thing physicians have shared loud and clear is that they deeply value staying current in their field," he added. "They believe they should spend time staying abreast of the latest updates in their discipline. We are talking with the community to assure that MOC gives them a structured way to stay current, and we all agree it is an important marker for patients that they have done so."

"The researchers make some claims about overall costs to the health care system," Dr. Baron said. "If you accept their methodology, which is a stretch, other research that appeared in JAMA in December showed greater overall savings - 30 times as much as the costs reported here - just in Medicare costs for physicians who participated in MOC. So maybe all those hours spent keeping up are worth it, not just for the physicians and the patients we take care of but for our entire health care system."

(Reuters Health) - Most older adults who are hospitalized for acute myocardial infarction do not attend even one of the recommended cardiac rehabilitation sessions, according to a new study.

Cardiac rehab increases physical and cardiovascular fitness through structured exercise and education sessions, said lead author Dr. Jacob A. Doll, of Duke Clinical Research Institute in Durham, North Carolina.

Patients may attend individual or group sessions to improve medication adherence, help them quit smoking, lose weight, improve their diet and manage chronic diseases, while also focusing on psychological and social wellbeing, he said.

"Some people will be too sick after a heart attack to exercise safely, but this should be a fairly low percentage," Doll told Reuters Health by email. "Most other people can benefit, especially older adults."

Researchers used data on 58,269 patients 65 years or older who had acute MI between 2007 and 2010.

The researchers found that 36,376 patients, or 62%, were referred to cardiac rehab - but only 11,862 attended at least one rehab session over the year following hospital discharge.

Of those who had not been referred, 1,795 attended at least one session.

Half of those who went to the rehab program attended less than 26 sessions, though insurance usually covers 36 sessions - or two to three sessions per week, as reported August 3 in JAMA Internal Medicine.

Less than a quarter of the total group of MI patients attended at least one rehab session, and only 5% completed 36 sessions.

Younger white male nonsmokers with few other health problems were most likely to attend cardiac rehab.

"Not all (heart attack) patients are referred, some for valid reasons such as inability to exercise, difficulty in scheduling due to their job, lack of transportation, need to care for a sick spouse, etc," said Dr. Jerome L. Fleg of the National Heart, Lung and Blood Institute in Bethesda, Maryland.

Rehab sessions typically involve five to 10 minutes of warm-up, 30 to 40 minutes of walking, stationary cycling, or elliptical machine exercise, followed by five to 10 minutes of cool down, said Fleg, who was not part of the new study.

Hospitals should improve referral rates, and should encourage enrolled patients to actually complete the rehab programs, Doll said.

"Many people might feel that cardiac rehab is not for them, potentially because they feel they are not able to exercise or are too sick," he said.

Medicare recipients, like those in this study, generally have all costs covered for cardiac rehab, Fleg told Reuters Health by email.

Most other insurances cover cardiac rehab, but copayments may be cost-prohibitive for some people, and those living in rural areas may have to drive long distances to find a center, Doll said.

"Health systems and insurers should consider reducing copayments in order to improve access, since cardiac rehabilitation has been shown (to) improve survival and functioning after a heart attack," he said. "For people that cannot attend a traditional program, we may need new ways to deliver rehab services, such as home-based programs."

(Reuters Health) - Most older adults who are hospitalized for acute myocardial infarction do not attend even one of the recommended cardiac rehabilitation sessions, according to a new study.

Cardiac rehab increases physical and cardiovascular fitness through structured exercise and education sessions, said lead author Dr. Jacob A. Doll, of Duke Clinical Research Institute in Durham, North Carolina.

Patients may attend individual or group sessions to improve medication adherence, help them quit smoking, lose weight, improve their diet and manage chronic diseases, while also focusing on psychological and social wellbeing, he said.

"Some people will be too sick after a heart attack to exercise safely, but this should be a fairly low percentage," Doll told Reuters Health by email. "Most other people can benefit, especially older adults."

Researchers used data on 58,269 patients 65 years or older who had acute MI between 2007 and 2010.

The researchers found that 36,376 patients, or 62%, were referred to cardiac rehab - but only 11,862 attended at least one rehab session over the year following hospital discharge.

Of those who had not been referred, 1,795 attended at least one session.

Half of those who went to the rehab program attended less than 26 sessions, though insurance usually covers 36 sessions - or two to three sessions per week, as reported August 3 in JAMA Internal Medicine.

Less than a quarter of the total group of MI patients attended at least one rehab session, and only 5% completed 36 sessions.

Younger white male nonsmokers with few other health problems were most likely to attend cardiac rehab.

"Not all (heart attack) patients are referred, some for valid reasons such as inability to exercise, difficulty in scheduling due to their job, lack of transportation, need to care for a sick spouse, etc," said Dr. Jerome L. Fleg of the National Heart, Lung and Blood Institute in Bethesda, Maryland.

Rehab sessions typically involve five to 10 minutes of warm-up, 30 to 40 minutes of walking, stationary cycling, or elliptical machine exercise, followed by five to 10 minutes of cool down, said Fleg, who was not part of the new study.

Hospitals should improve referral rates, and should encourage enrolled patients to actually complete the rehab programs, Doll said.

"Many people might feel that cardiac rehab is not for them, potentially because they feel they are not able to exercise or are too sick," he said.

Medicare recipients, like those in this study, generally have all costs covered for cardiac rehab, Fleg told Reuters Health by email.

Most other insurances cover cardiac rehab, but copayments may be cost-prohibitive for some people, and those living in rural areas may have to drive long distances to find a center, Doll said.

"Health systems and insurers should consider reducing copayments in order to improve access, since cardiac rehabilitation has been shown (to) improve survival and functioning after a heart attack," he said. "For people that cannot attend a traditional program, we may need new ways to deliver rehab services, such as home-based programs."

(Reuters Health) - Most older adults who are hospitalized for acute myocardial infarction do not attend even one of the recommended cardiac rehabilitation sessions, according to a new study.

Cardiac rehab increases physical and cardiovascular fitness through structured exercise and education sessions, said lead author Dr. Jacob A. Doll, of Duke Clinical Research Institute in Durham, North Carolina.

Patients may attend individual or group sessions to improve medication adherence, help them quit smoking, lose weight, improve their diet and manage chronic diseases, while also focusing on psychological and social wellbeing, he said.

"Some people will be too sick after a heart attack to exercise safely, but this should be a fairly low percentage," Doll told Reuters Health by email. "Most other people can benefit, especially older adults."

Researchers used data on 58,269 patients 65 years or older who had acute MI between 2007 and 2010.

The researchers found that 36,376 patients, or 62%, were referred to cardiac rehab - but only 11,862 attended at least one rehab session over the year following hospital discharge.

Of those who had not been referred, 1,795 attended at least one session.

Half of those who went to the rehab program attended less than 26 sessions, though insurance usually covers 36 sessions - or two to three sessions per week, as reported August 3 in JAMA Internal Medicine.

Less than a quarter of the total group of MI patients attended at least one rehab session, and only 5% completed 36 sessions.

Younger white male nonsmokers with few other health problems were most likely to attend cardiac rehab.

"Not all (heart attack) patients are referred, some for valid reasons such as inability to exercise, difficulty in scheduling due to their job, lack of transportation, need to care for a sick spouse, etc," said Dr. Jerome L. Fleg of the National Heart, Lung and Blood Institute in Bethesda, Maryland.

Rehab sessions typically involve five to 10 minutes of warm-up, 30 to 40 minutes of walking, stationary cycling, or elliptical machine exercise, followed by five to 10 minutes of cool down, said Fleg, who was not part of the new study.

Hospitals should improve referral rates, and should encourage enrolled patients to actually complete the rehab programs, Doll said.

"Many people might feel that cardiac rehab is not for them, potentially because they feel they are not able to exercise or are too sick," he said.

Medicare recipients, like those in this study, generally have all costs covered for cardiac rehab, Fleg told Reuters Health by email.

Most other insurances cover cardiac rehab, but copayments may be cost-prohibitive for some people, and those living in rural areas may have to drive long distances to find a center, Doll said.

"Health systems and insurers should consider reducing copayments in order to improve access, since cardiac rehabilitation has been shown (to) improve survival and functioning after a heart attack," he said. "For people that cannot attend a traditional program, we may need new ways to deliver rehab services, such as home-based programs."

VANCOUVER – Achieving effective local anesthesia is the critical first step in successful nail surgery, Dr. Chris G. Adigun said at the World Congress of Dermatology.

“Always remember: Nail surgery hurts. Your patients will applaud you enthusiastically when they’re back home for your having used a long-acting anesthetic,” said Dr. Adigun, a dermatologist in group practice in Chapel Hill, N.C.

The three most widely used anesthetic agents in nail surgery are lidocaine (Xylocaine), bupivacaine (Marcaine), and ropivacaine (Naropin). Dr. Adigun said she strongly prefers ropivacaine. It combines the best features of the other two: lidocaine’s rapid onset along with a duration of action that’s even longer than bupivacaine’s, she noted. Ropivacaine’s duration of action is 8-12 hours – and it comes without bupivacaine’s potential for cardiotoxicity. Moreover, ropivacaine has a vasoconstrictive effect, which improves hemostasis and enhances visualization during the surgery.

She provided numerous additional tips on how to predictably achieve effective anesthesia for nail surgery:

• Buffer with sodium bicarbonate. The idea is to bring the anesthetic solution close to physiologic pH, which makes for a far less painful experience than injecting the acidic unbuffered solution.

• Warm it. Investigators have shown that warming anesthetic fluid reduces pain upon injection of both nonbuffered and buffered local anesthetics (Ann Emerg Med. 2011 Jul;58(1):86-98).

• Stick to a small-gauge needle. Dr. Adigan said she favors 30 gauge. It makes for a smaller, less painful puncture and limits the rate of flow of anesthetic fluid into the digital space.

• Inject in a perpendicular plane. This will disrupt fewer nerve endings than when going in at an angle.

“I think this is something that’s not frequently taught to residents in dermatology. I think we almost always go in at an angle, but if you go in at a perpendicular plane, you’re going to cause less pain,” according to Dr. Adigun.

• Inject just below the dermis. The dermis is nociceptor rich, and stretching those tissues by injecting a volume of fluid there will cause intense, continuous pain until the local anesthetic has time to take effect.

• Use distraction techniques liberally. Dr. Adigun said she likes to tell stories and jokes, which she calls “talkesthesia.” She also utilizes a battery-powered massager.

“Put the massager as close to your surgical field as you’re comfortable with. Under the gate theory of pain, you want to create as much sensory ‘noise’ as possible with your distraction techniques so that gate is filled with your sensory noise rather than pain,” the dermatologist explained.

There are three solid, time-tested completely acceptable techniques for getting the target digit numb: the wing block, the traditional digital block, and the transthecal digital block.

Dr. Adigun said she generally relies upon the wing block unless she is concerned that the associated blanching might cause her to lose her digital landmarks during surgery addressing a subtle abnormality. In that situation she turns mainly to the traditional digital block, which doesn’t interfere with digital landmarks and effectively anesthetizes both the paired digital and volar nerves.

The downside of the traditional digital block is it entails a 15- to 20-minute wait for the anesthetic to diffuse. So does the transthecal digital block, which has the additional shortcoming of achieving predictable results only when applied for surgery on the second, third, or fourth digits.

The wing block is an efficient infiltrative technique targeting the distal digit. It offers immediate anesthesia of the total nail unit. To achieve an excellent wing block, initially inject just 0.1-0.2 mL of anesthetic fluid subcutaneously into the proximal nail fold midway between the cuticle and the distal interphalangeal joint. Wait for a wheal to form; then wait an additional 45-60 seconds. At that point, inject obliquely along the lateral edge of the nail fold in the direction of the digital tip. The needle should be advanced while maintaining a gentle fluid bolus ahead of the needle tip in order to minimize the patient’s sensation of the moving needle. The process is then repeated on the opposite side of the digit.

“You want to keep that needle in the dermal plane and avoid filling the pulp with anesthetic fluid. If you do this correctly, only one prick is felt by the patient. I very rarely have to use a full cc of anesthetic fluid when I use a wing block,” Dr. Adigun said.

If any additional needle insertions are needed, make sure they’re placed into tissue that’s already been anesthetized, she added.

Dr. Adigun reported having no financial conflicts of interest.

bjancin@frontlinemedcom.com

VANCOUVER – Achieving effective local anesthesia is the critical first step in successful nail surgery, Dr. Chris G. Adigun said at the World Congress of Dermatology.

“Always remember: Nail surgery hurts. Your patients will applaud you enthusiastically when they’re back home for your having used a long-acting anesthetic,” said Dr. Adigun, a dermatologist in group practice in Chapel Hill, N.C.

The three most widely used anesthetic agents in nail surgery are lidocaine (Xylocaine), bupivacaine (Marcaine), and ropivacaine (Naropin). Dr. Adigun said she strongly prefers ropivacaine. It combines the best features of the other two: lidocaine’s rapid onset along with a duration of action that’s even longer than bupivacaine’s, she noted. Ropivacaine’s duration of action is 8-12 hours – and it comes without bupivacaine’s potential for cardiotoxicity. Moreover, ropivacaine has a vasoconstrictive effect, which improves hemostasis and enhances visualization during the surgery.

She provided numerous additional tips on how to predictably achieve effective anesthesia for nail surgery:

• Buffer with sodium bicarbonate. The idea is to bring the anesthetic solution close to physiologic pH, which makes for a far less painful experience than injecting the acidic unbuffered solution.

• Warm it. Investigators have shown that warming anesthetic fluid reduces pain upon injection of both nonbuffered and buffered local anesthetics (Ann Emerg Med. 2011 Jul;58(1):86-98).

• Stick to a small-gauge needle. Dr. Adigan said she favors 30 gauge. It makes for a smaller, less painful puncture and limits the rate of flow of anesthetic fluid into the digital space.

• Inject in a perpendicular plane. This will disrupt fewer nerve endings than when going in at an angle.

“I think this is something that’s not frequently taught to residents in dermatology. I think we almost always go in at an angle, but if you go in at a perpendicular plane, you’re going to cause less pain,” according to Dr. Adigun.

• Inject just below the dermis. The dermis is nociceptor rich, and stretching those tissues by injecting a volume of fluid there will cause intense, continuous pain until the local anesthetic has time to take effect.

• Use distraction techniques liberally. Dr. Adigun said she likes to tell stories and jokes, which she calls “talkesthesia.” She also utilizes a battery-powered massager.

“Put the massager as close to your surgical field as you’re comfortable with. Under the gate theory of pain, you want to create as much sensory ‘noise’ as possible with your distraction techniques so that gate is filled with your sensory noise rather than pain,” the dermatologist explained.

There are three solid, time-tested completely acceptable techniques for getting the target digit numb: the wing block, the traditional digital block, and the transthecal digital block.

Dr. Adigun said she generally relies upon the wing block unless she is concerned that the associated blanching might cause her to lose her digital landmarks during surgery addressing a subtle abnormality. In that situation she turns mainly to the traditional digital block, which doesn’t interfere with digital landmarks and effectively anesthetizes both the paired digital and volar nerves.

The downside of the traditional digital block is it entails a 15- to 20-minute wait for the anesthetic to diffuse. So does the transthecal digital block, which has the additional shortcoming of achieving predictable results only when applied for surgery on the second, third, or fourth digits.

The wing block is an efficient infiltrative technique targeting the distal digit. It offers immediate anesthesia of the total nail unit. To achieve an excellent wing block, initially inject just 0.1-0.2 mL of anesthetic fluid subcutaneously into the proximal nail fold midway between the cuticle and the distal interphalangeal joint. Wait for a wheal to form; then wait an additional 45-60 seconds. At that point, inject obliquely along the lateral edge of the nail fold in the direction of the digital tip. The needle should be advanced while maintaining a gentle fluid bolus ahead of the needle tip in order to minimize the patient’s sensation of the moving needle. The process is then repeated on the opposite side of the digit.

“You want to keep that needle in the dermal plane and avoid filling the pulp with anesthetic fluid. If you do this correctly, only one prick is felt by the patient. I very rarely have to use a full cc of anesthetic fluid when I use a wing block,” Dr. Adigun said.

If any additional needle insertions are needed, make sure they’re placed into tissue that’s already been anesthetized, she added.

Dr. Adigun reported having no financial conflicts of interest.

bjancin@frontlinemedcom.com

VANCOUVER – Achieving effective local anesthesia is the critical first step in successful nail surgery, Dr. Chris G. Adigun said at the World Congress of Dermatology.

“Always remember: Nail surgery hurts. Your patients will applaud you enthusiastically when they’re back home for your having used a long-acting anesthetic,” said Dr. Adigun, a dermatologist in group practice in Chapel Hill, N.C.

The three most widely used anesthetic agents in nail surgery are lidocaine (Xylocaine), bupivacaine (Marcaine), and ropivacaine (Naropin). Dr. Adigun said she strongly prefers ropivacaine. It combines the best features of the other two: lidocaine’s rapid onset along with a duration of action that’s even longer than bupivacaine’s, she noted. Ropivacaine’s duration of action is 8-12 hours – and it comes without bupivacaine’s potential for cardiotoxicity. Moreover, ropivacaine has a vasoconstrictive effect, which improves hemostasis and enhances visualization during the surgery.

She provided numerous additional tips on how to predictably achieve effective anesthesia for nail surgery:

• Buffer with sodium bicarbonate. The idea is to bring the anesthetic solution close to physiologic pH, which makes for a far less painful experience than injecting the acidic unbuffered solution.

• Warm it. Investigators have shown that warming anesthetic fluid reduces pain upon injection of both nonbuffered and buffered local anesthetics (Ann Emerg Med. 2011 Jul;58(1):86-98).

• Stick to a small-gauge needle. Dr. Adigan said she favors 30 gauge. It makes for a smaller, less painful puncture and limits the rate of flow of anesthetic fluid into the digital space.

• Inject in a perpendicular plane. This will disrupt fewer nerve endings than when going in at an angle.

“I think this is something that’s not frequently taught to residents in dermatology. I think we almost always go in at an angle, but if you go in at a perpendicular plane, you’re going to cause less pain,” according to Dr. Adigun.

• Inject just below the dermis. The dermis is nociceptor rich, and stretching those tissues by injecting a volume of fluid there will cause intense, continuous pain until the local anesthetic has time to take effect.

• Use distraction techniques liberally. Dr. Adigun said she likes to tell stories and jokes, which she calls “talkesthesia.” She also utilizes a battery-powered massager.

“Put the massager as close to your surgical field as you’re comfortable with. Under the gate theory of pain, you want to create as much sensory ‘noise’ as possible with your distraction techniques so that gate is filled with your sensory noise rather than pain,” the dermatologist explained.

There are three solid, time-tested completely acceptable techniques for getting the target digit numb: the wing block, the traditional digital block, and the transthecal digital block.

Dr. Adigun said she generally relies upon the wing block unless she is concerned that the associated blanching might cause her to lose her digital landmarks during surgery addressing a subtle abnormality. In that situation she turns mainly to the traditional digital block, which doesn’t interfere with digital landmarks and effectively anesthetizes both the paired digital and volar nerves.

The downside of the traditional digital block is it entails a 15- to 20-minute wait for the anesthetic to diffuse. So does the transthecal digital block, which has the additional shortcoming of achieving predictable results only when applied for surgery on the second, third, or fourth digits.

The wing block is an efficient infiltrative technique targeting the distal digit. It offers immediate anesthesia of the total nail unit. To achieve an excellent wing block, initially inject just 0.1-0.2 mL of anesthetic fluid subcutaneously into the proximal nail fold midway between the cuticle and the distal interphalangeal joint. Wait for a wheal to form; then wait an additional 45-60 seconds. At that point, inject obliquely along the lateral edge of the nail fold in the direction of the digital tip. The needle should be advanced while maintaining a gentle fluid bolus ahead of the needle tip in order to minimize the patient’s sensation of the moving needle. The process is then repeated on the opposite side of the digit.

“You want to keep that needle in the dermal plane and avoid filling the pulp with anesthetic fluid. If you do this correctly, only one prick is felt by the patient. I very rarely have to use a full cc of anesthetic fluid when I use a wing block,” Dr. Adigun said.

If any additional needle insertions are needed, make sure they’re placed into tissue that’s already been anesthetized, she added.

Dr. Adigun reported having no financial conflicts of interest.

bjancin@frontlinemedcom.com

For patients with chronic primary immune thrombocytopenia, a three-drug regimen was associated with a high response rate and relapse-free survival, according to the results of a single-arm, phase IIb trial published online in Blood.

Twenty patients with primary immune thrombocytopenia (ITP) received an investigative triple therapy of oral dexamethasone 40 mg (days 1-4), oral cyclosporine 2.5-3.0 mg/kg daily (days 1-28), and intravenous rituximab 100 mg (day 7, 14, 21, and 28), and of this group, 12 patients responded. The median time to response was 7.4 days, and all patients maintained their response for at least 7 months, Dr. Philip Young-Ill Choi, of St. George Clinical School, University of New South Wales, Kogarah, Australia, and his colleagues reported (Blood 2015;126[4]:500-3).

Complete response was 30% at 6 months, and only two patients relapsed during a median follow-up period of 17.5 months (range, 7-47 months). Among patients who responded, relapse-free survival at 12 and 24 months was 92% and 76%, respectively (95% confidence intervals, 53%-98% and 30%-93%, respectively).

Peripheral T cells declined for all patients, irrespective of response, but responders had lower CD4+ T cells than did nonresponders for 6 months after treatment (median, 0.62 vs. 0.91 x 10⁹/L; P less than .0001). Peripheral CD19+ B cells became undetectable for all patients by day 28, but recovery was earlier for patients younger than 50 years (median, 6.5 months vs. not reached; P = .0105).

The regimen was generally well tolerated, without any deaths, treatment-related serious adverse events, serum sickness, interruptions, or delays caused by toxicity.

A major advantage of this regimen is its short duration of therapy, and yet 12 of 20 patients enjoyed a prolonged remission of 7 months or longer without needing further treatment. However, interpretation of the data was limited by the small sample size, the investigators noted.

“Although our study shows encouraging results, the incremental benefit of cyclosporine to rituximab and dexamethasone remains unresolved, and randomized controlled trials are required,” they wrote.

No funding source for the study was given. One author reported receiving speaker’s fees from Roche, and another is on the speakers bureau and receives research funding from GlaxoSmithKline and Amgen. The remaining authors declared no competing financial interests.

For patients with chronic primary immune thrombocytopenia, a three-drug regimen was associated with a high response rate and relapse-free survival, according to the results of a single-arm, phase IIb trial published online in Blood.

Twenty patients with primary immune thrombocytopenia (ITP) received an investigative triple therapy of oral dexamethasone 40 mg (days 1-4), oral cyclosporine 2.5-3.0 mg/kg daily (days 1-28), and intravenous rituximab 100 mg (day 7, 14, 21, and 28), and of this group, 12 patients responded. The median time to response was 7.4 days, and all patients maintained their response for at least 7 months, Dr. Philip Young-Ill Choi, of St. George Clinical School, University of New South Wales, Kogarah, Australia, and his colleagues reported (Blood 2015;126[4]:500-3).

Complete response was 30% at 6 months, and only two patients relapsed during a median follow-up period of 17.5 months (range, 7-47 months). Among patients who responded, relapse-free survival at 12 and 24 months was 92% and 76%, respectively (95% confidence intervals, 53%-98% and 30%-93%, respectively).

Peripheral T cells declined for all patients, irrespective of response, but responders had lower CD4+ T cells than did nonresponders for 6 months after treatment (median, 0.62 vs. 0.91 x 10⁹/L; P less than .0001). Peripheral CD19+ B cells became undetectable for all patients by day 28, but recovery was earlier for patients younger than 50 years (median, 6.5 months vs. not reached; P = .0105).

The regimen was generally well tolerated, without any deaths, treatment-related serious adverse events, serum sickness, interruptions, or delays caused by toxicity.

A major advantage of this regimen is its short duration of therapy, and yet 12 of 20 patients enjoyed a prolonged remission of 7 months or longer without needing further treatment. However, interpretation of the data was limited by the small sample size, the investigators noted.

“Although our study shows encouraging results, the incremental benefit of cyclosporine to rituximab and dexamethasone remains unresolved, and randomized controlled trials are required,” they wrote.

No funding source for the study was given. One author reported receiving speaker’s fees from Roche, and another is on the speakers bureau and receives research funding from GlaxoSmithKline and Amgen. The remaining authors declared no competing financial interests.

For patients with chronic primary immune thrombocytopenia, a three-drug regimen was associated with a high response rate and relapse-free survival, according to the results of a single-arm, phase IIb trial published online in Blood.

Twenty patients with primary immune thrombocytopenia (ITP) received an investigative triple therapy of oral dexamethasone 40 mg (days 1-4), oral cyclosporine 2.5-3.0 mg/kg daily (days 1-28), and intravenous rituximab 100 mg (day 7, 14, 21, and 28), and of this group, 12 patients responded. The median time to response was 7.4 days, and all patients maintained their response for at least 7 months, Dr. Philip Young-Ill Choi, of St. George Clinical School, University of New South Wales, Kogarah, Australia, and his colleagues reported (Blood 2015;126[4]:500-3).

Complete response was 30% at 6 months, and only two patients relapsed during a median follow-up period of 17.5 months (range, 7-47 months). Among patients who responded, relapse-free survival at 12 and 24 months was 92% and 76%, respectively (95% confidence intervals, 53%-98% and 30%-93%, respectively).

Peripheral T cells declined for all patients, irrespective of response, but responders had lower CD4+ T cells than did nonresponders for 6 months after treatment (median, 0.62 vs. 0.91 x 10⁹/L; P less than .0001). Peripheral CD19+ B cells became undetectable for all patients by day 28, but recovery was earlier for patients younger than 50 years (median, 6.5 months vs. not reached; P = .0105).

The regimen was generally well tolerated, without any deaths, treatment-related serious adverse events, serum sickness, interruptions, or delays caused by toxicity.

A major advantage of this regimen is its short duration of therapy, and yet 12 of 20 patients enjoyed a prolonged remission of 7 months or longer without needing further treatment. However, interpretation of the data was limited by the small sample size, the investigators noted.

“Although our study shows encouraging results, the incremental benefit of cyclosporine to rituximab and dexamethasone remains unresolved, and randomized controlled trials are required,” they wrote.

No funding source for the study was given. One author reported receiving speaker’s fees from Roche, and another is on the speakers bureau and receives research funding from GlaxoSmithKline and Amgen. The remaining authors declared no competing financial interests.

As readers of this column know, the move to value-based payment for population health management can lead to a golden era for proactive primary care physicians. This conclusion is only strengthened by recent legislation mandating value incentives and penalties: the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), sometimes called the “SGR fix.”

This radical change, tellingly supported by both parties and both houses of Congress, would have been unthinkable just a few years ago. Under MACRA’s new Merit-Based Incentive Payment System (MIPS), you are looking at fee increases or reductions ranging from an upside of 4%-9% over time and an equal potential for reduction.

But, if you participate in a Medicare ACO or similar entity under the new alternative payment model, you get a 5% bump and are excluded from any MIPS and meaningful use requirements or penalties.

This merely adds to the growing list of incentives for primary care physician–led coordinated care. There is an extra compensation for wellness exams and chronic care management amounting to potentially more than $100,000 per primary care physician per year. Do not forget the $840 million the Centers for Medicare & Medicaid Services is designating to the Transforming Clinical Practice Initiative limited to training clinicians, and the $800 million for rural accountable care organizations (ACO) operations costs limited to physicians, critical access hospitals, and small hospitals.

Oh, by the way, all of the high-value opportunities for ACOs are in the primary care physician’s wheelhouse. Success stories of primary care–led ACOs are impressive.

A no-brainer, right? Well, apparently not for most primary care physicians. Why? This all will require change. It can be a very beneficial change of your status – measured by professional and financial reward – but it is big-time change.

As Mark Twain is quoted as saying, “I’m all for progress; it’s change I object to.”

You have not been in such a position of influence before, you don’t have teams of advisors like others in health care, and you don’t have the experience for this. You do not have spare intellectual bandwidth to deal with this and everything else. You are accustomed to things being run by the big health systems and managed care companies.

It is human nature to deal with stress with the survivalist instincts of fight, flight, or freeze. You may be feeling an almost irresistible urge to hunker down and do nothing. It’s natural. It is your “default future.”

But being unprepared is not an option. This shift is coming inexorably and rapidly. You can either stay sitting on the tracks or drive the train. It’s up to you.

Your default future is one controlled by others. It is one of the missed opportunity of a lifetime for primary care. The government is paying you for training, ACO start-up and operations, and incentivizing your leadership through both coding- and value-based financial inducements.

The bottom line is that America is asking you to run the new health care system and wants to pay you to do it, on top of your fee-for-service payments.

Think of the impact on your patients. Isn’t this why you went to medical school? Failure to do anything means you actually have made a bigger choice for your default future – guaranteeing even greater change being imposed on you by others. Control your agenda; do not wait to become part of someone else’s.

In closing, a recent email comment by one of your fellow readers sums it up best: “The default future (or the ostrich option) is a destiny of marginalization and consumption by the beast, an outcome not in our patients’ best interest.”

Mr. Bobbitt is a senior partner and head of the health law group at the Smith Anderson law firm in Raleigh, N.C. He has many years’ experience assisting physicians form integrated delivery systems. He has spoken and written nationally to primary care physicians on the strategies and practicalities of forming or joining ACOs. This article is meant to be educational and does not constitute legal advice. For additional information, readers may contact the author at bbobbitt@smithlaw.com or 919-821-6612.

As readers of this column know, the move to value-based payment for population health management can lead to a golden era for proactive primary care physicians. This conclusion is only strengthened by recent legislation mandating value incentives and penalties: the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), sometimes called the “SGR fix.”

This radical change, tellingly supported by both parties and both houses of Congress, would have been unthinkable just a few years ago. Under MACRA’s new Merit-Based Incentive Payment System (MIPS), you are looking at fee increases or reductions ranging from an upside of 4%-9% over time and an equal potential for reduction.

But, if you participate in a Medicare ACO or similar entity under the new alternative payment model, you get a 5% bump and are excluded from any MIPS and meaningful use requirements or penalties.

This merely adds to the growing list of incentives for primary care physician–led coordinated care. There is an extra compensation for wellness exams and chronic care management amounting to potentially more than $100,000 per primary care physician per year. Do not forget the $840 million the Centers for Medicare & Medicaid Services is designating to the Transforming Clinical Practice Initiative limited to training clinicians, and the $800 million for rural accountable care organizations (ACO) operations costs limited to physicians, critical access hospitals, and small hospitals.

Oh, by the way, all of the high-value opportunities for ACOs are in the primary care physician’s wheelhouse. Success stories of primary care–led ACOs are impressive.

A no-brainer, right? Well, apparently not for most primary care physicians. Why? This all will require change. It can be a very beneficial change of your status – measured by professional and financial reward – but it is big-time change.

As Mark Twain is quoted as saying, “I’m all for progress; it’s change I object to.”

You have not been in such a position of influence before, you don’t have teams of advisors like others in health care, and you don’t have the experience for this. You do not have spare intellectual bandwidth to deal with this and everything else. You are accustomed to things being run by the big health systems and managed care companies.

It is human nature to deal with stress with the survivalist instincts of fight, flight, or freeze. You may be feeling an almost irresistible urge to hunker down and do nothing. It’s natural. It is your “default future.”

But being unprepared is not an option. This shift is coming inexorably and rapidly. You can either stay sitting on the tracks or drive the train. It’s up to you.

Your default future is one controlled by others. It is one of the missed opportunity of a lifetime for primary care. The government is paying you for training, ACO start-up and operations, and incentivizing your leadership through both coding- and value-based financial inducements.

The bottom line is that America is asking you to run the new health care system and wants to pay you to do it, on top of your fee-for-service payments.

Think of the impact on your patients. Isn’t this why you went to medical school? Failure to do anything means you actually have made a bigger choice for your default future – guaranteeing even greater change being imposed on you by others. Control your agenda; do not wait to become part of someone else’s.

In closing, a recent email comment by one of your fellow readers sums it up best: “The default future (or the ostrich option) is a destiny of marginalization and consumption by the beast, an outcome not in our patients’ best interest.”

Mr. Bobbitt is a senior partner and head of the health law group at the Smith Anderson law firm in Raleigh, N.C. He has many years’ experience assisting physicians form integrated delivery systems. He has spoken and written nationally to primary care physicians on the strategies and practicalities of forming or joining ACOs. This article is meant to be educational and does not constitute legal advice. For additional information, readers may contact the author at bbobbitt@smithlaw.com or 919-821-6612.

As readers of this column know, the move to value-based payment for population health management can lead to a golden era for proactive primary care physicians. This conclusion is only strengthened by recent legislation mandating value incentives and penalties: the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), sometimes called the “SGR fix.”

This radical change, tellingly supported by both parties and both houses of Congress, would have been unthinkable just a few years ago. Under MACRA’s new Merit-Based Incentive Payment System (MIPS), you are looking at fee increases or reductions ranging from an upside of 4%-9% over time and an equal potential for reduction.

But, if you participate in a Medicare ACO or similar entity under the new alternative payment model, you get a 5% bump and are excluded from any MIPS and meaningful use requirements or penalties.

This merely adds to the growing list of incentives for primary care physician–led coordinated care. There is an extra compensation for wellness exams and chronic care management amounting to potentially more than $100,000 per primary care physician per year. Do not forget the $840 million the Centers for Medicare & Medicaid Services is designating to the Transforming Clinical Practice Initiative limited to training clinicians, and the $800 million for rural accountable care organizations (ACO) operations costs limited to physicians, critical access hospitals, and small hospitals.

Oh, by the way, all of the high-value opportunities for ACOs are in the primary care physician’s wheelhouse. Success stories of primary care–led ACOs are impressive.

A no-brainer, right? Well, apparently not for most primary care physicians. Why? This all will require change. It can be a very beneficial change of your status – measured by professional and financial reward – but it is big-time change.

As Mark Twain is quoted as saying, “I’m all for progress; it’s change I object to.”

You have not been in such a position of influence before, you don’t have teams of advisors like others in health care, and you don’t have the experience for this. You do not have spare intellectual bandwidth to deal with this and everything else. You are accustomed to things being run by the big health systems and managed care companies.

It is human nature to deal with stress with the survivalist instincts of fight, flight, or freeze. You may be feeling an almost irresistible urge to hunker down and do nothing. It’s natural. It is your “default future.”

But being unprepared is not an option. This shift is coming inexorably and rapidly. You can either stay sitting on the tracks or drive the train. It’s up to you.

Your default future is one controlled by others. It is one of the missed opportunity of a lifetime for primary care. The government is paying you for training, ACO start-up and operations, and incentivizing your leadership through both coding- and value-based financial inducements.

The bottom line is that America is asking you to run the new health care system and wants to pay you to do it, on top of your fee-for-service payments.

Think of the impact on your patients. Isn’t this why you went to medical school? Failure to do anything means you actually have made a bigger choice for your default future – guaranteeing even greater change being imposed on you by others. Control your agenda; do not wait to become part of someone else’s.

In closing, a recent email comment by one of your fellow readers sums it up best: “The default future (or the ostrich option) is a destiny of marginalization and consumption by the beast, an outcome not in our patients’ best interest.”

Mr. Bobbitt is a senior partner and head of the health law group at the Smith Anderson law firm in Raleigh, N.C. He has many years’ experience assisting physicians form integrated delivery systems. He has spoken and written nationally to primary care physicians on the strategies and practicalities of forming or joining ACOs. This article is meant to be educational and does not constitute legal advice. For additional information, readers may contact the author at bbobbitt@smithlaw.com or 919-821-6612.