Previously, I introduced the topic of self-care for patients with diabetes to prevent complications. Now let’s explore how to help reduce risk for cardiovascular conditions in these patients, starting with blood pressure control.

CASE CONTINUED

Mr. W’s vitals include a heart rate of 82; BP, 150/86 mm Hg; and O2 saturation, 98%. He is afebrile. You consider how to best manage glucose control and reduce the risk for cardiovascular conditions.

Reducing the Risk for Cardiovascular Conditions

The ADA recommends at least annual systematic assessment of cardiovascular risk factors, including weight, hypertension, dyslipidemia, chronic kidney disease (CKD), and presence of albuminuria.² Managing these conditions to the standards supported by currently available evidence should reduce the risk for ASCVD in patients such as Mr. W. Two newer medication classes—glucagon-like peptide-1 receptor agonists and sodium-glucose cotransporter-2 inhibitors—offer potential benefit in reducing cardiovascular risk.^15,16 Consider these medications for patients with diabetes or known ASCVD or for those who are at high risk for ASCVD and/or CKD.^2,7

Furthermore, the ADA recommends using a risk calculator, such as the ASCVD Risk Estimator Plus created by the American College of Cardiology/American Heart Association (see http://tools.acc.org/ASCVD-Risk-Estimator-Plus), to stratify the 10-year risk for a first ASCVD event.2 This calculator can produce results that can help guide an individualized risk-reduction treatment plan for each patient. Also, consider low-dose aspirin for primary prevention in those at high risk for ASCVD (10-year risk > 10%) and for secondary prevention of ASCVD in those who have already had a cardiovascular event.^2,7

Setting and Meeting BP Goals

Hypertension is common in patients with diabetes, with a recent study suggesting that ≥ 67% of these patients have elevated BP.¹⁷ Significant evidence demonstrates that BP control reduces morbidity and mortality in diabetes.¹⁸ Although the importance of BP control in this setting is widely known, recent studies have demonstrated that only 30% to 42% of affected patients meet their BP goals.^19,20

How to make a BP goal. Guideline recommendations for setting specific BP goals have varied slightly over the past several years and are influenced by known comorbidities such as ASCVD and CKD. Patients should be part of the decision-making process to individualize goals based on their circumstances and safety. A BP goal of < 130/80 mm Hg is generally acceptable for patients who are known to have ASCVD or who are at high risk (≥ 15% risk) for ASCVD in the next 10 years.⁷ A goal of < 140/90 mm Hg is considered appropriate in those with a lower risk for ASCVD.^7,8,21,22

Medications. Selecting an appropriate antihypertensive medication relies on multiple factors. Evidence supports the use of angiotensin-converting enzyme inhibitors and angiotensin II receptor blockers for diabetes, and both the AACE and ADA recommend these medications as an initial treatment option.^2,7 They help reduce the progression of kidney disease in patients with albuminuria and may improve cardiovascular outcomes.^23-27 When additional agents are needed to meet BP goals, the ADA recommends thiazide-like diuretics (chlorthalidone and indapamide) or calcium channel blockers (dihydropyridine).² Although some hyperglycemic adverse effects have been observed with use of thiazide-like diuretics, these might be outweighed by the benefit of BP control.²⁴

Continue to: Monitor the patient's BP

Monitor the patient’s BP at every visit, and advise the patient to regularly measure his or her BP at home with a BP cuff. Patients who may need assistance with at-home monitoring can be directed to an online guide on how to accurately measure their BP (see www.heart.org/en/health-topics/high-blood-pressure/understanding-blood-pressure-readings/monitoring-your-blood-pressure-at-home). For those who report consistently above-goal measurements at home, advise them to check their BP cuff, because an ill-fitting cuff is a well-known cause of inaccurate measurement. Patients also should be assessed for medication nonadherence, white coat hypertension, and secondary hypertension.^7,8 If a patient’s BP is truly above goal, a step-up in therapy may be appropriate because without adequate BP control, the benefit in mortality and morbidity may not be fully realized.²⁸

In Part 3, we’ll check in with Mr. W and discuss which patients require assessment for dyslipidemia. We’ll also explore the treatments, such as statin therapy, for this condition.

Previously, I introduced the topic of self-care for patients with diabetes to prevent complications. Now let’s explore how to help reduce risk for cardiovascular conditions in these patients, starting with blood pressure control.

CASE CONTINUED

Mr. W’s vitals include a heart rate of 82; BP, 150/86 mm Hg; and O2 saturation, 98%. He is afebrile. You consider how to best manage glucose control and reduce the risk for cardiovascular conditions.

Reducing the Risk for Cardiovascular Conditions

The ADA recommends at least annual systematic assessment of cardiovascular risk factors, including weight, hypertension, dyslipidemia, chronic kidney disease (CKD), and presence of albuminuria.² Managing these conditions to the standards supported by currently available evidence should reduce the risk for ASCVD in patients such as Mr. W. Two newer medication classes—glucagon-like peptide-1 receptor agonists and sodium-glucose cotransporter-2 inhibitors—offer potential benefit in reducing cardiovascular risk.^15,16 Consider these medications for patients with diabetes or known ASCVD or for those who are at high risk for ASCVD and/or CKD.^2,7

Furthermore, the ADA recommends using a risk calculator, such as the ASCVD Risk Estimator Plus created by the American College of Cardiology/American Heart Association (see http://tools.acc.org/ASCVD-Risk-Estimator-Plus), to stratify the 10-year risk for a first ASCVD event.2 This calculator can produce results that can help guide an individualized risk-reduction treatment plan for each patient. Also, consider low-dose aspirin for primary prevention in those at high risk for ASCVD (10-year risk > 10%) and for secondary prevention of ASCVD in those who have already had a cardiovascular event.^2,7

Setting and Meeting BP Goals

Hypertension is common in patients with diabetes, with a recent study suggesting that ≥ 67% of these patients have elevated BP.¹⁷ Significant evidence demonstrates that BP control reduces morbidity and mortality in diabetes.¹⁸ Although the importance of BP control in this setting is widely known, recent studies have demonstrated that only 30% to 42% of affected patients meet their BP goals.^19,20

How to make a BP goal. Guideline recommendations for setting specific BP goals have varied slightly over the past several years and are influenced by known comorbidities such as ASCVD and CKD. Patients should be part of the decision-making process to individualize goals based on their circumstances and safety. A BP goal of < 130/80 mm Hg is generally acceptable for patients who are known to have ASCVD or who are at high risk (≥ 15% risk) for ASCVD in the next 10 years.⁷ A goal of < 140/90 mm Hg is considered appropriate in those with a lower risk for ASCVD.^7,8,21,22

Medications. Selecting an appropriate antihypertensive medication relies on multiple factors. Evidence supports the use of angiotensin-converting enzyme inhibitors and angiotensin II receptor blockers for diabetes, and both the AACE and ADA recommend these medications as an initial treatment option.^2,7 They help reduce the progression of kidney disease in patients with albuminuria and may improve cardiovascular outcomes.^23-27 When additional agents are needed to meet BP goals, the ADA recommends thiazide-like diuretics (chlorthalidone and indapamide) or calcium channel blockers (dihydropyridine).² Although some hyperglycemic adverse effects have been observed with use of thiazide-like diuretics, these might be outweighed by the benefit of BP control.²⁴

Continue to: Monitor the patient's BP

Monitor the patient’s BP at every visit, and advise the patient to regularly measure his or her BP at home with a BP cuff. Patients who may need assistance with at-home monitoring can be directed to an online guide on how to accurately measure their BP (see www.heart.org/en/health-topics/high-blood-pressure/understanding-blood-pressure-readings/monitoring-your-blood-pressure-at-home). For those who report consistently above-goal measurements at home, advise them to check their BP cuff, because an ill-fitting cuff is a well-known cause of inaccurate measurement. Patients also should be assessed for medication nonadherence, white coat hypertension, and secondary hypertension.^7,8 If a patient’s BP is truly above goal, a step-up in therapy may be appropriate because without adequate BP control, the benefit in mortality and morbidity may not be fully realized.²⁸

In Part 3, we’ll check in with Mr. W and discuss which patients require assessment for dyslipidemia. We’ll also explore the treatments, such as statin therapy, for this condition.

Previously, I introduced the topic of self-care for patients with diabetes to prevent complications. Now let’s explore how to help reduce risk for cardiovascular conditions in these patients, starting with blood pressure control.

CASE CONTINUED

Mr. W’s vitals include a heart rate of 82; BP, 150/86 mm Hg; and O2 saturation, 98%. He is afebrile. You consider how to best manage glucose control and reduce the risk for cardiovascular conditions.

Reducing the Risk for Cardiovascular Conditions

The ADA recommends at least annual systematic assessment of cardiovascular risk factors, including weight, hypertension, dyslipidemia, chronic kidney disease (CKD), and presence of albuminuria.² Managing these conditions to the standards supported by currently available evidence should reduce the risk for ASCVD in patients such as Mr. W. Two newer medication classes—glucagon-like peptide-1 receptor agonists and sodium-glucose cotransporter-2 inhibitors—offer potential benefit in reducing cardiovascular risk.^15,16 Consider these medications for patients with diabetes or known ASCVD or for those who are at high risk for ASCVD and/or CKD.^2,7

Furthermore, the ADA recommends using a risk calculator, such as the ASCVD Risk Estimator Plus created by the American College of Cardiology/American Heart Association (see http://tools.acc.org/ASCVD-Risk-Estimator-Plus), to stratify the 10-year risk for a first ASCVD event.2 This calculator can produce results that can help guide an individualized risk-reduction treatment plan for each patient. Also, consider low-dose aspirin for primary prevention in those at high risk for ASCVD (10-year risk > 10%) and for secondary prevention of ASCVD in those who have already had a cardiovascular event.^2,7

Setting and Meeting BP Goals

Hypertension is common in patients with diabetes, with a recent study suggesting that ≥ 67% of these patients have elevated BP.¹⁷ Significant evidence demonstrates that BP control reduces morbidity and mortality in diabetes.¹⁸ Although the importance of BP control in this setting is widely known, recent studies have demonstrated that only 30% to 42% of affected patients meet their BP goals.^19,20

How to make a BP goal. Guideline recommendations for setting specific BP goals have varied slightly over the past several years and are influenced by known comorbidities such as ASCVD and CKD. Patients should be part of the decision-making process to individualize goals based on their circumstances and safety. A BP goal of < 130/80 mm Hg is generally acceptable for patients who are known to have ASCVD or who are at high risk (≥ 15% risk) for ASCVD in the next 10 years.⁷ A goal of < 140/90 mm Hg is considered appropriate in those with a lower risk for ASCVD.^7,8,21,22

Medications. Selecting an appropriate antihypertensive medication relies on multiple factors. Evidence supports the use of angiotensin-converting enzyme inhibitors and angiotensin II receptor blockers for diabetes, and both the AACE and ADA recommend these medications as an initial treatment option.^2,7 They help reduce the progression of kidney disease in patients with albuminuria and may improve cardiovascular outcomes.^23-27 When additional agents are needed to meet BP goals, the ADA recommends thiazide-like diuretics (chlorthalidone and indapamide) or calcium channel blockers (dihydropyridine).² Although some hyperglycemic adverse effects have been observed with use of thiazide-like diuretics, these might be outweighed by the benefit of BP control.²⁴

Continue to: Monitor the patient's BP

Monitor the patient’s BP at every visit, and advise the patient to regularly measure his or her BP at home with a BP cuff. Patients who may need assistance with at-home monitoring can be directed to an online guide on how to accurately measure their BP (see www.heart.org/en/health-topics/high-blood-pressure/understanding-blood-pressure-readings/monitoring-your-blood-pressure-at-home). For those who report consistently above-goal measurements at home, advise them to check their BP cuff, because an ill-fitting cuff is a well-known cause of inaccurate measurement. Patients also should be assessed for medication nonadherence, white coat hypertension, and secondary hypertension.^7,8 If a patient’s BP is truly above goal, a step-up in therapy may be appropriate because without adequate BP control, the benefit in mortality and morbidity may not be fully realized.²⁸

In Part 3, we’ll check in with Mr. W and discuss which patients require assessment for dyslipidemia. We’ll also explore the treatments, such as statin therapy, for this condition.

Dear colleagues,

I have the privilege and honor to serve as AGA president as of June 1, 2020. When we look back at the first half of 2020, we will remember the COVID-19 pandemic and the unimaginable loss of life, morbidity, and economic impact it had. We will also remember the grief and anger that have characterized the recent weeks. I hope that the second half of 2020 will be a time that reshapes us for the better and allows us to seize the opportunity to make meaningful changes, in addition to recovering from the impact of the pandemic. The ongoing protests for the past 16 days against police brutality finally have our country recognizing front-and-center injustices facing African Americans.

While recognition of an injustice is a start, it is essentially meaningless unless action is taken to ensure equity in all facets of society. Of particular interest to AGA is access to health care without bias, addressing racial disparities in health care, diversity within the practice of GI, and supporting the careers of diverse researchers. AGA has a diversity policy and a solid history of programs supporting minority physicians and researchers. We know that’s not enough and AGA, with our dedicated committees, staff, and leadership, will continue to implement and assess plans for meaningful improvements. Watch for more on this topic in the future.

In addition, AGA took a pledge with our GI sister organizations to “continue to advocate for diversity in our staff and governance, grant awards to research health care disparities, ensure quality care for all, and work tirelessly to reduce inequalities in health care delivery and access.” We plan to honor this pledge with our own efforts and by making a concerted effort to work with AASLD, ACG, ASGE, DHPA, and other societies, colleagues, and friends.

The COVID-19 pandemic has been a major challenge for our practices and to our research community. To all AGA members, please know that we have your back with a stream of practice guidance, business support, advocacy, and funding. You can find these resources collected at www.gastro.org/COVID.

My special thanks to the following AGA members, among several AGA staff and expert participants, for making these resources possible and highly engaging:

• Maria Abreu, who oversees our weekly COVID Connection webinar.
• Shahnaz Sultan and Joseph Lim whose Guidelines and Clinical Practice Update committees have generated evidence-based practice guidance at an incredible pace.
• Vivek Kaul and Vijay Shah who lead regular townhall webinars with division chiefs to share how GI divisions are pivoting to address the numerous current challenges.
• Rhonda Souza, chair of AGA Council, which is already thinking about how to make DDW 2021 a success.

Throughout my time as AGA president, I plan to communicate with you on a regular basis and welcome your input and suggestions. Watch the AGA Community for updates and announcements. Every other month, I plan to host a Townhall with the AGA President webinar on Zoom, where we can gather to hear from AGA leaders and staff on their work. My first webinar is planned for July 10, 2020, at 11 a.m. United States Eastern time. Watch for more info to come.

My goals are to build on what past president Hashem El-Serag has initiated and to work closely with John Inadomi (president-elect), John Carethers (vice president), the AGA Governing Board, committees, and staff. Along these lines, we will work tirelessly to support AGA domestic and international members and the gastroenterology community needs, be it patient care and those who provide the care, basic and clinical scientific discovery, education and training, advocacy, and ABIM recertification. I look forward to working with you and for you throughout the year.

Sincerely,
Bishr Omary, MD, PhD, AGAF
AGA Institute President

Dear colleagues,

I have the privilege and honor to serve as AGA president as of June 1, 2020. When we look back at the first half of 2020, we will remember the COVID-19 pandemic and the unimaginable loss of life, morbidity, and economic impact it had. We will also remember the grief and anger that have characterized the recent weeks. I hope that the second half of 2020 will be a time that reshapes us for the better and allows us to seize the opportunity to make meaningful changes, in addition to recovering from the impact of the pandemic. The ongoing protests for the past 16 days against police brutality finally have our country recognizing front-and-center injustices facing African Americans.

While recognition of an injustice is a start, it is essentially meaningless unless action is taken to ensure equity in all facets of society. Of particular interest to AGA is access to health care without bias, addressing racial disparities in health care, diversity within the practice of GI, and supporting the careers of diverse researchers. AGA has a diversity policy and a solid history of programs supporting minority physicians and researchers. We know that’s not enough and AGA, with our dedicated committees, staff, and leadership, will continue to implement and assess plans for meaningful improvements. Watch for more on this topic in the future.

In addition, AGA took a pledge with our GI sister organizations to “continue to advocate for diversity in our staff and governance, grant awards to research health care disparities, ensure quality care for all, and work tirelessly to reduce inequalities in health care delivery and access.” We plan to honor this pledge with our own efforts and by making a concerted effort to work with AASLD, ACG, ASGE, DHPA, and other societies, colleagues, and friends.

The COVID-19 pandemic has been a major challenge for our practices and to our research community. To all AGA members, please know that we have your back with a stream of practice guidance, business support, advocacy, and funding. You can find these resources collected at www.gastro.org/COVID.

My special thanks to the following AGA members, among several AGA staff and expert participants, for making these resources possible and highly engaging:

• Maria Abreu, who oversees our weekly COVID Connection webinar.
• Shahnaz Sultan and Joseph Lim whose Guidelines and Clinical Practice Update committees have generated evidence-based practice guidance at an incredible pace.
• Vivek Kaul and Vijay Shah who lead regular townhall webinars with division chiefs to share how GI divisions are pivoting to address the numerous current challenges.
• Rhonda Souza, chair of AGA Council, which is already thinking about how to make DDW 2021 a success.

Throughout my time as AGA president, I plan to communicate with you on a regular basis and welcome your input and suggestions. Watch the AGA Community for updates and announcements. Every other month, I plan to host a Townhall with the AGA President webinar on Zoom, where we can gather to hear from AGA leaders and staff on their work. My first webinar is planned for July 10, 2020, at 11 a.m. United States Eastern time. Watch for more info to come.

My goals are to build on what past president Hashem El-Serag has initiated and to work closely with John Inadomi (president-elect), John Carethers (vice president), the AGA Governing Board, committees, and staff. Along these lines, we will work tirelessly to support AGA domestic and international members and the gastroenterology community needs, be it patient care and those who provide the care, basic and clinical scientific discovery, education and training, advocacy, and ABIM recertification. I look forward to working with you and for you throughout the year.

Sincerely,
Bishr Omary, MD, PhD, AGAF
AGA Institute President

Dear colleagues,

I have the privilege and honor to serve as AGA president as of June 1, 2020. When we look back at the first half of 2020, we will remember the COVID-19 pandemic and the unimaginable loss of life, morbidity, and economic impact it had. We will also remember the grief and anger that have characterized the recent weeks. I hope that the second half of 2020 will be a time that reshapes us for the better and allows us to seize the opportunity to make meaningful changes, in addition to recovering from the impact of the pandemic. The ongoing protests for the past 16 days against police brutality finally have our country recognizing front-and-center injustices facing African Americans.

While recognition of an injustice is a start, it is essentially meaningless unless action is taken to ensure equity in all facets of society. Of particular interest to AGA is access to health care without bias, addressing racial disparities in health care, diversity within the practice of GI, and supporting the careers of diverse researchers. AGA has a diversity policy and a solid history of programs supporting minority physicians and researchers. We know that’s not enough and AGA, with our dedicated committees, staff, and leadership, will continue to implement and assess plans for meaningful improvements. Watch for more on this topic in the future.

In addition, AGA took a pledge with our GI sister organizations to “continue to advocate for diversity in our staff and governance, grant awards to research health care disparities, ensure quality care for all, and work tirelessly to reduce inequalities in health care delivery and access.” We plan to honor this pledge with our own efforts and by making a concerted effort to work with AASLD, ACG, ASGE, DHPA, and other societies, colleagues, and friends.

The COVID-19 pandemic has been a major challenge for our practices and to our research community. To all AGA members, please know that we have your back with a stream of practice guidance, business support, advocacy, and funding. You can find these resources collected at www.gastro.org/COVID.

My special thanks to the following AGA members, among several AGA staff and expert participants, for making these resources possible and highly engaging:

• Maria Abreu, who oversees our weekly COVID Connection webinar.
• Shahnaz Sultan and Joseph Lim whose Guidelines and Clinical Practice Update committees have generated evidence-based practice guidance at an incredible pace.
• Vivek Kaul and Vijay Shah who lead regular townhall webinars with division chiefs to share how GI divisions are pivoting to address the numerous current challenges.
• Rhonda Souza, chair of AGA Council, which is already thinking about how to make DDW 2021 a success.

Throughout my time as AGA president, I plan to communicate with you on a regular basis and welcome your input and suggestions. Watch the AGA Community for updates and announcements. Every other month, I plan to host a Townhall with the AGA President webinar on Zoom, where we can gather to hear from AGA leaders and staff on their work. My first webinar is planned for July 10, 2020, at 11 a.m. United States Eastern time. Watch for more info to come.

My goals are to build on what past president Hashem El-Serag has initiated and to work closely with John Inadomi (president-elect), John Carethers (vice president), the AGA Governing Board, committees, and staff. Along these lines, we will work tirelessly to support AGA domestic and international members and the gastroenterology community needs, be it patient care and those who provide the care, basic and clinical scientific discovery, education and training, advocacy, and ABIM recertification. I look forward to working with you and for you throughout the year.

Sincerely,
Bishr Omary, MD, PhD, AGAF
AGA Institute President

Author’s note: In December 2018, Atlanta Gastroenterology Associates partnered with Frazier Healthcare Partners to form the practice management company United Digestive (UD). Since that time, colleagues across the country have evaluated their own private equity prospects and partnerships, as well as monitored the progress of our transition.

So how are things going? Enjoy part two of this two-part article where we reached out to several team members from all levels within the organization and asked them to share their personal experiences – both highlights and challenges – during UD’s first year.

Did you miss Part 1? Don’t worry, you can read Part 1 here (https://www.mdedge.com/gihepnews/practice-management-toolbox).

There are several private equity–backed GI practice management groups across the country. Why did you and your colleagues decide to partner with UD last year, and, how is the relationship going to date?
Mark Murphy, MD, UD Physician Executive Committee Member Center for Digestive and Liver Health in Savannah, Ga.

• “We previously investigated other partnerships but felt they really did not bring enough value to make our group stronger or more viable. United Digestive was different. The idea of partnering with like-minded gastroenterologists to become a larger, single-specialty entity, with contract negotiation leverage and economies of scale was appealing and would not be possible as a 10-person group. Further, the partnership represented an opportunity to eliminate debt, minimize future risk to younger partners, and yet also embrace an ability to add new services and physicians.

“There were expected hiccups in the beginning: specifically IT and HR issues, which were remedied appropriately and timely. One month after the partnership was completed, reports started coming out of China about a new viral illness – an illness that telescoped our perspective on the consequences of our decision into a timeline of months rather than years.

“UD’s response to the COVID-19 epidemic has been phenomenal. The organization made the tough, but proper clinical calls that limited risks to patients and staff. They came up with a game plan to salvage fiscal viability – rolling out telemedicine in a matter of days and establishing the manner in which patients with high acuity could still be seen and cared for expediently.

“As a solo GI practice, we would have struggled mightily to survive and might have gone bankrupt. Had we been part of a larger non-GI entity (a hospital or multispecialty group), we might have been pressured to engage in unsafe or unethical practices and not consistent with national societal recommendations. Instead, we found ourselves having active discussions with our GI colleagues about the right path forward.”

How do you feel UD has helped improve the quality of patient care and positively impacted patient satisfaction?
Aja McCutchen, MD

• “Prior to UD, we worked diligently to improve our centralized patient service center, phone trees, and optimize the time and communication between patients, providers, and our staff. We now have tools which help identify and track gaps in communication on all levels. We have been able to improve our MA work flow, shorten wait times, and improve the direct dialogue between our practice and our patients. We have also been able to enhance our ancillary service offerings and expand programs that directly benefit our patients.”

Kimberly Orleck, PA-C

• “I think our quality of care has always been top notch and that thankfully has not been altered. UD has concentrated on workflow optimization, enhanced training to our frontline teams, and improved scheduled processes to decrease patient wait time. UD is also paying closer attention to patient ratings, reviews, and calculating net promotor scores. ”

Have there been any initiatives in the first year which improved the management of the organization?
Elizabeth Escalante, Senior Regional Director of Operations, UD

• “Implementation of a business analytics tool was huge this year. It greatly improved visibility into the information we need to have at our fingertips in order to make data-driven decisions for our business. Drilling this down to the frontline manager has increased our understanding of what it truly takes to run a successful practice, and in turn, increased stakeholder buy-in.”

Lakeeta White, Clinical Office Team Lead, and Alexis Sweeney, Medical Assistant

• “The formation of our MA Advisory Committee has been instrumental in helping standardize best practices across the organization. It is comprised of medical assistants across our geographic footprint, and they provide feedback to the management team regarding process improvements, areas for continued training, and more.”

Though many positives may arise out of change, so can some challenges. Have there been any unforeseen hurdles you experience as a result of the new partnership with PE?
Elizabeth Escalante

• “Overall, I believe the changes to the structure of the practice and reorganization of leadership has been positive. As with any organization, one area of improvement is in communication.”

Dr. Patel and Dr. Sonenshine are with Atlanta Gastroenterology Associates, which is part of United Digestive. They have no conflicts.

Author’s note: In December 2018, Atlanta Gastroenterology Associates partnered with Frazier Healthcare Partners to form the practice management company United Digestive (UD). Since that time, colleagues across the country have evaluated their own private equity prospects and partnerships, as well as monitored the progress of our transition.

So how are things going? Enjoy part two of this two-part article where we reached out to several team members from all levels within the organization and asked them to share their personal experiences – both highlights and challenges – during UD’s first year.

Did you miss Part 1? Don’t worry, you can read Part 1 here (https://www.mdedge.com/gihepnews/practice-management-toolbox).

There are several private equity–backed GI practice management groups across the country. Why did you and your colleagues decide to partner with UD last year, and, how is the relationship going to date?
Mark Murphy, MD, UD Physician Executive Committee Member Center for Digestive and Liver Health in Savannah, Ga.

• “We previously investigated other partnerships but felt they really did not bring enough value to make our group stronger or more viable. United Digestive was different. The idea of partnering with like-minded gastroenterologists to become a larger, single-specialty entity, with contract negotiation leverage and economies of scale was appealing and would not be possible as a 10-person group. Further, the partnership represented an opportunity to eliminate debt, minimize future risk to younger partners, and yet also embrace an ability to add new services and physicians.

“There were expected hiccups in the beginning: specifically IT and HR issues, which were remedied appropriately and timely. One month after the partnership was completed, reports started coming out of China about a new viral illness – an illness that telescoped our perspective on the consequences of our decision into a timeline of months rather than years.

“UD’s response to the COVID-19 epidemic has been phenomenal. The organization made the tough, but proper clinical calls that limited risks to patients and staff. They came up with a game plan to salvage fiscal viability – rolling out telemedicine in a matter of days and establishing the manner in which patients with high acuity could still be seen and cared for expediently.

“As a solo GI practice, we would have struggled mightily to survive and might have gone bankrupt. Had we been part of a larger non-GI entity (a hospital or multispecialty group), we might have been pressured to engage in unsafe or unethical practices and not consistent with national societal recommendations. Instead, we found ourselves having active discussions with our GI colleagues about the right path forward.”

How do you feel UD has helped improve the quality of patient care and positively impacted patient satisfaction?
Aja McCutchen, MD

• “Prior to UD, we worked diligently to improve our centralized patient service center, phone trees, and optimize the time and communication between patients, providers, and our staff. We now have tools which help identify and track gaps in communication on all levels. We have been able to improve our MA work flow, shorten wait times, and improve the direct dialogue between our practice and our patients. We have also been able to enhance our ancillary service offerings and expand programs that directly benefit our patients.”

Kimberly Orleck, PA-C

• “I think our quality of care has always been top notch and that thankfully has not been altered. UD has concentrated on workflow optimization, enhanced training to our frontline teams, and improved scheduled processes to decrease patient wait time. UD is also paying closer attention to patient ratings, reviews, and calculating net promotor scores. ”

Have there been any initiatives in the first year which improved the management of the organization?
Elizabeth Escalante, Senior Regional Director of Operations, UD

• “Implementation of a business analytics tool was huge this year. It greatly improved visibility into the information we need to have at our fingertips in order to make data-driven decisions for our business. Drilling this down to the frontline manager has increased our understanding of what it truly takes to run a successful practice, and in turn, increased stakeholder buy-in.”

Lakeeta White, Clinical Office Team Lead, and Alexis Sweeney, Medical Assistant

• “The formation of our MA Advisory Committee has been instrumental in helping standardize best practices across the organization. It is comprised of medical assistants across our geographic footprint, and they provide feedback to the management team regarding process improvements, areas for continued training, and more.”

Though many positives may arise out of change, so can some challenges. Have there been any unforeseen hurdles you experience as a result of the new partnership with PE?
Elizabeth Escalante

• “Overall, I believe the changes to the structure of the practice and reorganization of leadership has been positive. As with any organization, one area of improvement is in communication.”

Dr. Patel and Dr. Sonenshine are with Atlanta Gastroenterology Associates, which is part of United Digestive. They have no conflicts.

Author’s note: In December 2018, Atlanta Gastroenterology Associates partnered with Frazier Healthcare Partners to form the practice management company United Digestive (UD). Since that time, colleagues across the country have evaluated their own private equity prospects and partnerships, as well as monitored the progress of our transition.

So how are things going? Enjoy part two of this two-part article where we reached out to several team members from all levels within the organization and asked them to share their personal experiences – both highlights and challenges – during UD’s first year.

Did you miss Part 1? Don’t worry, you can read Part 1 here (https://www.mdedge.com/gihepnews/practice-management-toolbox).

There are several private equity–backed GI practice management groups across the country. Why did you and your colleagues decide to partner with UD last year, and, how is the relationship going to date?
Mark Murphy, MD, UD Physician Executive Committee Member Center for Digestive and Liver Health in Savannah, Ga.

• “We previously investigated other partnerships but felt they really did not bring enough value to make our group stronger or more viable. United Digestive was different. The idea of partnering with like-minded gastroenterologists to become a larger, single-specialty entity, with contract negotiation leverage and economies of scale was appealing and would not be possible as a 10-person group. Further, the partnership represented an opportunity to eliminate debt, minimize future risk to younger partners, and yet also embrace an ability to add new services and physicians.

“There were expected hiccups in the beginning: specifically IT and HR issues, which were remedied appropriately and timely. One month after the partnership was completed, reports started coming out of China about a new viral illness – an illness that telescoped our perspective on the consequences of our decision into a timeline of months rather than years.

“UD’s response to the COVID-19 epidemic has been phenomenal. The organization made the tough, but proper clinical calls that limited risks to patients and staff. They came up with a game plan to salvage fiscal viability – rolling out telemedicine in a matter of days and establishing the manner in which patients with high acuity could still be seen and cared for expediently.

“As a solo GI practice, we would have struggled mightily to survive and might have gone bankrupt. Had we been part of a larger non-GI entity (a hospital or multispecialty group), we might have been pressured to engage in unsafe or unethical practices and not consistent with national societal recommendations. Instead, we found ourselves having active discussions with our GI colleagues about the right path forward.”

How do you feel UD has helped improve the quality of patient care and positively impacted patient satisfaction?
Aja McCutchen, MD

• “Prior to UD, we worked diligently to improve our centralized patient service center, phone trees, and optimize the time and communication between patients, providers, and our staff. We now have tools which help identify and track gaps in communication on all levels. We have been able to improve our MA work flow, shorten wait times, and improve the direct dialogue between our practice and our patients. We have also been able to enhance our ancillary service offerings and expand programs that directly benefit our patients.”

Kimberly Orleck, PA-C

• “I think our quality of care has always been top notch and that thankfully has not been altered. UD has concentrated on workflow optimization, enhanced training to our frontline teams, and improved scheduled processes to decrease patient wait time. UD is also paying closer attention to patient ratings, reviews, and calculating net promotor scores. ”

Have there been any initiatives in the first year which improved the management of the organization?
Elizabeth Escalante, Senior Regional Director of Operations, UD

• “Implementation of a business analytics tool was huge this year. It greatly improved visibility into the information we need to have at our fingertips in order to make data-driven decisions for our business. Drilling this down to the frontline manager has increased our understanding of what it truly takes to run a successful practice, and in turn, increased stakeholder buy-in.”

Lakeeta White, Clinical Office Team Lead, and Alexis Sweeney, Medical Assistant

• “The formation of our MA Advisory Committee has been instrumental in helping standardize best practices across the organization. It is comprised of medical assistants across our geographic footprint, and they provide feedback to the management team regarding process improvements, areas for continued training, and more.”

Though many positives may arise out of change, so can some challenges. Have there been any unforeseen hurdles you experience as a result of the new partnership with PE?
Elizabeth Escalante

• “Overall, I believe the changes to the structure of the practice and reorganization of leadership has been positive. As with any organization, one area of improvement is in communication.”

Dr. Patel and Dr. Sonenshine are with Atlanta Gastroenterology Associates, which is part of United Digestive. They have no conflicts.

It was early March, and our second day of advocacy on Capitol Hill with the Digestive Health Physicians Association (DHPA) was cut short when congressional offices were shuttered because of the COVID-19 pandemic. Sitting with several of my GI physician colleagues from across the country, we knew that our practices, our patients, and our communities would be impacted by the coronavirus. None of us could have known the extent.

We also didn’t know in that moment that our advocacy work through DHPA would be one of the most important factors in ensuring that our practices were prepared to weather the pandemic. Our membership, legal counsel, and legislative lobbyists helped us remain informed about new legislation and regulations and ensured that we had much-needed access to government resources.

Just a few months into what is now the COVID-19 pandemic, independent GI practice leaders have learned a lot about how to strengthen our practices to respond to future crises – and what early-career GIs should look for in the practices they are considering.

First and foremost, practice leadership is key. One thing most successful GI practices have in common is that they hire really smart executives and administrative teams who excel at taking care of the business side of things so that physicians like me can do what we do best: treat patients.
 

Stay informed about state and federal policies

As a member of DHPA, Capital Digestive Care was well positioned to keep up to date on the government response to the coronavirus and the support it provided to small businesses and to health care providers.

Over the past 5 years, DHPA physician leaders have established strong relationships with our elected federal leaders. During our Capitol Hill visits in early March, we discussed the coronavirus in addition to our policy priorities.

The relationships we’ve built with policymakers have helped us educate them about how private practices were being affected and make the case that it was crucial to include private practices in health care stimulus packages.

Without this federal financial support, many medical groups may have had to close their doors – leaving a large gap in care once the pandemic subsides.

In addition to the federal government’s financial support, our policy advocacy efforts kept us informed about federal health agencies’ decisions on telehealth coverage. We were able to educate our physicians and staff about state and federal adjustments to telehealth rules for the pandemic, on the guidelines for elective procedures, on employee furlough and leave rules, as well as other congressional and state actions that would impact our practice.

You can’t be an independent physician without being open to learning about the business of health care and understanding how health policies affect your ability to practice medicine and care for people in your community. Every early-career physician who is looking to join a practice should ask how its leadership remains informed about health policy at the state and federal levels.
 

Make plans, be flexible

Implementing telehealth was critical in responding to the coronavirus pandemic. We were able to get up and running quickly on telemedicine because we had already invested in telehealth and had conducted a pilot of the platform with a smaller group of providers well before the pandemic hit.

In March, we were able to expand the telehealth platform to accommodate virtual visits by all of our providers. We also had to figure out how to shift our employees to telework, develop remote desktop and VPN solutions, and make sure that our scheduling and revenue cycle team members were fully operational.

The overriding goal was the safety of patients, staff, and our providers while continuing to provide medical care. Our inflammatory bowel disease patients needing visits to receive medication infusions took over an entire office so that there could be appropriate spacing and limited contacts with staff and other patients.

Our administrators knew early on that we needed a back-up plan and worked with physicians and providers doing telehealth visits to provide the flexibility to switch to Centers for Medicare & Medicaid–approved platforms (including Facetime) for those instances in which patients were uncomfortable using our main platform or when it was strained by bandwidth issues – a common challenge with any platform. Virtual check-in and check-out procedures were developed utilizing our usual office staff from remote locations.

For patients who had indications for gastroenterology procedures, we established a prioritization system, based on state guidelines, for those that were needed urgently or routinely as our endoscopy centers began to reopen. Safety measures were put into place including screening questionnaires, preprocedure COVID rt-PCT testing, personal protective equipment, and workflow changes to achieve social distancing.

As an early-career GI physician who is considering private practice, you’ll likely have several conversations with administrative leaders when deciding what practice to join. Ask about how the practice responded to COVID-19, and what processes it has in place to prepare for future emergencies.

During the early weeks of the pandemic, the CDC Board of Managers met two to three times per week. Task forces to discuss office operations and planning for ambulatory surgery center opening were established with participation by nearly every provider and manager. Communication between all providers and managers was important to decrease the obvious anxiety everyone was experiencing.
 

Old financial models may no longer work

Most practices develop budgets based on historical data. We quickly figured out that budgets from historical forecasts no longer worked and that we needed to understand the impact to budgets almost in real time.

We immediately looked to conserve cash and reduce expenses, requesting that our large vendors extend payment terms or provide a period of forbearance. We looked at everything from our EMR costs to lab supplies and everything in between.

Changing how we modeled our budgets and reducing costs made some of our hard decisions less difficult. While we had to furlough staff, our models for reducing physician compensation and lowering our costs allowed us to create a model for the return to work that included the use of paid time off and paid health care for our furloughed employees.

Our operations team also set up systems to gather information that was needed to apply for and report on federal loans and grants. They also set up ways to track revenue per visit and appeals for denied telehealth and other services in an effort to create new models and budgets as COVID-19 progressed. The revenue cycle team focused on unpaid older accounts receivable.
 

Focused on the future

It’s an understatement to say that COVID-19 has forever changed the practice of medicine. The health care industry will need to transform.

For some time now, GI practices have discussed the consequence of disruptive innovation affecting utilization of endoscopic procedures. We were looking at technology that might eventually replace office personnel. No one was thinking about a pandemic that would cause nearly overnight closure of endoscopy suites and curtail the entire in-office administrative workforce. The coronavirus pandemic is likely to be the catalyst that brings many innovations into the mainstream.

We’ll most likely see a transition to the virtual medical office for those visits that don’t require a patient to see a physician in person. This will make online scheduling and registration, on-demand messaging, and remote patient monitoring and chronic care management necessities.

We may also see more rapid adoption of technologies that allow information from health trackers and wearables to be integrated into EMRs that easily follow the patient from physician to physician. Administrative support and patient assistance from remote locations will become the norm.

Inquiring about how practices plan for emergencies and how their leadership thinks about the future of gastroenterology is a great way to show that you’re thinking holistically about health care delivery and how medicine is practiced now and in the future.

So much has changed in the decades I’ve been practicing medicine and so much is yet to change. As early-career GI physicians who are familiar with new technologies, you are in a great position to lead the practices you join into the future of gastroenterology.

Dr. Weinstein is president and CEO of Capital Digestive Care and the immediate past president of the Digestive Health Physicians Association.

It was early March, and our second day of advocacy on Capitol Hill with the Digestive Health Physicians Association (DHPA) was cut short when congressional offices were shuttered because of the COVID-19 pandemic. Sitting with several of my GI physician colleagues from across the country, we knew that our practices, our patients, and our communities would be impacted by the coronavirus. None of us could have known the extent.

We also didn’t know in that moment that our advocacy work through DHPA would be one of the most important factors in ensuring that our practices were prepared to weather the pandemic. Our membership, legal counsel, and legislative lobbyists helped us remain informed about new legislation and regulations and ensured that we had much-needed access to government resources.

Just a few months into what is now the COVID-19 pandemic, independent GI practice leaders have learned a lot about how to strengthen our practices to respond to future crises – and what early-career GIs should look for in the practices they are considering.

First and foremost, practice leadership is key. One thing most successful GI practices have in common is that they hire really smart executives and administrative teams who excel at taking care of the business side of things so that physicians like me can do what we do best: treat patients.
 

Stay informed about state and federal policies

As a member of DHPA, Capital Digestive Care was well positioned to keep up to date on the government response to the coronavirus and the support it provided to small businesses and to health care providers.

Over the past 5 years, DHPA physician leaders have established strong relationships with our elected federal leaders. During our Capitol Hill visits in early March, we discussed the coronavirus in addition to our policy priorities.

The relationships we’ve built with policymakers have helped us educate them about how private practices were being affected and make the case that it was crucial to include private practices in health care stimulus packages.

Without this federal financial support, many medical groups may have had to close their doors – leaving a large gap in care once the pandemic subsides.

In addition to the federal government’s financial support, our policy advocacy efforts kept us informed about federal health agencies’ decisions on telehealth coverage. We were able to educate our physicians and staff about state and federal adjustments to telehealth rules for the pandemic, on the guidelines for elective procedures, on employee furlough and leave rules, as well as other congressional and state actions that would impact our practice.

You can’t be an independent physician without being open to learning about the business of health care and understanding how health policies affect your ability to practice medicine and care for people in your community. Every early-career physician who is looking to join a practice should ask how its leadership remains informed about health policy at the state and federal levels.
 

Make plans, be flexible

Implementing telehealth was critical in responding to the coronavirus pandemic. We were able to get up and running quickly on telemedicine because we had already invested in telehealth and had conducted a pilot of the platform with a smaller group of providers well before the pandemic hit.

In March, we were able to expand the telehealth platform to accommodate virtual visits by all of our providers. We also had to figure out how to shift our employees to telework, develop remote desktop and VPN solutions, and make sure that our scheduling and revenue cycle team members were fully operational.

The overriding goal was the safety of patients, staff, and our providers while continuing to provide medical care. Our inflammatory bowel disease patients needing visits to receive medication infusions took over an entire office so that there could be appropriate spacing and limited contacts with staff and other patients.

Our administrators knew early on that we needed a back-up plan and worked with physicians and providers doing telehealth visits to provide the flexibility to switch to Centers for Medicare & Medicaid–approved platforms (including Facetime) for those instances in which patients were uncomfortable using our main platform or when it was strained by bandwidth issues – a common challenge with any platform. Virtual check-in and check-out procedures were developed utilizing our usual office staff from remote locations.

For patients who had indications for gastroenterology procedures, we established a prioritization system, based on state guidelines, for those that were needed urgently or routinely as our endoscopy centers began to reopen. Safety measures were put into place including screening questionnaires, preprocedure COVID rt-PCT testing, personal protective equipment, and workflow changes to achieve social distancing.

As an early-career GI physician who is considering private practice, you’ll likely have several conversations with administrative leaders when deciding what practice to join. Ask about how the practice responded to COVID-19, and what processes it has in place to prepare for future emergencies.

During the early weeks of the pandemic, the CDC Board of Managers met two to three times per week. Task forces to discuss office operations and planning for ambulatory surgery center opening were established with participation by nearly every provider and manager. Communication between all providers and managers was important to decrease the obvious anxiety everyone was experiencing.
 

Old financial models may no longer work

Most practices develop budgets based on historical data. We quickly figured out that budgets from historical forecasts no longer worked and that we needed to understand the impact to budgets almost in real time.

We immediately looked to conserve cash and reduce expenses, requesting that our large vendors extend payment terms or provide a period of forbearance. We looked at everything from our EMR costs to lab supplies and everything in between.

Changing how we modeled our budgets and reducing costs made some of our hard decisions less difficult. While we had to furlough staff, our models for reducing physician compensation and lowering our costs allowed us to create a model for the return to work that included the use of paid time off and paid health care for our furloughed employees.

Our operations team also set up systems to gather information that was needed to apply for and report on federal loans and grants. They also set up ways to track revenue per visit and appeals for denied telehealth and other services in an effort to create new models and budgets as COVID-19 progressed. The revenue cycle team focused on unpaid older accounts receivable.
 

Focused on the future

It’s an understatement to say that COVID-19 has forever changed the practice of medicine. The health care industry will need to transform.

For some time now, GI practices have discussed the consequence of disruptive innovation affecting utilization of endoscopic procedures. We were looking at technology that might eventually replace office personnel. No one was thinking about a pandemic that would cause nearly overnight closure of endoscopy suites and curtail the entire in-office administrative workforce. The coronavirus pandemic is likely to be the catalyst that brings many innovations into the mainstream.

We’ll most likely see a transition to the virtual medical office for those visits that don’t require a patient to see a physician in person. This will make online scheduling and registration, on-demand messaging, and remote patient monitoring and chronic care management necessities.

We may also see more rapid adoption of technologies that allow information from health trackers and wearables to be integrated into EMRs that easily follow the patient from physician to physician. Administrative support and patient assistance from remote locations will become the norm.

Inquiring about how practices plan for emergencies and how their leadership thinks about the future of gastroenterology is a great way to show that you’re thinking holistically about health care delivery and how medicine is practiced now and in the future.

So much has changed in the decades I’ve been practicing medicine and so much is yet to change. As early-career GI physicians who are familiar with new technologies, you are in a great position to lead the practices you join into the future of gastroenterology.

Dr. Weinstein is president and CEO of Capital Digestive Care and the immediate past president of the Digestive Health Physicians Association.

It was early March, and our second day of advocacy on Capitol Hill with the Digestive Health Physicians Association (DHPA) was cut short when congressional offices were shuttered because of the COVID-19 pandemic. Sitting with several of my GI physician colleagues from across the country, we knew that our practices, our patients, and our communities would be impacted by the coronavirus. None of us could have known the extent.

We also didn’t know in that moment that our advocacy work through DHPA would be one of the most important factors in ensuring that our practices were prepared to weather the pandemic. Our membership, legal counsel, and legislative lobbyists helped us remain informed about new legislation and regulations and ensured that we had much-needed access to government resources.

Just a few months into what is now the COVID-19 pandemic, independent GI practice leaders have learned a lot about how to strengthen our practices to respond to future crises – and what early-career GIs should look for in the practices they are considering.

First and foremost, practice leadership is key. One thing most successful GI practices have in common is that they hire really smart executives and administrative teams who excel at taking care of the business side of things so that physicians like me can do what we do best: treat patients.
 

Stay informed about state and federal policies

As a member of DHPA, Capital Digestive Care was well positioned to keep up to date on the government response to the coronavirus and the support it provided to small businesses and to health care providers.

Over the past 5 years, DHPA physician leaders have established strong relationships with our elected federal leaders. During our Capitol Hill visits in early March, we discussed the coronavirus in addition to our policy priorities.

The relationships we’ve built with policymakers have helped us educate them about how private practices were being affected and make the case that it was crucial to include private practices in health care stimulus packages.

Without this federal financial support, many medical groups may have had to close their doors – leaving a large gap in care once the pandemic subsides.

In addition to the federal government’s financial support, our policy advocacy efforts kept us informed about federal health agencies’ decisions on telehealth coverage. We were able to educate our physicians and staff about state and federal adjustments to telehealth rules for the pandemic, on the guidelines for elective procedures, on employee furlough and leave rules, as well as other congressional and state actions that would impact our practice.

You can’t be an independent physician without being open to learning about the business of health care and understanding how health policies affect your ability to practice medicine and care for people in your community. Every early-career physician who is looking to join a practice should ask how its leadership remains informed about health policy at the state and federal levels.
 

Make plans, be flexible

Implementing telehealth was critical in responding to the coronavirus pandemic. We were able to get up and running quickly on telemedicine because we had already invested in telehealth and had conducted a pilot of the platform with a smaller group of providers well before the pandemic hit.

In March, we were able to expand the telehealth platform to accommodate virtual visits by all of our providers. We also had to figure out how to shift our employees to telework, develop remote desktop and VPN solutions, and make sure that our scheduling and revenue cycle team members were fully operational.

The overriding goal was the safety of patients, staff, and our providers while continuing to provide medical care. Our inflammatory bowel disease patients needing visits to receive medication infusions took over an entire office so that there could be appropriate spacing and limited contacts with staff and other patients.

Our administrators knew early on that we needed a back-up plan and worked with physicians and providers doing telehealth visits to provide the flexibility to switch to Centers for Medicare & Medicaid–approved platforms (including Facetime) for those instances in which patients were uncomfortable using our main platform or when it was strained by bandwidth issues – a common challenge with any platform. Virtual check-in and check-out procedures were developed utilizing our usual office staff from remote locations.

For patients who had indications for gastroenterology procedures, we established a prioritization system, based on state guidelines, for those that were needed urgently or routinely as our endoscopy centers began to reopen. Safety measures were put into place including screening questionnaires, preprocedure COVID rt-PCT testing, personal protective equipment, and workflow changes to achieve social distancing.

As an early-career GI physician who is considering private practice, you’ll likely have several conversations with administrative leaders when deciding what practice to join. Ask about how the practice responded to COVID-19, and what processes it has in place to prepare for future emergencies.

During the early weeks of the pandemic, the CDC Board of Managers met two to three times per week. Task forces to discuss office operations and planning for ambulatory surgery center opening were established with participation by nearly every provider and manager. Communication between all providers and managers was important to decrease the obvious anxiety everyone was experiencing.
 

Old financial models may no longer work

Most practices develop budgets based on historical data. We quickly figured out that budgets from historical forecasts no longer worked and that we needed to understand the impact to budgets almost in real time.

We immediately looked to conserve cash and reduce expenses, requesting that our large vendors extend payment terms or provide a period of forbearance. We looked at everything from our EMR costs to lab supplies and everything in between.

Changing how we modeled our budgets and reducing costs made some of our hard decisions less difficult. While we had to furlough staff, our models for reducing physician compensation and lowering our costs allowed us to create a model for the return to work that included the use of paid time off and paid health care for our furloughed employees.

Our operations team also set up systems to gather information that was needed to apply for and report on federal loans and grants. They also set up ways to track revenue per visit and appeals for denied telehealth and other services in an effort to create new models and budgets as COVID-19 progressed. The revenue cycle team focused on unpaid older accounts receivable.
 

Focused on the future

It’s an understatement to say that COVID-19 has forever changed the practice of medicine. The health care industry will need to transform.

For some time now, GI practices have discussed the consequence of disruptive innovation affecting utilization of endoscopic procedures. We were looking at technology that might eventually replace office personnel. No one was thinking about a pandemic that would cause nearly overnight closure of endoscopy suites and curtail the entire in-office administrative workforce. The coronavirus pandemic is likely to be the catalyst that brings many innovations into the mainstream.

We’ll most likely see a transition to the virtual medical office for those visits that don’t require a patient to see a physician in person. This will make online scheduling and registration, on-demand messaging, and remote patient monitoring and chronic care management necessities.

We may also see more rapid adoption of technologies that allow information from health trackers and wearables to be integrated into EMRs that easily follow the patient from physician to physician. Administrative support and patient assistance from remote locations will become the norm.

Inquiring about how practices plan for emergencies and how their leadership thinks about the future of gastroenterology is a great way to show that you’re thinking holistically about health care delivery and how medicine is practiced now and in the future.

So much has changed in the decades I’ve been practicing medicine and so much is yet to change. As early-career GI physicians who are familiar with new technologies, you are in a great position to lead the practices you join into the future of gastroenterology.

Dr. Weinstein is president and CEO of Capital Digestive Care and the immediate past president of the Digestive Health Physicians Association.

One might immediately think of the deaths of Eric Garner, George Floyd, or even the fictional character Radio Raheem from Spike Lee’s critically acclaimed film, “Do the Right Thing,” when they hear the words “I can’t breathe.” These words are a cry for help. The deaths of these unarmed black men is devastating and has led to a state of rage, palpable pain, and protest across the world.

However, in this moment, I am talking about the health inequity exposed by the COVID-19 pandemic. Whether it be acute respiratory distress syndrome (ARDS) secondary to severe COVID-19, or the subsequent hypercoagulable state of COVID-19 that leads to venous thromboembolism, many black people in this country are left breathless. Many black patients who had no employee-based health insurance also had no primary care physician to order a SARS-CoV2 PCR lab test for them. Many of these patients have preexisting conditions, such as asthma from living in redlined communities affected by environmental racism. Many grew up in food deserts, where no fresh-produce store was interested enough to set up shop in their neighborhoods. They have been eating fast food since early childhood, as a fast-food burger is still cheaper than a salad. The result is obesity, an epidemic that can lead to diabetes mellitus, hypertension that can lead to coronary artery disease, stroke, and end-stage renal disease. 

Earlier in my career, I once had a colleague gleefully tell me that all black people drank Kool-Aid while in discussion of the effects of high-sugar diets in our patients; this colleague was sure I would agree. Not all black people drink Kool-Aid. Secondary to my fear of the backlash that can come from the discomfort of “white fragility” that Robin DiAngelo describes in her New York Times bestseller by the same name, ”White Fragility: Why It’s So Hard for White People to Talk About Racism,” I refrained from expressing my own hurt, and I did not offer explicit correction. I, instead, took a serious pause. That pause, which lasted only minutes, seemed to last 400 years. It was a brief reflection of the 400 years of systemic racism seeping into everyday life. This included the circumstances that would lead to the health inequities that result in the health disparities from which many black patients suffer. It is that same systemic racism that could create two America’s in which my colleague might not have to know the historic context in which that question could be hurtful. I retorted with modified shock and a chuckle so that I could muster up enough strength to repeat what was said and leave it open for reflection. The goal was for my colleague to realize the obvious implicit bias that lingered, despite intention. The chuckle was also to cover my pain.

Whether we know it or not, we all carry some form of implicit bias, regardless of race, class, gender, ethnicity, sexual preference, or socioeconomic status. In this case, it is the same implicit bias that causes physicians to ignore some black patients when they have said that they are in pain. A groundbreaking April 2016 article in Proceedings of the National Academy of Sciences, “Racial Bias in Pain Assessment and Treatment Recommendations, and False Beliefs about Biological Differences Between Blacks and Whites” (doi: 10.1073/pnas.1516047113), revealed that racial disparities in pain assessment and treatment recommendations can be directly connected to the racial bias of the provider. It could be possible that this phenomenon has affected black patients who have walked into clinics and emergency departments and said, “I’m short of breath. I think that I might have coronavirus and need to be tested.” It may be that same implicit bias that has cut the air supply to a patient encounter. Instead of inquiring further, the patient might be met with minimum questions while their provider obtains their history and physical. Assumptions and blame on behavior and lack of personal responsibility secretly replace questions that could have been asked. Differentials between exacerbations and other etiologies are not explored. Could that patient have been sent home without a SARS-CoV2 polymerase chain reaction test? Well, what if the tests were in short supply? Sometimes they may have been sent home without a chest x-ray. In most cases, there are no funds to send them home with a pulse oximeter.

The act of assuming a person’s story that we consider to be one dimensional is always dangerous – and even more so during this pandemic. That person we can relate to – secondary to a cool pop culture moment, a TikTok song, or a negative stereotype – is not one dimensional. That assumption and that stereotype can make room for implicit bias. That same implicit bias is the knee on a neck of any marginalized patient. Implicit bias is the choke hold that slowly removes the light and life from a person who has a story, who has a family, and who has been an essential worker who can’t work from home. That person is telling us that they can’t breathe, but sometimes the only things seen are comorbidities through a misinformed or biased lens that suggest an assumed lack of personal responsibility. In a May 2020 New England Journal of Medicine perspective, “Racial health disparities and Covid-19” (doi: 10.1056/NEJMp2012910), Merlin Chowkwanyun, PhD, MPH, and Adolph L. Reed Jr., PhD, caution us against creating race-based explanations for presumed behavioral patterns.

Systemic racism has created the myth that the playing field has been leveled since the end of enslavement. It hasn’t. That black man, woman, or nonbinary person is telling you “I can’t breathe. I’m tired. I’m short of breath ... I have a cough ... I’m feeling weak these days, Doc.” However, implicit bias is still that knee that won’t let up. It has not let up. Communities with lower-income black and Hispanic patients have already seen local hospitals and frontline workers fight to save their lives while losing their own to COVID-19. We all witnessed the battle for scarce resources and PPE [personal protective equipment]. In contrast, some wealthy neighborhoods have occupants who most likely have access to a primary care physician and more testing centers.

As we reexamine ourselves and look at these cases of police brutality against unarmed black men, women, and children with the appropriate shame and outrage, let us reflect upon the privileges that we enjoy. Let us find our voice as we speak up for black lives. Let us look deeply into the history of medicine as it relates to black patients by reading “Medical Apartheid: The Dark History of Medical Experimentation on Black Americans from Colonial Times to the Present” by Harriet A. Washington. Let us examine that painful legacy, which, while having moments of good intention, still carries the stain of indifference, racism, neglect, and even experimentation without informed consent.

Why should we do these things? Because some of our black patients have also yelled or whispered, “I can’t breathe,” and we were not always listening either.
 

Dr. Ajala is a hospitalist and associate site director for education at Grady Memorial Hospital in Atlanta. She is a member of the executive council for SHM’s Care for Vulnerable Populations special interest group.

One might immediately think of the deaths of Eric Garner, George Floyd, or even the fictional character Radio Raheem from Spike Lee’s critically acclaimed film, “Do the Right Thing,” when they hear the words “I can’t breathe.” These words are a cry for help. The deaths of these unarmed black men is devastating and has led to a state of rage, palpable pain, and protest across the world.

However, in this moment, I am talking about the health inequity exposed by the COVID-19 pandemic. Whether it be acute respiratory distress syndrome (ARDS) secondary to severe COVID-19, or the subsequent hypercoagulable state of COVID-19 that leads to venous thromboembolism, many black people in this country are left breathless. Many black patients who had no employee-based health insurance also had no primary care physician to order a SARS-CoV2 PCR lab test for them. Many of these patients have preexisting conditions, such as asthma from living in redlined communities affected by environmental racism. Many grew up in food deserts, where no fresh-produce store was interested enough to set up shop in their neighborhoods. They have been eating fast food since early childhood, as a fast-food burger is still cheaper than a salad. The result is obesity, an epidemic that can lead to diabetes mellitus, hypertension that can lead to coronary artery disease, stroke, and end-stage renal disease. 

Earlier in my career, I once had a colleague gleefully tell me that all black people drank Kool-Aid while in discussion of the effects of high-sugar diets in our patients; this colleague was sure I would agree. Not all black people drink Kool-Aid. Secondary to my fear of the backlash that can come from the discomfort of “white fragility” that Robin DiAngelo describes in her New York Times bestseller by the same name, ”White Fragility: Why It’s So Hard for White People to Talk About Racism,” I refrained from expressing my own hurt, and I did not offer explicit correction. I, instead, took a serious pause. That pause, which lasted only minutes, seemed to last 400 years. It was a brief reflection of the 400 years of systemic racism seeping into everyday life. This included the circumstances that would lead to the health inequities that result in the health disparities from which many black patients suffer. It is that same systemic racism that could create two America’s in which my colleague might not have to know the historic context in which that question could be hurtful. I retorted with modified shock and a chuckle so that I could muster up enough strength to repeat what was said and leave it open for reflection. The goal was for my colleague to realize the obvious implicit bias that lingered, despite intention. The chuckle was also to cover my pain.

Whether we know it or not, we all carry some form of implicit bias, regardless of race, class, gender, ethnicity, sexual preference, or socioeconomic status. In this case, it is the same implicit bias that causes physicians to ignore some black patients when they have said that they are in pain. A groundbreaking April 2016 article in Proceedings of the National Academy of Sciences, “Racial Bias in Pain Assessment and Treatment Recommendations, and False Beliefs about Biological Differences Between Blacks and Whites” (doi: 10.1073/pnas.1516047113), revealed that racial disparities in pain assessment and treatment recommendations can be directly connected to the racial bias of the provider. It could be possible that this phenomenon has affected black patients who have walked into clinics and emergency departments and said, “I’m short of breath. I think that I might have coronavirus and need to be tested.” It may be that same implicit bias that has cut the air supply to a patient encounter. Instead of inquiring further, the patient might be met with minimum questions while their provider obtains their history and physical. Assumptions and blame on behavior and lack of personal responsibility secretly replace questions that could have been asked. Differentials between exacerbations and other etiologies are not explored. Could that patient have been sent home without a SARS-CoV2 polymerase chain reaction test? Well, what if the tests were in short supply? Sometimes they may have been sent home without a chest x-ray. In most cases, there are no funds to send them home with a pulse oximeter.

The act of assuming a person’s story that we consider to be one dimensional is always dangerous – and even more so during this pandemic. That person we can relate to – secondary to a cool pop culture moment, a TikTok song, or a negative stereotype – is not one dimensional. That assumption and that stereotype can make room for implicit bias. That same implicit bias is the knee on a neck of any marginalized patient. Implicit bias is the choke hold that slowly removes the light and life from a person who has a story, who has a family, and who has been an essential worker who can’t work from home. That person is telling us that they can’t breathe, but sometimes the only things seen are comorbidities through a misinformed or biased lens that suggest an assumed lack of personal responsibility. In a May 2020 New England Journal of Medicine perspective, “Racial health disparities and Covid-19” (doi: 10.1056/NEJMp2012910), Merlin Chowkwanyun, PhD, MPH, and Adolph L. Reed Jr., PhD, caution us against creating race-based explanations for presumed behavioral patterns.

Systemic racism has created the myth that the playing field has been leveled since the end of enslavement. It hasn’t. That black man, woman, or nonbinary person is telling you “I can’t breathe. I’m tired. I’m short of breath ... I have a cough ... I’m feeling weak these days, Doc.” However, implicit bias is still that knee that won’t let up. It has not let up. Communities with lower-income black and Hispanic patients have already seen local hospitals and frontline workers fight to save their lives while losing their own to COVID-19. We all witnessed the battle for scarce resources and PPE [personal protective equipment]. In contrast, some wealthy neighborhoods have occupants who most likely have access to a primary care physician and more testing centers.

As we reexamine ourselves and look at these cases of police brutality against unarmed black men, women, and children with the appropriate shame and outrage, let us reflect upon the privileges that we enjoy. Let us find our voice as we speak up for black lives. Let us look deeply into the history of medicine as it relates to black patients by reading “Medical Apartheid: The Dark History of Medical Experimentation on Black Americans from Colonial Times to the Present” by Harriet A. Washington. Let us examine that painful legacy, which, while having moments of good intention, still carries the stain of indifference, racism, neglect, and even experimentation without informed consent.

Why should we do these things? Because some of our black patients have also yelled or whispered, “I can’t breathe,” and we were not always listening either.
 

Dr. Ajala is a hospitalist and associate site director for education at Grady Memorial Hospital in Atlanta. She is a member of the executive council for SHM’s Care for Vulnerable Populations special interest group.

One might immediately think of the deaths of Eric Garner, George Floyd, or even the fictional character Radio Raheem from Spike Lee’s critically acclaimed film, “Do the Right Thing,” when they hear the words “I can’t breathe.” These words are a cry for help. The deaths of these unarmed black men is devastating and has led to a state of rage, palpable pain, and protest across the world.

However, in this moment, I am talking about the health inequity exposed by the COVID-19 pandemic. Whether it be acute respiratory distress syndrome (ARDS) secondary to severe COVID-19, or the subsequent hypercoagulable state of COVID-19 that leads to venous thromboembolism, many black people in this country are left breathless. Many black patients who had no employee-based health insurance also had no primary care physician to order a SARS-CoV2 PCR lab test for them. Many of these patients have preexisting conditions, such as asthma from living in redlined communities affected by environmental racism. Many grew up in food deserts, where no fresh-produce store was interested enough to set up shop in their neighborhoods. They have been eating fast food since early childhood, as a fast-food burger is still cheaper than a salad. The result is obesity, an epidemic that can lead to diabetes mellitus, hypertension that can lead to coronary artery disease, stroke, and end-stage renal disease. 

Earlier in my career, I once had a colleague gleefully tell me that all black people drank Kool-Aid while in discussion of the effects of high-sugar diets in our patients; this colleague was sure I would agree. Not all black people drink Kool-Aid. Secondary to my fear of the backlash that can come from the discomfort of “white fragility” that Robin DiAngelo describes in her New York Times bestseller by the same name, ”White Fragility: Why It’s So Hard for White People to Talk About Racism,” I refrained from expressing my own hurt, and I did not offer explicit correction. I, instead, took a serious pause. That pause, which lasted only minutes, seemed to last 400 years. It was a brief reflection of the 400 years of systemic racism seeping into everyday life. This included the circumstances that would lead to the health inequities that result in the health disparities from which many black patients suffer. It is that same systemic racism that could create two America’s in which my colleague might not have to know the historic context in which that question could be hurtful. I retorted with modified shock and a chuckle so that I could muster up enough strength to repeat what was said and leave it open for reflection. The goal was for my colleague to realize the obvious implicit bias that lingered, despite intention. The chuckle was also to cover my pain.

Whether we know it or not, we all carry some form of implicit bias, regardless of race, class, gender, ethnicity, sexual preference, or socioeconomic status. In this case, it is the same implicit bias that causes physicians to ignore some black patients when they have said that they are in pain. A groundbreaking April 2016 article in Proceedings of the National Academy of Sciences, “Racial Bias in Pain Assessment and Treatment Recommendations, and False Beliefs about Biological Differences Between Blacks and Whites” (doi: 10.1073/pnas.1516047113), revealed that racial disparities in pain assessment and treatment recommendations can be directly connected to the racial bias of the provider. It could be possible that this phenomenon has affected black patients who have walked into clinics and emergency departments and said, “I’m short of breath. I think that I might have coronavirus and need to be tested.” It may be that same implicit bias that has cut the air supply to a patient encounter. Instead of inquiring further, the patient might be met with minimum questions while their provider obtains their history and physical. Assumptions and blame on behavior and lack of personal responsibility secretly replace questions that could have been asked. Differentials between exacerbations and other etiologies are not explored. Could that patient have been sent home without a SARS-CoV2 polymerase chain reaction test? Well, what if the tests were in short supply? Sometimes they may have been sent home without a chest x-ray. In most cases, there are no funds to send them home with a pulse oximeter.

The act of assuming a person’s story that we consider to be one dimensional is always dangerous – and even more so during this pandemic. That person we can relate to – secondary to a cool pop culture moment, a TikTok song, or a negative stereotype – is not one dimensional. That assumption and that stereotype can make room for implicit bias. That same implicit bias is the knee on a neck of any marginalized patient. Implicit bias is the choke hold that slowly removes the light and life from a person who has a story, who has a family, and who has been an essential worker who can’t work from home. That person is telling us that they can’t breathe, but sometimes the only things seen are comorbidities through a misinformed or biased lens that suggest an assumed lack of personal responsibility. In a May 2020 New England Journal of Medicine perspective, “Racial health disparities and Covid-19” (doi: 10.1056/NEJMp2012910), Merlin Chowkwanyun, PhD, MPH, and Adolph L. Reed Jr., PhD, caution us against creating race-based explanations for presumed behavioral patterns.

Systemic racism has created the myth that the playing field has been leveled since the end of enslavement. It hasn’t. That black man, woman, or nonbinary person is telling you “I can’t breathe. I’m tired. I’m short of breath ... I have a cough ... I’m feeling weak these days, Doc.” However, implicit bias is still that knee that won’t let up. It has not let up. Communities with lower-income black and Hispanic patients have already seen local hospitals and frontline workers fight to save their lives while losing their own to COVID-19. We all witnessed the battle for scarce resources and PPE [personal protective equipment]. In contrast, some wealthy neighborhoods have occupants who most likely have access to a primary care physician and more testing centers.

As we reexamine ourselves and look at these cases of police brutality against unarmed black men, women, and children with the appropriate shame and outrage, let us reflect upon the privileges that we enjoy. Let us find our voice as we speak up for black lives. Let us look deeply into the history of medicine as it relates to black patients by reading “Medical Apartheid: The Dark History of Medical Experimentation on Black Americans from Colonial Times to the Present” by Harriet A. Washington. Let us examine that painful legacy, which, while having moments of good intention, still carries the stain of indifference, racism, neglect, and even experimentation without informed consent.

Why should we do these things? Because some of our black patients have also yelled or whispered, “I can’t breathe,” and we were not always listening either.
 

Dr. Ajala is a hospitalist and associate site director for education at Grady Memorial Hospital in Atlanta. She is a member of the executive council for SHM’s Care for Vulnerable Populations special interest group.

The Food and Administration has approved a new indication for the PD-L1 inhibitor avelumab.

Physicians can now prescribe avelumab (Bavencio) as maintenance treatment for patients with locally advanced or metastatic urothelial carcinoma (UC) that has not progressed after first-line platinum-containing chemotherapy.

Wikimedia Commons/FitzColinGerald/ Creative Commons License

The new indication adds to avelumab use in other patient populations, including people with locally advanced or metastatic UC who experience disease progression during or following platinum-containing chemotherapy. The FDA also previously approved avelumab for patients who experienced UC progression within 12 months of neoadjuvant or adjuvant treatment with platinum-containing chemotherapy.

The FDA first approved marketing of avelumab in 2017. Other uses include treatment of metastatic Merkel cell carcinoma and first-line treatment of advanced renal cell carcinoma in combination with axitinib.

The new maintenance therapy indication for avelumab is based on efficacy demonstrated in the JAVELIN Bladder 100 trial. Results from this trial were presented as part of the American Society of Clinical Oncology virtual scientific program.

Investigators randomly assigned 700 patients with unresectable, locally advanced or metastatic UC to intravenous avelumab and best supportive care or best supportive care alone. All participants had UC that had not progressed after first-line platinum-containing chemotherapy.

The median overall survival was 21.4 months in the avelumab arm and 14.3 months in the best supportive care–alone arm (hazard ratio, 0.69; 95% confidence interval, 0.56-0.86). This difference was statistically significant (P = .001).

Avelumab also was associated with significantly longer overall survival in the 51% of participants with PD-L1–positive tumors (hazard ratio, 0.56; 95% confidence interval, 0.40-0.79; P < .001).

Results from the JAVELIN Bladder 100 trial allowed the FDA to convert an initial accelerated approval of avelumab to a regular approval.

Fatigue, musculoskeletal pain, urinary tract infection, and rash were the most common adverse events reported in 20% or more of trial participants. In all, 28% of patients experienced serious adverse events, and one patient died from sepsis during the trial.

Recommended avelumab dosing is 800 mg administered as an intravenous infusion over 60 minutes every 2 weeks until disease progresses or toxicity becomes unacceptable.

See the full prescribing information for more details.

The Food and Administration has approved a new indication for the PD-L1 inhibitor avelumab.

Physicians can now prescribe avelumab (Bavencio) as maintenance treatment for patients with locally advanced or metastatic urothelial carcinoma (UC) that has not progressed after first-line platinum-containing chemotherapy.

Wikimedia Commons/FitzColinGerald/ Creative Commons License

The new indication adds to avelumab use in other patient populations, including people with locally advanced or metastatic UC who experience disease progression during or following platinum-containing chemotherapy. The FDA also previously approved avelumab for patients who experienced UC progression within 12 months of neoadjuvant or adjuvant treatment with platinum-containing chemotherapy.

The FDA first approved marketing of avelumab in 2017. Other uses include treatment of metastatic Merkel cell carcinoma and first-line treatment of advanced renal cell carcinoma in combination with axitinib.

The new maintenance therapy indication for avelumab is based on efficacy demonstrated in the JAVELIN Bladder 100 trial. Results from this trial were presented as part of the American Society of Clinical Oncology virtual scientific program.

Investigators randomly assigned 700 patients with unresectable, locally advanced or metastatic UC to intravenous avelumab and best supportive care or best supportive care alone. All participants had UC that had not progressed after first-line platinum-containing chemotherapy.

The median overall survival was 21.4 months in the avelumab arm and 14.3 months in the best supportive care–alone arm (hazard ratio, 0.69; 95% confidence interval, 0.56-0.86). This difference was statistically significant (P = .001).

Avelumab also was associated with significantly longer overall survival in the 51% of participants with PD-L1–positive tumors (hazard ratio, 0.56; 95% confidence interval, 0.40-0.79; P < .001).

Results from the JAVELIN Bladder 100 trial allowed the FDA to convert an initial accelerated approval of avelumab to a regular approval.

Fatigue, musculoskeletal pain, urinary tract infection, and rash were the most common adverse events reported in 20% or more of trial participants. In all, 28% of patients experienced serious adverse events, and one patient died from sepsis during the trial.

Recommended avelumab dosing is 800 mg administered as an intravenous infusion over 60 minutes every 2 weeks until disease progresses or toxicity becomes unacceptable.

See the full prescribing information for more details.

The Food and Administration has approved a new indication for the PD-L1 inhibitor avelumab.

Physicians can now prescribe avelumab (Bavencio) as maintenance treatment for patients with locally advanced or metastatic urothelial carcinoma (UC) that has not progressed after first-line platinum-containing chemotherapy.

Wikimedia Commons/FitzColinGerald/ Creative Commons License

The new indication adds to avelumab use in other patient populations, including people with locally advanced or metastatic UC who experience disease progression during or following platinum-containing chemotherapy. The FDA also previously approved avelumab for patients who experienced UC progression within 12 months of neoadjuvant or adjuvant treatment with platinum-containing chemotherapy.

The FDA first approved marketing of avelumab in 2017. Other uses include treatment of metastatic Merkel cell carcinoma and first-line treatment of advanced renal cell carcinoma in combination with axitinib.

The new maintenance therapy indication for avelumab is based on efficacy demonstrated in the JAVELIN Bladder 100 trial. Results from this trial were presented as part of the American Society of Clinical Oncology virtual scientific program.

Investigators randomly assigned 700 patients with unresectable, locally advanced or metastatic UC to intravenous avelumab and best supportive care or best supportive care alone. All participants had UC that had not progressed after first-line platinum-containing chemotherapy.

The median overall survival was 21.4 months in the avelumab arm and 14.3 months in the best supportive care–alone arm (hazard ratio, 0.69; 95% confidence interval, 0.56-0.86). This difference was statistically significant (P = .001).

Avelumab also was associated with significantly longer overall survival in the 51% of participants with PD-L1–positive tumors (hazard ratio, 0.56; 95% confidence interval, 0.40-0.79; P < .001).

Results from the JAVELIN Bladder 100 trial allowed the FDA to convert an initial accelerated approval of avelumab to a regular approval.

Fatigue, musculoskeletal pain, urinary tract infection, and rash were the most common adverse events reported in 20% or more of trial participants. In all, 28% of patients experienced serious adverse events, and one patient died from sepsis during the trial.

Recommended avelumab dosing is 800 mg administered as an intravenous infusion over 60 minutes every 2 weeks until disease progresses or toxicity becomes unacceptable.

See the full prescribing information for more details.

Migraine can significantly influence a woman’s decision to have children, new research shows. Results from a multicenter study of more than 600 women showed that, among participants with migraine, those who were younger, had menstrual migraine, or had chronic migraine were more likely to decide to not become pregnant.

Although women with migraine who avoided pregnancy believed their migraines would worsen during pregnancy or make their pregnancy difficult, previous observational research indicates that migraine often improves during pregnancy.

“Women who avoided pregnancy due to migraine were most concerned that migraine would make raising a child difficult, that the migraine medications they take would have a negative impact on their child’s development, and that their migraine pattern would worsen during or just after pregnancy,” said study investigator Ryotaro Ishii, MD, PhD, a visiting scientist at Mayo Clinic in Phoenix, Arizona.

The findings were presented at the virtual annual meeting of the American Headache Society.
 

Plans for the future

There is a paucity of research on the effects of migraine on pregnancy planning, the researchers noted. The few studies that have investigated this issue have focused on women’s previous family planning decisions and experience rather than on plans for the future, the researchers noted.

To evaluate how migraine in women influences pregnancy planning, the investigators analyzed data from the American Registry for Migraine Research (ARMR). The registry, which was established by the American Migraine Foundation, collects clinical data about individuals with migraine and other headache disorders from multiple centers.

Participants eligible for the current analysis were women who had been diagnosed with migraine on the basis of the International Classification of Headache Disorders–3 criteria. All completed the ARMR questionnaire between February 2016 and September 2019. The investigators excluded patients with trigeminal autonomic cephalalgia, secondary headache, painful cranial neuropathies, other facial pain, and other headaches.

They identified 895 eligible women with migraine. Of these, 607 completed the pregnancy question. Among those participants, 121 women (19.9%) reported that migraine was a factor in their decision to not become pregnant. Of this group, 70 (11.5%) reported that migraine was a “significant” factor in deciding to not have children, and 8.4% said it was “somewhat” of a factor. The remainder of the cohort (479) reported that migraine had no influence on their pregnancy plans.

There were no between-group differences by race, marital status, employment, or income. This finding suggests that sociodemographic differences “have less impact on pregnancy planning than migraine-specific characteristics like headache frequency and experience with having migraine attacks triggered by menstruation,” Dr. Ishii said.
 

“Substantial burden”

Not surprisingly, women who avoided pregnancy had fewer children than the rest of the sample. About 60% of those who made the decision to not become pregnant had no children, and 72% had not been pregnant since they began experiencing migraine.

Compared with women who reported that migraine had no influence on their pregnancy plans, those who avoided pregnancy were more likely to have chronic migraine at 81.8% versus 70.2%. They were also more likely to have menstrual migraine at 4.1% versus 1%. In addition, women who decided to not have children because of migraine were significantly younger at an average age of 37.5 versus 47.2 years.

The number of days with headache per 3-month interval was 53.9 among women who avoided pregnancy versus 42.5 among the other women. The Migraine Disability Assessment score was also higher for women who avoided pregnancy (132.5) than for it was the other women (91.7), indicating more severe disability.

In addition, more of the women who avoided pregnancy had a history of depression (48.8%) compared with the other women (37.7%). The average score on the Patient Health Questionnaire–4 was higher among women who avoided pregnancy (4.0) than among other women (3.1), which indicates greater anxiety or depression. Among women who avoided pregnancy, 72.5% believed their migraine would worsen during pregnancy, and 68.3% believed that migraine would make pregnancy very difficult.

“Clinicians need to recognize that migraine often has a substantial burden on multiple aspects of life, including one’s plans for having children,” Dr. Ishii said.

“Clinicians should educate their patients who are considering pregnancy about the most likely course of migraine during pregnancy, migraine treatment during pregnancy, and the potential impacts of migraine and its treatment on pregnancy outcomes,” he added.
 

More education needed

Commenting on the study, Susan Hutchinson, MD, director of the Orange County Migraine and Headache Center, Irvine, California, said that not knowing how pregnancy is going to affect patients’ migraines can be “very scary” for women. In addition, patients often wonder what migraine treatments they can safely take once they do become pregnant, said Dr. Hutchinson, who was not involved in the research.

She noted that advantages of the ARMR data are that they are derived from a multicenter study and that migraine diagnoses were made by a headache specialist. A potential limitation of the study is that the population may not reflect outcomes of the millions of women who have migraine and become pregnant but never see a specialist.

“These findings show that more education is needed,” Dr. Hutchinson said.

Most women, especially those who have migraine without aura, note improvement with migraine during pregnancy, primarily because of the high, steady levels of estradiol, especially in the second and third trimesters, she said. In light of this, neurologists should reassure women that migraine is not a contraindication to pregnancy, she added.

There is also a need for additional research to assess how past experience with migraine and pregnancy influences a woman’s comfort level with additional pregnancies. Studies as to which treatments are safest for acute and preventive treatment of migraine during prepregnancy, pregnancy, and lactation are also needed, Dr. Hutchinson noted.

“If women knew they had treatment options that were evidence-based, they might be much more comfortable contemplating a pregnancy,” she said.

Dr. Ishii and Dr. Hutchinson have disclosed no relevant financial relationships.

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

Migraine can significantly influence a woman’s decision to have children, new research shows. Results from a multicenter study of more than 600 women showed that, among participants with migraine, those who were younger, had menstrual migraine, or had chronic migraine were more likely to decide to not become pregnant.

Although women with migraine who avoided pregnancy believed their migraines would worsen during pregnancy or make their pregnancy difficult, previous observational research indicates that migraine often improves during pregnancy.

“Women who avoided pregnancy due to migraine were most concerned that migraine would make raising a child difficult, that the migraine medications they take would have a negative impact on their child’s development, and that their migraine pattern would worsen during or just after pregnancy,” said study investigator Ryotaro Ishii, MD, PhD, a visiting scientist at Mayo Clinic in Phoenix, Arizona.

The findings were presented at the virtual annual meeting of the American Headache Society.
 

Plans for the future

There is a paucity of research on the effects of migraine on pregnancy planning, the researchers noted. The few studies that have investigated this issue have focused on women’s previous family planning decisions and experience rather than on plans for the future, the researchers noted.

To evaluate how migraine in women influences pregnancy planning, the investigators analyzed data from the American Registry for Migraine Research (ARMR). The registry, which was established by the American Migraine Foundation, collects clinical data about individuals with migraine and other headache disorders from multiple centers.

Participants eligible for the current analysis were women who had been diagnosed with migraine on the basis of the International Classification of Headache Disorders–3 criteria. All completed the ARMR questionnaire between February 2016 and September 2019. The investigators excluded patients with trigeminal autonomic cephalalgia, secondary headache, painful cranial neuropathies, other facial pain, and other headaches.

They identified 895 eligible women with migraine. Of these, 607 completed the pregnancy question. Among those participants, 121 women (19.9%) reported that migraine was a factor in their decision to not become pregnant. Of this group, 70 (11.5%) reported that migraine was a “significant” factor in deciding to not have children, and 8.4% said it was “somewhat” of a factor. The remainder of the cohort (479) reported that migraine had no influence on their pregnancy plans.

There were no between-group differences by race, marital status, employment, or income. This finding suggests that sociodemographic differences “have less impact on pregnancy planning than migraine-specific characteristics like headache frequency and experience with having migraine attacks triggered by menstruation,” Dr. Ishii said.
 

“Substantial burden”

Not surprisingly, women who avoided pregnancy had fewer children than the rest of the sample. About 60% of those who made the decision to not become pregnant had no children, and 72% had not been pregnant since they began experiencing migraine.

Compared with women who reported that migraine had no influence on their pregnancy plans, those who avoided pregnancy were more likely to have chronic migraine at 81.8% versus 70.2%. They were also more likely to have menstrual migraine at 4.1% versus 1%. In addition, women who decided to not have children because of migraine were significantly younger at an average age of 37.5 versus 47.2 years.

The number of days with headache per 3-month interval was 53.9 among women who avoided pregnancy versus 42.5 among the other women. The Migraine Disability Assessment score was also higher for women who avoided pregnancy (132.5) than for it was the other women (91.7), indicating more severe disability.

In addition, more of the women who avoided pregnancy had a history of depression (48.8%) compared with the other women (37.7%). The average score on the Patient Health Questionnaire–4 was higher among women who avoided pregnancy (4.0) than among other women (3.1), which indicates greater anxiety or depression. Among women who avoided pregnancy, 72.5% believed their migraine would worsen during pregnancy, and 68.3% believed that migraine would make pregnancy very difficult.

“Clinicians need to recognize that migraine often has a substantial burden on multiple aspects of life, including one’s plans for having children,” Dr. Ishii said.

“Clinicians should educate their patients who are considering pregnancy about the most likely course of migraine during pregnancy, migraine treatment during pregnancy, and the potential impacts of migraine and its treatment on pregnancy outcomes,” he added.
 

More education needed

Commenting on the study, Susan Hutchinson, MD, director of the Orange County Migraine and Headache Center, Irvine, California, said that not knowing how pregnancy is going to affect patients’ migraines can be “very scary” for women. In addition, patients often wonder what migraine treatments they can safely take once they do become pregnant, said Dr. Hutchinson, who was not involved in the research.

She noted that advantages of the ARMR data are that they are derived from a multicenter study and that migraine diagnoses were made by a headache specialist. A potential limitation of the study is that the population may not reflect outcomes of the millions of women who have migraine and become pregnant but never see a specialist.

“These findings show that more education is needed,” Dr. Hutchinson said.

Most women, especially those who have migraine without aura, note improvement with migraine during pregnancy, primarily because of the high, steady levels of estradiol, especially in the second and third trimesters, she said. In light of this, neurologists should reassure women that migraine is not a contraindication to pregnancy, she added.

There is also a need for additional research to assess how past experience with migraine and pregnancy influences a woman’s comfort level with additional pregnancies. Studies as to which treatments are safest for acute and preventive treatment of migraine during prepregnancy, pregnancy, and lactation are also needed, Dr. Hutchinson noted.

“If women knew they had treatment options that were evidence-based, they might be much more comfortable contemplating a pregnancy,” she said.

Dr. Ishii and Dr. Hutchinson have disclosed no relevant financial relationships.

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

Migraine can significantly influence a woman’s decision to have children, new research shows. Results from a multicenter study of more than 600 women showed that, among participants with migraine, those who were younger, had menstrual migraine, or had chronic migraine were more likely to decide to not become pregnant.

Although women with migraine who avoided pregnancy believed their migraines would worsen during pregnancy or make their pregnancy difficult, previous observational research indicates that migraine often improves during pregnancy.

“Women who avoided pregnancy due to migraine were most concerned that migraine would make raising a child difficult, that the migraine medications they take would have a negative impact on their child’s development, and that their migraine pattern would worsen during or just after pregnancy,” said study investigator Ryotaro Ishii, MD, PhD, a visiting scientist at Mayo Clinic in Phoenix, Arizona.

The findings were presented at the virtual annual meeting of the American Headache Society.
 

Plans for the future

There is a paucity of research on the effects of migraine on pregnancy planning, the researchers noted. The few studies that have investigated this issue have focused on women’s previous family planning decisions and experience rather than on plans for the future, the researchers noted.

To evaluate how migraine in women influences pregnancy planning, the investigators analyzed data from the American Registry for Migraine Research (ARMR). The registry, which was established by the American Migraine Foundation, collects clinical data about individuals with migraine and other headache disorders from multiple centers.

Participants eligible for the current analysis were women who had been diagnosed with migraine on the basis of the International Classification of Headache Disorders–3 criteria. All completed the ARMR questionnaire between February 2016 and September 2019. The investigators excluded patients with trigeminal autonomic cephalalgia, secondary headache, painful cranial neuropathies, other facial pain, and other headaches.

They identified 895 eligible women with migraine. Of these, 607 completed the pregnancy question. Among those participants, 121 women (19.9%) reported that migraine was a factor in their decision to not become pregnant. Of this group, 70 (11.5%) reported that migraine was a “significant” factor in deciding to not have children, and 8.4% said it was “somewhat” of a factor. The remainder of the cohort (479) reported that migraine had no influence on their pregnancy plans.

There were no between-group differences by race, marital status, employment, or income. This finding suggests that sociodemographic differences “have less impact on pregnancy planning than migraine-specific characteristics like headache frequency and experience with having migraine attacks triggered by menstruation,” Dr. Ishii said.
 

“Substantial burden”

Not surprisingly, women who avoided pregnancy had fewer children than the rest of the sample. About 60% of those who made the decision to not become pregnant had no children, and 72% had not been pregnant since they began experiencing migraine.

Compared with women who reported that migraine had no influence on their pregnancy plans, those who avoided pregnancy were more likely to have chronic migraine at 81.8% versus 70.2%. They were also more likely to have menstrual migraine at 4.1% versus 1%. In addition, women who decided to not have children because of migraine were significantly younger at an average age of 37.5 versus 47.2 years.

The number of days with headache per 3-month interval was 53.9 among women who avoided pregnancy versus 42.5 among the other women. The Migraine Disability Assessment score was also higher for women who avoided pregnancy (132.5) than for it was the other women (91.7), indicating more severe disability.

In addition, more of the women who avoided pregnancy had a history of depression (48.8%) compared with the other women (37.7%). The average score on the Patient Health Questionnaire–4 was higher among women who avoided pregnancy (4.0) than among other women (3.1), which indicates greater anxiety or depression. Among women who avoided pregnancy, 72.5% believed their migraine would worsen during pregnancy, and 68.3% believed that migraine would make pregnancy very difficult.

“Clinicians need to recognize that migraine often has a substantial burden on multiple aspects of life, including one’s plans for having children,” Dr. Ishii said.

“Clinicians should educate their patients who are considering pregnancy about the most likely course of migraine during pregnancy, migraine treatment during pregnancy, and the potential impacts of migraine and its treatment on pregnancy outcomes,” he added.
 

More education needed

Commenting on the study, Susan Hutchinson, MD, director of the Orange County Migraine and Headache Center, Irvine, California, said that not knowing how pregnancy is going to affect patients’ migraines can be “very scary” for women. In addition, patients often wonder what migraine treatments they can safely take once they do become pregnant, said Dr. Hutchinson, who was not involved in the research.

She noted that advantages of the ARMR data are that they are derived from a multicenter study and that migraine diagnoses were made by a headache specialist. A potential limitation of the study is that the population may not reflect outcomes of the millions of women who have migraine and become pregnant but never see a specialist.

“These findings show that more education is needed,” Dr. Hutchinson said.

Most women, especially those who have migraine without aura, note improvement with migraine during pregnancy, primarily because of the high, steady levels of estradiol, especially in the second and third trimesters, she said. In light of this, neurologists should reassure women that migraine is not a contraindication to pregnancy, she added.

There is also a need for additional research to assess how past experience with migraine and pregnancy influences a woman’s comfort level with additional pregnancies. Studies as to which treatments are safest for acute and preventive treatment of migraine during prepregnancy, pregnancy, and lactation are also needed, Dr. Hutchinson noted.

“If women knew they had treatment options that were evidence-based, they might be much more comfortable contemplating a pregnancy,” she said.

Dr. Ishii and Dr. Hutchinson have disclosed no relevant financial relationships.

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

Here are the stories our MDedge editors across specialties think you need to know about today:

Three stages to COVID-19 brain damage, new review suggests

A new review outlined a three-stage classification of the impact of COVID-19 on the central nervous system and recommended all hospitalized patients with the virus undergo MRI to flag potential neurologic damage and inform postdischarge monitoring. 

In stage 1, viral damage is limited to epithelial cells of the nose and mouth, and in stage 2 blood clots that form in the lungs may travel to the brain, leading to stroke. In stage 3, the virus crosses the blood-brain barrier and invades the brain.

“Our major take-home points are that patients with COVID-19 symptoms, such as shortness of breath, headache, or dizziness, may have neurological symptoms that, at the time of hospitalization, might not be noticed or prioritized, or whose neurological symptoms may become apparent only after they leave the hospital,” said lead author Majid Fotuhi, MD, PhD. The review was published online in the Journal of Alzheimer’s Disease. Read more.
 

Topline results for novel intranasal med to treat opioid overdose

Topline results show positive results for the experimental intranasal nalmefene product OX125 for opioid overdose reversal, Orexo, the drug’s manufacturer, announced.

A crossover, comparative bioavailability study was conducted in healthy volunteers to assess nalmefene absorption of three development formulations of OX125. Preliminary results showed “extensive and rapid absorption” across all three formulations versus an intramuscular injection of nalmefene, Orexo reported.

“As the U.S. heroin crisis has developed to a fentanyl crisis, the medical need for novel and more powerful opioid rescue medications is vast,” Nikolaj Sørensen, president and CEO of Orexo, said in a press release. Read more.

Republican or Democrat, Americans vote for face masks

Most Americans support the required use of face masks in public, along with universal COVID-19 testing, to provide a safe work environment during the pandemic, according to a new report from the Commonwealth Fund.

Results of a recent survey show that 85% of adults believe that it is very or somewhat important to require everyone to wear a face mask “at work, when shopping, and on public transportation,” said Sara R. Collins, PhD, vice president for health care coverage and access at the fund, and associates.

Regarding regular testing, 66% of Republicans and those leaning Republican said that such testing was very/somewhat important to ensure a safe work environment, as did 91% on the Democratic side. Read more.

Weight loss failures drive bariatric surgery regrets

Not all weight loss surgery patients “live happily ever after,” according to Daniel B. Jones, MD. 

A 2014 study of 22 women who underwent weight loss surgery reported lower energy, worse quality of life, and persistent eating disorders.

Of gastric band patients, “almost 20% did not think they made the right decision,” he said. As for RYGP patients, 13% of patients at 1 year and 4 years reported that weight loss surgery caused “some” or “a lot” of negative effects. Read more.

For more on COVID-19, visit our Resource Center. All of our latest news is available on MDedge.com.

Here are the stories our MDedge editors across specialties think you need to know about today:

Three stages to COVID-19 brain damage, new review suggests

A new review outlined a three-stage classification of the impact of COVID-19 on the central nervous system and recommended all hospitalized patients with the virus undergo MRI to flag potential neurologic damage and inform postdischarge monitoring. 

In stage 1, viral damage is limited to epithelial cells of the nose and mouth, and in stage 2 blood clots that form in the lungs may travel to the brain, leading to stroke. In stage 3, the virus crosses the blood-brain barrier and invades the brain.

“Our major take-home points are that patients with COVID-19 symptoms, such as shortness of breath, headache, or dizziness, may have neurological symptoms that, at the time of hospitalization, might not be noticed or prioritized, or whose neurological symptoms may become apparent only after they leave the hospital,” said lead author Majid Fotuhi, MD, PhD. The review was published online in the Journal of Alzheimer’s Disease. Read more.
 

Topline results for novel intranasal med to treat opioid overdose

Topline results show positive results for the experimental intranasal nalmefene product OX125 for opioid overdose reversal, Orexo, the drug’s manufacturer, announced.

A crossover, comparative bioavailability study was conducted in healthy volunteers to assess nalmefene absorption of three development formulations of OX125. Preliminary results showed “extensive and rapid absorption” across all three formulations versus an intramuscular injection of nalmefene, Orexo reported.

“As the U.S. heroin crisis has developed to a fentanyl crisis, the medical need for novel and more powerful opioid rescue medications is vast,” Nikolaj Sørensen, president and CEO of Orexo, said in a press release. Read more.

Republican or Democrat, Americans vote for face masks

Most Americans support the required use of face masks in public, along with universal COVID-19 testing, to provide a safe work environment during the pandemic, according to a new report from the Commonwealth Fund.

Results of a recent survey show that 85% of adults believe that it is very or somewhat important to require everyone to wear a face mask “at work, when shopping, and on public transportation,” said Sara R. Collins, PhD, vice president for health care coverage and access at the fund, and associates.

Regarding regular testing, 66% of Republicans and those leaning Republican said that such testing was very/somewhat important to ensure a safe work environment, as did 91% on the Democratic side. Read more.

Weight loss failures drive bariatric surgery regrets

Not all weight loss surgery patients “live happily ever after,” according to Daniel B. Jones, MD. 

A 2014 study of 22 women who underwent weight loss surgery reported lower energy, worse quality of life, and persistent eating disorders.

Of gastric band patients, “almost 20% did not think they made the right decision,” he said. As for RYGP patients, 13% of patients at 1 year and 4 years reported that weight loss surgery caused “some” or “a lot” of negative effects. Read more.

For more on COVID-19, visit our Resource Center. All of our latest news is available on MDedge.com.

Here are the stories our MDedge editors across specialties think you need to know about today:

Three stages to COVID-19 brain damage, new review suggests

A new review outlined a three-stage classification of the impact of COVID-19 on the central nervous system and recommended all hospitalized patients with the virus undergo MRI to flag potential neurologic damage and inform postdischarge monitoring. 

In stage 1, viral damage is limited to epithelial cells of the nose and mouth, and in stage 2 blood clots that form in the lungs may travel to the brain, leading to stroke. In stage 3, the virus crosses the blood-brain barrier and invades the brain.

“Our major take-home points are that patients with COVID-19 symptoms, such as shortness of breath, headache, or dizziness, may have neurological symptoms that, at the time of hospitalization, might not be noticed or prioritized, or whose neurological symptoms may become apparent only after they leave the hospital,” said lead author Majid Fotuhi, MD, PhD. The review was published online in the Journal of Alzheimer’s Disease. Read more.
 

Topline results for novel intranasal med to treat opioid overdose

Topline results show positive results for the experimental intranasal nalmefene product OX125 for opioid overdose reversal, Orexo, the drug’s manufacturer, announced.

A crossover, comparative bioavailability study was conducted in healthy volunteers to assess nalmefene absorption of three development formulations of OX125. Preliminary results showed “extensive and rapid absorption” across all three formulations versus an intramuscular injection of nalmefene, Orexo reported.

“As the U.S. heroin crisis has developed to a fentanyl crisis, the medical need for novel and more powerful opioid rescue medications is vast,” Nikolaj Sørensen, president and CEO of Orexo, said in a press release. Read more.

Republican or Democrat, Americans vote for face masks

Most Americans support the required use of face masks in public, along with universal COVID-19 testing, to provide a safe work environment during the pandemic, according to a new report from the Commonwealth Fund.

Results of a recent survey show that 85% of adults believe that it is very or somewhat important to require everyone to wear a face mask “at work, when shopping, and on public transportation,” said Sara R. Collins, PhD, vice president for health care coverage and access at the fund, and associates.

Regarding regular testing, 66% of Republicans and those leaning Republican said that such testing was very/somewhat important to ensure a safe work environment, as did 91% on the Democratic side. Read more.

Weight loss failures drive bariatric surgery regrets

Not all weight loss surgery patients “live happily ever after,” according to Daniel B. Jones, MD. 

A 2014 study of 22 women who underwent weight loss surgery reported lower energy, worse quality of life, and persistent eating disorders.

Of gastric band patients, “almost 20% did not think they made the right decision,” he said. As for RYGP patients, 13% of patients at 1 year and 4 years reported that weight loss surgery caused “some” or “a lot” of negative effects. Read more.

For more on COVID-19, visit our Resource Center. All of our latest news is available on MDedge.com.

A systematic two-stent approach to complex coronary bifurcation lesions led to significantly improved clinical outcomes at 1 year, compared with the long-popular provisional stenting technique, in the first randomized trial to prospectively validate a standardized definition of what constitutes a complex bifurcation.

Since the double-kissing (DK) crush technique was employed in 78% of the systematic two-stent procedures, and the two-stent approach provided superior outcomes, it’s reasonable to infer that the DK crush is the preferred technique in patients with truly complex coronary bifurcation lesions (CBLs), Shao-Liang Chen, MD, reported at the virtual annual meeting of the European Association of Percutaneous Cardiovascular Interventions.

He presented the results of the DEFINITION II trial, a multinational trial in which 653 patients at 49 medical centers who fulfilled the criteria for complex CBLs were randomized to a systematic two-stent approach or provisional stenting, with a second stent deployed by interventionalists as needed. Dr. Chen, director of the cardiology department and deputy president of Nanjing (China) Medical University, and coworkers had previously published their standardized criteria for CBLs (JACC Cardiovasc Interv. 2014 Nov;7[11]:1266-76), which they developed by analysis of a large bifurcation cohort; however, until the DEFINITION II trial, the criteria had never been used in a prospective randomized trial.

According to the standardized definition developed by Dr. Chen and associates, complex coronary bifurcation lesions must meet one major and two minor criteria.

Major criteria:

• A side branch lesion length of at least 10 mm with a diameter stenosis of 70% or more for distal left main bifurcation lesions.
• For non–left main bifurcation lesions, a side branch diameter stenosis of at least 90% along with a side branch lesion length of at least 10 mm.

Minor criteria:

• Moderate to severe calcification multiple lesions
• Bifurcation angle of <45 degrees or >70 degrees
• Thrombus-containing lesions
• Main vessel residual diameter <2.5 mm
• Main vessel lesion length of at least 25 mm

Interventionalists were strongly encouraged to utilize the DK crush or culotte stenting techniques in patients randomized to the systematic two-stent approach. In contrast, in the provisional stenting group, where 23% of patients received a second stent, that stent was placed using the T and small protrusion technique 64% of the time.

The primary endpoint was the target lesion failure rate at 1-year of follow-up. Target lesion failure was a composite comprising cardiac death, target vessel MI, and clinically driven target vessel revascularization. The rate was 6.1% in the systematic two-stent group and 11.4% with provisional stenting, for a highly significant 48% relative risk reduction. The difference was driven largely by the systematic two-stent group’s lower rates of target vessel MI – 3.0% versus 7.1% with provisional stenting – and target lesion revascularization, with rates of 2.4% and 5.5%, respectively.

“The underlying mechanisms for the increased target vessel MI rate after the provisional stenting technique are unclear, and further study is urgently warranted,” Dr. Chen said.

There were no significant between-group differences in all-cause mortality or cardiac death, although both endpoints were numerically less frequent in the two-stent group.

The primary safety outcome was the 12-month rate of definite or probable stent thrombosis. This occurred in 1.2% of the systematic two-stent group and 2.5% of the provisional stent patients, a nonsignificant difference.

Bruce Jancin/MDedge News

Discussant Davide Capodanno, MD, PhD, declared the DEFINITE II trial to be “another success for this DK crush technique everyone is talking about recently.”

He noted that, in a recent meta-analysis of 21 randomized, controlled trials including 5,711 patients with bifurcation lesions treated using five different percutaneous coronary intervention techniques, DK crush stood out from the pack. Particularly impressive was the finding that the target lesion revascularization rate in patients treated using the DK crush technique was 64% lower than with provisional stenting (JACC Cardiovasc Interv. 2020 Jun 22;13[12]:1432-44).

Dr. Capodanno said that, although the DEFINITE II results were strongly positive in favor of the systematic two-stent approach and DK crush technique, he’s not convinced of the generalizability of the study results.

“These investigators are very expert in this technique. They invented it. They’ve been using it for 10 years. So of course you may expect excellent results when you have masters of this technique,” observed Dr. Capodanno, a cardiologist at the University of Catania (Italy).

Independent replication of the DEFINITE II findings is needed. Fortunately, two ongoing randomized trials are addressing the issue of how to best treat bifurcation lesions. The EBC-MAIN trial is comparing the provisional approach with the systematic two-stent strategy in patients with left main bifurcation lesions; the study will include the DK crush as well as culotte and TAP PCI techniques, with a primary endpoint consisting of the 12-month rate of death, MI, and target lesion revascularization. And the BBK-3 trial will compare systematic two-stent strategies pitting the culotte against the DK crush, with the primary endpoint being the 9-month rate of angiographic restenosis by quantitative coronary angiography.

“After these trials are complete, we’ll probably know much more about the tailoring of bifurcation techniques for particular patients,” according to Dr. Capodanno.

Simultaneous with Dr. Chen’s presentation, the results of the DEFINITION II trial were published online (Eur Heart J. 2020 Jun 26.doi: 10.1093/eurheartj/ehaa543).

Dr. Chen and Dr. Capodanno reported having no financial conflicts of interest regarding the study, which was funded mainly by the National Science Foundation of China.

bjancin@mdedge.com

A systematic two-stent approach to complex coronary bifurcation lesions led to significantly improved clinical outcomes at 1 year, compared with the long-popular provisional stenting technique, in the first randomized trial to prospectively validate a standardized definition of what constitutes a complex bifurcation.

Since the double-kissing (DK) crush technique was employed in 78% of the systematic two-stent procedures, and the two-stent approach provided superior outcomes, it’s reasonable to infer that the DK crush is the preferred technique in patients with truly complex coronary bifurcation lesions (CBLs), Shao-Liang Chen, MD, reported at the virtual annual meeting of the European Association of Percutaneous Cardiovascular Interventions.

He presented the results of the DEFINITION II trial, a multinational trial in which 653 patients at 49 medical centers who fulfilled the criteria for complex CBLs were randomized to a systematic two-stent approach or provisional stenting, with a second stent deployed by interventionalists as needed. Dr. Chen, director of the cardiology department and deputy president of Nanjing (China) Medical University, and coworkers had previously published their standardized criteria for CBLs (JACC Cardiovasc Interv. 2014 Nov;7[11]:1266-76), which they developed by analysis of a large bifurcation cohort; however, until the DEFINITION II trial, the criteria had never been used in a prospective randomized trial.

According to the standardized definition developed by Dr. Chen and associates, complex coronary bifurcation lesions must meet one major and two minor criteria.

Major criteria:

• A side branch lesion length of at least 10 mm with a diameter stenosis of 70% or more for distal left main bifurcation lesions.
• For non–left main bifurcation lesions, a side branch diameter stenosis of at least 90% along with a side branch lesion length of at least 10 mm.

Minor criteria:

• Moderate to severe calcification multiple lesions
• Bifurcation angle of <45 degrees or >70 degrees
• Thrombus-containing lesions
• Main vessel residual diameter <2.5 mm
• Main vessel lesion length of at least 25 mm

Interventionalists were strongly encouraged to utilize the DK crush or culotte stenting techniques in patients randomized to the systematic two-stent approach. In contrast, in the provisional stenting group, where 23% of patients received a second stent, that stent was placed using the T and small protrusion technique 64% of the time.

The primary endpoint was the target lesion failure rate at 1-year of follow-up. Target lesion failure was a composite comprising cardiac death, target vessel MI, and clinically driven target vessel revascularization. The rate was 6.1% in the systematic two-stent group and 11.4% with provisional stenting, for a highly significant 48% relative risk reduction. The difference was driven largely by the systematic two-stent group’s lower rates of target vessel MI – 3.0% versus 7.1% with provisional stenting – and target lesion revascularization, with rates of 2.4% and 5.5%, respectively.

“The underlying mechanisms for the increased target vessel MI rate after the provisional stenting technique are unclear, and further study is urgently warranted,” Dr. Chen said.

There were no significant between-group differences in all-cause mortality or cardiac death, although both endpoints were numerically less frequent in the two-stent group.

The primary safety outcome was the 12-month rate of definite or probable stent thrombosis. This occurred in 1.2% of the systematic two-stent group and 2.5% of the provisional stent patients, a nonsignificant difference.

Bruce Jancin/MDedge News

Discussant Davide Capodanno, MD, PhD, declared the DEFINITE II trial to be “another success for this DK crush technique everyone is talking about recently.”

He noted that, in a recent meta-analysis of 21 randomized, controlled trials including 5,711 patients with bifurcation lesions treated using five different percutaneous coronary intervention techniques, DK crush stood out from the pack. Particularly impressive was the finding that the target lesion revascularization rate in patients treated using the DK crush technique was 64% lower than with provisional stenting (JACC Cardiovasc Interv. 2020 Jun 22;13[12]:1432-44).

Dr. Capodanno said that, although the DEFINITE II results were strongly positive in favor of the systematic two-stent approach and DK crush technique, he’s not convinced of the generalizability of the study results.

“These investigators are very expert in this technique. They invented it. They’ve been using it for 10 years. So of course you may expect excellent results when you have masters of this technique,” observed Dr. Capodanno, a cardiologist at the University of Catania (Italy).

Independent replication of the DEFINITE II findings is needed. Fortunately, two ongoing randomized trials are addressing the issue of how to best treat bifurcation lesions. The EBC-MAIN trial is comparing the provisional approach with the systematic two-stent strategy in patients with left main bifurcation lesions; the study will include the DK crush as well as culotte and TAP PCI techniques, with a primary endpoint consisting of the 12-month rate of death, MI, and target lesion revascularization. And the BBK-3 trial will compare systematic two-stent strategies pitting the culotte against the DK crush, with the primary endpoint being the 9-month rate of angiographic restenosis by quantitative coronary angiography.

“After these trials are complete, we’ll probably know much more about the tailoring of bifurcation techniques for particular patients,” according to Dr. Capodanno.

Simultaneous with Dr. Chen’s presentation, the results of the DEFINITION II trial were published online (Eur Heart J. 2020 Jun 26.doi: 10.1093/eurheartj/ehaa543).

Dr. Chen and Dr. Capodanno reported having no financial conflicts of interest regarding the study, which was funded mainly by the National Science Foundation of China.

bjancin@mdedge.com

A systematic two-stent approach to complex coronary bifurcation lesions led to significantly improved clinical outcomes at 1 year, compared with the long-popular provisional stenting technique, in the first randomized trial to prospectively validate a standardized definition of what constitutes a complex bifurcation.

Since the double-kissing (DK) crush technique was employed in 78% of the systematic two-stent procedures, and the two-stent approach provided superior outcomes, it’s reasonable to infer that the DK crush is the preferred technique in patients with truly complex coronary bifurcation lesions (CBLs), Shao-Liang Chen, MD, reported at the virtual annual meeting of the European Association of Percutaneous Cardiovascular Interventions.

He presented the results of the DEFINITION II trial, a multinational trial in which 653 patients at 49 medical centers who fulfilled the criteria for complex CBLs were randomized to a systematic two-stent approach or provisional stenting, with a second stent deployed by interventionalists as needed. Dr. Chen, director of the cardiology department and deputy president of Nanjing (China) Medical University, and coworkers had previously published their standardized criteria for CBLs (JACC Cardiovasc Interv. 2014 Nov;7[11]:1266-76), which they developed by analysis of a large bifurcation cohort; however, until the DEFINITION II trial, the criteria had never been used in a prospective randomized trial.

According to the standardized definition developed by Dr. Chen and associates, complex coronary bifurcation lesions must meet one major and two minor criteria.

Major criteria:

• A side branch lesion length of at least 10 mm with a diameter stenosis of 70% or more for distal left main bifurcation lesions.
• For non–left main bifurcation lesions, a side branch diameter stenosis of at least 90% along with a side branch lesion length of at least 10 mm.

Minor criteria:

• Moderate to severe calcification multiple lesions
• Bifurcation angle of <45 degrees or >70 degrees
• Thrombus-containing lesions
• Main vessel residual diameter <2.5 mm
• Main vessel lesion length of at least 25 mm

Interventionalists were strongly encouraged to utilize the DK crush or culotte stenting techniques in patients randomized to the systematic two-stent approach. In contrast, in the provisional stenting group, where 23% of patients received a second stent, that stent was placed using the T and small protrusion technique 64% of the time.

The primary endpoint was the target lesion failure rate at 1-year of follow-up. Target lesion failure was a composite comprising cardiac death, target vessel MI, and clinically driven target vessel revascularization. The rate was 6.1% in the systematic two-stent group and 11.4% with provisional stenting, for a highly significant 48% relative risk reduction. The difference was driven largely by the systematic two-stent group’s lower rates of target vessel MI – 3.0% versus 7.1% with provisional stenting – and target lesion revascularization, with rates of 2.4% and 5.5%, respectively.

“The underlying mechanisms for the increased target vessel MI rate after the provisional stenting technique are unclear, and further study is urgently warranted,” Dr. Chen said.

There were no significant between-group differences in all-cause mortality or cardiac death, although both endpoints were numerically less frequent in the two-stent group.

The primary safety outcome was the 12-month rate of definite or probable stent thrombosis. This occurred in 1.2% of the systematic two-stent group and 2.5% of the provisional stent patients, a nonsignificant difference.

Bruce Jancin/MDedge News

Discussant Davide Capodanno, MD, PhD, declared the DEFINITE II trial to be “another success for this DK crush technique everyone is talking about recently.”

He noted that, in a recent meta-analysis of 21 randomized, controlled trials including 5,711 patients with bifurcation lesions treated using five different percutaneous coronary intervention techniques, DK crush stood out from the pack. Particularly impressive was the finding that the target lesion revascularization rate in patients treated using the DK crush technique was 64% lower than with provisional stenting (JACC Cardiovasc Interv. 2020 Jun 22;13[12]:1432-44).

Dr. Capodanno said that, although the DEFINITE II results were strongly positive in favor of the systematic two-stent approach and DK crush technique, he’s not convinced of the generalizability of the study results.

“These investigators are very expert in this technique. They invented it. They’ve been using it for 10 years. So of course you may expect excellent results when you have masters of this technique,” observed Dr. Capodanno, a cardiologist at the University of Catania (Italy).

Independent replication of the DEFINITE II findings is needed. Fortunately, two ongoing randomized trials are addressing the issue of how to best treat bifurcation lesions. The EBC-MAIN trial is comparing the provisional approach with the systematic two-stent strategy in patients with left main bifurcation lesions; the study will include the DK crush as well as culotte and TAP PCI techniques, with a primary endpoint consisting of the 12-month rate of death, MI, and target lesion revascularization. And the BBK-3 trial will compare systematic two-stent strategies pitting the culotte against the DK crush, with the primary endpoint being the 9-month rate of angiographic restenosis by quantitative coronary angiography.

“After these trials are complete, we’ll probably know much more about the tailoring of bifurcation techniques for particular patients,” according to Dr. Capodanno.

Simultaneous with Dr. Chen’s presentation, the results of the DEFINITION II trial were published online (Eur Heart J. 2020 Jun 26.doi: 10.1093/eurheartj/ehaa543).

Dr. Chen and Dr. Capodanno reported having no financial conflicts of interest regarding the study, which was funded mainly by the National Science Foundation of China.

bjancin@mdedge.com

Patients hospitalized for sepsis are more likely to require readmission within a month after discharge if they live in disadvantaged neighborhoods, according to a study published in Critical Care Medicine.

The association between living in a disadvantaged neighborhood and 30-day readmission remained significant even after adjustment for “individual demographic variables, active tobacco use, length of index hospitalization, severity of acute and chronic morbidity, and place of initial discharge,” wrote Panagis Galiatsatos, MD, of Johns Hopkins University in Baltimore, and colleagues.

“Our findings suggest the need for interventions that emphasize neighborhood-level socioeconomic variables in addition to individual-level efforts in an effort to promote and achieve health equity for patients who survive a hospitalization due to sepsis,” the authors wrote. “With a third of our cohort rehospitalized with infections, and other studies emphasizing that the most common readmission diagnosis was infection, attention toward both anticipating and attenuating the risk of infection in sepsis survivors, especially among those who live in higher risk neighborhoods, must be a priority for the prevention of readmissions.”

Although she did not find the study results surprising, Eva DuGoff, PhD, a senior managing consultant with the Berkeley Research Group and a visiting assistant professor at University of Maryland School of Public Health, College Park, said in an interview that she was impressed with how clinically rigorous the analysis was, both in confirming an accurate sepsis diagnosis and in using the more refined measure of the Area Deprivation Index (ADI) to assess neighborhood disadvantage.

“I think it makes sense that people who have less means and are in neighborhoods with fewer resources would run into more issues and would need to return to the hospital, above and beyond the clinical risk factors, such as smoking and chronic conditions,” said Dr. DuGoff, who studies health disparities but was not involved in this study.

Shayla N.M. Durfey MD, ScM, a pediatric resident at Hasbro Children’s Hospital in Providence, R.I., said in an interview she was similarly unsurprised by the findings.

“People who live in disadvantaged neighborhoods may have less access to walking spaces, healthy food, and safe housing and more exposure to poor air quality, toxic stress, and violence – any of which can negatively impact health or recovery from illness through stress responses, nutritional deficiencies, or comorbidities, such as reactive airway disease, obesity, hypertension, and diabetes,” said Dr. Durfey, who studies health disparities but was not involved in this study. “Our research has found these neighborhood-level factors often matter above and beyond individual social determinants of health.”

Dr. Galiatsatos and associates conducted a retrospective study in Baltimore that compared readmission rates in 2017 at Johns Hopkins Bayview Medical Center among patients discharged after a hospitalization for sepsis, coded via ICD-10. They relied on the ADI to categorize the neighborhoods of patients’ residential addresses. The ADI rates various socioeconomic components, including income, education, employment, and housing characteristics, on a scale of 1-100 in geographic blocks, with higher score indicating a greater level of disadvantage.

Among 647 hospitalized patients with an ICD-10 code of sepsis who also met criteria for sepsis or septic shock per the Sepsis-3 definition, 17.9% were excluded from the analysis because they died or were transferred to hospice care. The other 531 patients had an average age of 61, and just under one-third (30.9%) were active smokers. Their average length of stay was 6.9 days, with a mean Charlson Comorbidity Index of 4.2 and a mean Sequential Organ Failure Assessment score of 4.9.

The average ADI for all the patients was 54.2, but the average score was 63 for the 22% of patients who were readmitted within 30 days of initial discharge, compared with an average 51.8 for patients not readmitted (P < .001).

Among those 117 readmitted, “39 patients had a reinfection, 68 had an exacerbation of their chronic conditions, and 10 were admitted for ‘concerning symptoms’ without a primary admitting diagnosis,” the investigators reported. Because “a third of our cohort was readmitted with an infection, it is possible that more disadvantaged neighborhoods created more challenges for a person’s immune system, which may be compromised after recovering from sepsis.”

Dr. DuGoff further noted that health literacy may be lower among people living in less advantaged neighborhoods.

“A number of studies suggest when patients leave the hospital, they’re not sure what they need to do. The language is complicated, and it’s hard to know what kind of medication to take when, and when you’re supposed to return to the doctor or the hospital,” Dr. DuGoff said. “Managing all of that can be pretty scary for people, particularly after a traumatic experience with sepsis at the hospital.”

Most patients had been discharged home (67.3%), but the 31.6% discharged to a skilled nursing facility had a greater likelihood of readmission, compared with those discharged home (P < .01); 1% were discharged to acute rehabilitation. The average length of stay during the index hospitalization was also greater for those readmitted (8.7 days) than for those not readmitted (6.4 days). The groups did not differ in terms of their acute organ dysfunction or severity of their comorbidities.

However, even after adjustment for these factors, “neighborhood disadvantage remained significantly associated with 30-day rehospitalization in patients who were discharged with sepsis,” the authors said. Specifically, each additional standard deviation greater in patients’ ADI was associated with increased risk of 30-day readmission (P < .001).

“Given that the ADI is a composite score, we cannot identify which component is the predominant driver of rehospitalizations for patients who survive sepsis,” the authors wrote. “However, all components that make up the index are intertwined, and policy efforts targeting one (i.e., unemployment) will likely impact others (i.e., housing).”

Dr. Durfey said that medical schools have not traditionally provided training related to management of social risk factors, although this is changing in more recent curricula. But the findings still have clinical relevance for practitioners.

“Certainly, the first step is awareness of where and how patients live and being mindful of how treatment plans may be impacted by social factors at both the individual and community levels,” Dr. Durfey said. “An important part of this is working in partnership with social workers and case managers. Importantly, clinicians can also partner with disadvantaged communities to advocate for improved conditions through policy change and act as expert witnesses to how neighborhood level factors impact health.”

Dr. DuGoff also wondered what implications these findings might have currently, with regards to COVID-19.

“People living in disadvantaged neighborhoods are already at higher risk for getting the disease, and this study raises really good questions about how we should be monitoring discharge now in anticipation of these types of issues,” she said.

The authors noted that their study is cross-sectional and cannot indicate causation, and the findings of a single urban institution may not be generalizable elsewhere. They also did not consider what interventions individual patients had during their index hospitalization that could have increased frailty.

The study did not note external funding. One coauthor of the study, Suchi Saria, PhD, reported receiving honoraria and travel reimbursement from two dozen biotechnology companies for keynotes and advisory board service; she also holds equity in Patient Ping and Bayesian Health. The other authors reported no industry disclosures. In addition to consulting for Berkeley Research Group, Dr. DuGoff has received a past honorarium from Zimmer Biomet. Dr. Durfey has no disclosures.

SOURCE: Galiatsatos P et al. Crit Care Med. 2020 Jun;48(6):808-14.

Patients hospitalized for sepsis are more likely to require readmission within a month after discharge if they live in disadvantaged neighborhoods, according to a study published in Critical Care Medicine.

The association between living in a disadvantaged neighborhood and 30-day readmission remained significant even after adjustment for “individual demographic variables, active tobacco use, length of index hospitalization, severity of acute and chronic morbidity, and place of initial discharge,” wrote Panagis Galiatsatos, MD, of Johns Hopkins University in Baltimore, and colleagues.

“Our findings suggest the need for interventions that emphasize neighborhood-level socioeconomic variables in addition to individual-level efforts in an effort to promote and achieve health equity for patients who survive a hospitalization due to sepsis,” the authors wrote. “With a third of our cohort rehospitalized with infections, and other studies emphasizing that the most common readmission diagnosis was infection, attention toward both anticipating and attenuating the risk of infection in sepsis survivors, especially among those who live in higher risk neighborhoods, must be a priority for the prevention of readmissions.”

Although she did not find the study results surprising, Eva DuGoff, PhD, a senior managing consultant with the Berkeley Research Group and a visiting assistant professor at University of Maryland School of Public Health, College Park, said in an interview that she was impressed with how clinically rigorous the analysis was, both in confirming an accurate sepsis diagnosis and in using the more refined measure of the Area Deprivation Index (ADI) to assess neighborhood disadvantage.

“I think it makes sense that people who have less means and are in neighborhoods with fewer resources would run into more issues and would need to return to the hospital, above and beyond the clinical risk factors, such as smoking and chronic conditions,” said Dr. DuGoff, who studies health disparities but was not involved in this study.

Shayla N.M. Durfey MD, ScM, a pediatric resident at Hasbro Children’s Hospital in Providence, R.I., said in an interview she was similarly unsurprised by the findings.

“People who live in disadvantaged neighborhoods may have less access to walking spaces, healthy food, and safe housing and more exposure to poor air quality, toxic stress, and violence – any of which can negatively impact health or recovery from illness through stress responses, nutritional deficiencies, or comorbidities, such as reactive airway disease, obesity, hypertension, and diabetes,” said Dr. Durfey, who studies health disparities but was not involved in this study. “Our research has found these neighborhood-level factors often matter above and beyond individual social determinants of health.”

Dr. Galiatsatos and associates conducted a retrospective study in Baltimore that compared readmission rates in 2017 at Johns Hopkins Bayview Medical Center among patients discharged after a hospitalization for sepsis, coded via ICD-10. They relied on the ADI to categorize the neighborhoods of patients’ residential addresses. The ADI rates various socioeconomic components, including income, education, employment, and housing characteristics, on a scale of 1-100 in geographic blocks, with higher score indicating a greater level of disadvantage.

Among 647 hospitalized patients with an ICD-10 code of sepsis who also met criteria for sepsis or septic shock per the Sepsis-3 definition, 17.9% were excluded from the analysis because they died or were transferred to hospice care. The other 531 patients had an average age of 61, and just under one-third (30.9%) were active smokers. Their average length of stay was 6.9 days, with a mean Charlson Comorbidity Index of 4.2 and a mean Sequential Organ Failure Assessment score of 4.9.

The average ADI for all the patients was 54.2, but the average score was 63 for the 22% of patients who were readmitted within 30 days of initial discharge, compared with an average 51.8 for patients not readmitted (P < .001).

Among those 117 readmitted, “39 patients had a reinfection, 68 had an exacerbation of their chronic conditions, and 10 were admitted for ‘concerning symptoms’ without a primary admitting diagnosis,” the investigators reported. Because “a third of our cohort was readmitted with an infection, it is possible that more disadvantaged neighborhoods created more challenges for a person’s immune system, which may be compromised after recovering from sepsis.”

Dr. DuGoff further noted that health literacy may be lower among people living in less advantaged neighborhoods.

“A number of studies suggest when patients leave the hospital, they’re not sure what they need to do. The language is complicated, and it’s hard to know what kind of medication to take when, and when you’re supposed to return to the doctor or the hospital,” Dr. DuGoff said. “Managing all of that can be pretty scary for people, particularly after a traumatic experience with sepsis at the hospital.”

Most patients had been discharged home (67.3%), but the 31.6% discharged to a skilled nursing facility had a greater likelihood of readmission, compared with those discharged home (P < .01); 1% were discharged to acute rehabilitation. The average length of stay during the index hospitalization was also greater for those readmitted (8.7 days) than for those not readmitted (6.4 days). The groups did not differ in terms of their acute organ dysfunction or severity of their comorbidities.

However, even after adjustment for these factors, “neighborhood disadvantage remained significantly associated with 30-day rehospitalization in patients who were discharged with sepsis,” the authors said. Specifically, each additional standard deviation greater in patients’ ADI was associated with increased risk of 30-day readmission (P < .001).

“Given that the ADI is a composite score, we cannot identify which component is the predominant driver of rehospitalizations for patients who survive sepsis,” the authors wrote. “However, all components that make up the index are intertwined, and policy efforts targeting one (i.e., unemployment) will likely impact others (i.e., housing).”

Dr. Durfey said that medical schools have not traditionally provided training related to management of social risk factors, although this is changing in more recent curricula. But the findings still have clinical relevance for practitioners.

“Certainly, the first step is awareness of where and how patients live and being mindful of how treatment plans may be impacted by social factors at both the individual and community levels,” Dr. Durfey said. “An important part of this is working in partnership with social workers and case managers. Importantly, clinicians can also partner with disadvantaged communities to advocate for improved conditions through policy change and act as expert witnesses to how neighborhood level factors impact health.”

Dr. DuGoff also wondered what implications these findings might have currently, with regards to COVID-19.

“People living in disadvantaged neighborhoods are already at higher risk for getting the disease, and this study raises really good questions about how we should be monitoring discharge now in anticipation of these types of issues,” she said.

The authors noted that their study is cross-sectional and cannot indicate causation, and the findings of a single urban institution may not be generalizable elsewhere. They also did not consider what interventions individual patients had during their index hospitalization that could have increased frailty.

The study did not note external funding. One coauthor of the study, Suchi Saria, PhD, reported receiving honoraria and travel reimbursement from two dozen biotechnology companies for keynotes and advisory board service; she also holds equity in Patient Ping and Bayesian Health. The other authors reported no industry disclosures. In addition to consulting for Berkeley Research Group, Dr. DuGoff has received a past honorarium from Zimmer Biomet. Dr. Durfey has no disclosures.

SOURCE: Galiatsatos P et al. Crit Care Med. 2020 Jun;48(6):808-14.

Patients hospitalized for sepsis are more likely to require readmission within a month after discharge if they live in disadvantaged neighborhoods, according to a study published in Critical Care Medicine.

The association between living in a disadvantaged neighborhood and 30-day readmission remained significant even after adjustment for “individual demographic variables, active tobacco use, length of index hospitalization, severity of acute and chronic morbidity, and place of initial discharge,” wrote Panagis Galiatsatos, MD, of Johns Hopkins University in Baltimore, and colleagues.

“Our findings suggest the need for interventions that emphasize neighborhood-level socioeconomic variables in addition to individual-level efforts in an effort to promote and achieve health equity for patients who survive a hospitalization due to sepsis,” the authors wrote. “With a third of our cohort rehospitalized with infections, and other studies emphasizing that the most common readmission diagnosis was infection, attention toward both anticipating and attenuating the risk of infection in sepsis survivors, especially among those who live in higher risk neighborhoods, must be a priority for the prevention of readmissions.”

Although she did not find the study results surprising, Eva DuGoff, PhD, a senior managing consultant with the Berkeley Research Group and a visiting assistant professor at University of Maryland School of Public Health, College Park, said in an interview that she was impressed with how clinically rigorous the analysis was, both in confirming an accurate sepsis diagnosis and in using the more refined measure of the Area Deprivation Index (ADI) to assess neighborhood disadvantage.

“I think it makes sense that people who have less means and are in neighborhoods with fewer resources would run into more issues and would need to return to the hospital, above and beyond the clinical risk factors, such as smoking and chronic conditions,” said Dr. DuGoff, who studies health disparities but was not involved in this study.

Shayla N.M. Durfey MD, ScM, a pediatric resident at Hasbro Children’s Hospital in Providence, R.I., said in an interview she was similarly unsurprised by the findings.

“People who live in disadvantaged neighborhoods may have less access to walking spaces, healthy food, and safe housing and more exposure to poor air quality, toxic stress, and violence – any of which can negatively impact health or recovery from illness through stress responses, nutritional deficiencies, or comorbidities, such as reactive airway disease, obesity, hypertension, and diabetes,” said Dr. Durfey, who studies health disparities but was not involved in this study. “Our research has found these neighborhood-level factors often matter above and beyond individual social determinants of health.”

Dr. Galiatsatos and associates conducted a retrospective study in Baltimore that compared readmission rates in 2017 at Johns Hopkins Bayview Medical Center among patients discharged after a hospitalization for sepsis, coded via ICD-10. They relied on the ADI to categorize the neighborhoods of patients’ residential addresses. The ADI rates various socioeconomic components, including income, education, employment, and housing characteristics, on a scale of 1-100 in geographic blocks, with higher score indicating a greater level of disadvantage.

Among 647 hospitalized patients with an ICD-10 code of sepsis who also met criteria for sepsis or septic shock per the Sepsis-3 definition, 17.9% were excluded from the analysis because they died or were transferred to hospice care. The other 531 patients had an average age of 61, and just under one-third (30.9%) were active smokers. Their average length of stay was 6.9 days, with a mean Charlson Comorbidity Index of 4.2 and a mean Sequential Organ Failure Assessment score of 4.9.

The average ADI for all the patients was 54.2, but the average score was 63 for the 22% of patients who were readmitted within 30 days of initial discharge, compared with an average 51.8 for patients not readmitted (P < .001).

Among those 117 readmitted, “39 patients had a reinfection, 68 had an exacerbation of their chronic conditions, and 10 were admitted for ‘concerning symptoms’ without a primary admitting diagnosis,” the investigators reported. Because “a third of our cohort was readmitted with an infection, it is possible that more disadvantaged neighborhoods created more challenges for a person’s immune system, which may be compromised after recovering from sepsis.”

Dr. DuGoff further noted that health literacy may be lower among people living in less advantaged neighborhoods.

“A number of studies suggest when patients leave the hospital, they’re not sure what they need to do. The language is complicated, and it’s hard to know what kind of medication to take when, and when you’re supposed to return to the doctor or the hospital,” Dr. DuGoff said. “Managing all of that can be pretty scary for people, particularly after a traumatic experience with sepsis at the hospital.”

Most patients had been discharged home (67.3%), but the 31.6% discharged to a skilled nursing facility had a greater likelihood of readmission, compared with those discharged home (P < .01); 1% were discharged to acute rehabilitation. The average length of stay during the index hospitalization was also greater for those readmitted (8.7 days) than for those not readmitted (6.4 days). The groups did not differ in terms of their acute organ dysfunction or severity of their comorbidities.

However, even after adjustment for these factors, “neighborhood disadvantage remained significantly associated with 30-day rehospitalization in patients who were discharged with sepsis,” the authors said. Specifically, each additional standard deviation greater in patients’ ADI was associated with increased risk of 30-day readmission (P < .001).

“Given that the ADI is a composite score, we cannot identify which component is the predominant driver of rehospitalizations for patients who survive sepsis,” the authors wrote. “However, all components that make up the index are intertwined, and policy efforts targeting one (i.e., unemployment) will likely impact others (i.e., housing).”

Dr. Durfey said that medical schools have not traditionally provided training related to management of social risk factors, although this is changing in more recent curricula. But the findings still have clinical relevance for practitioners.

“Certainly, the first step is awareness of where and how patients live and being mindful of how treatment plans may be impacted by social factors at both the individual and community levels,” Dr. Durfey said. “An important part of this is working in partnership with social workers and case managers. Importantly, clinicians can also partner with disadvantaged communities to advocate for improved conditions through policy change and act as expert witnesses to how neighborhood level factors impact health.”

Dr. DuGoff also wondered what implications these findings might have currently, with regards to COVID-19.

“People living in disadvantaged neighborhoods are already at higher risk for getting the disease, and this study raises really good questions about how we should be monitoring discharge now in anticipation of these types of issues,” she said.

The authors noted that their study is cross-sectional and cannot indicate causation, and the findings of a single urban institution may not be generalizable elsewhere. They also did not consider what interventions individual patients had during their index hospitalization that could have increased frailty.

The study did not note external funding. One coauthor of the study, Suchi Saria, PhD, reported receiving honoraria and travel reimbursement from two dozen biotechnology companies for keynotes and advisory board service; she also holds equity in Patient Ping and Bayesian Health. The other authors reported no industry disclosures. In addition to consulting for Berkeley Research Group, Dr. DuGoff has received a past honorarium from Zimmer Biomet. Dr. Durfey has no disclosures.

SOURCE: Galiatsatos P et al. Crit Care Med. 2020 Jun;48(6):808-14.