M. Alexander Otto

SAN FRANCISCO – Beware of vocal cord dysfunction mimicking asthma and other respiratory problems, especially in women, the overweight, and in patients with psychiatric diagnoses, according to a retrospective chart review of patients with the condition.

Of 100 patients diagnosed with vocal cord dysfunction at the University of Pittsburgh Medical Center’s outpatient adult allergy and immunology clinic, 86 were female, 68 were overweight, and 50 had psychiatric conditions.

For those patients especially, the possibility of vocal cord dysfunction (VCD) must be kept in mind when working up airway problems, said lead investigator Dr. Chitra Rao, an internal medicine resident at the medical center.

The reason is that VCD – in which the vocal cords spasm or even, to some extent, close on inspiration – is a notorious mimic of asthma, anaphylaxis, and other respiratory problems. Identifying it quickly not only speeds treatment but also prevents mistreatment for conditions patients do not have.

"I think it should definitely be on the differential, especially of severe or poorly controlled asthma. It can very much act like asthma," Dr. Rao said.

Dr. Rao and her colleagues reviewed the charts of 100 VCD patients and found that 26 had been misdiagnosed with asthma before presenting or being referred to the clinic; 9 were misdiagnosed with angioedema, 7 with anaphylaxis, and 3 with drug allergies.

In one, VCD had been mistaken for a reaction to omalizumab (Xolair). "While we were doing a desensitization challenge, [the patient] complained of the symptoms. We had a scope there and looked, and her vocal chords were spasming," Dr. Rao said.

The remaining 55 patients came to the clinic with undiagnosed respiratory complaints, including shortness of breath, wheezing, chest tightness, and throat tightness.

History and laryngoscopy ruled out asthma in half (13) of the patients mistakenly diagnosed with it; methacholine challenge testing excluded the other half.

Most patients were diagnosed with VCD by laryngoscopy, the remainder by history. Paradoxical vocal cord motion or other abnormalities were found by laryngoscope in 61 asymptomatic patients, without trigger maneuvers. A strong scent – Christian Dior’s "Poison" – was used to trigger an attack in some other patients to help seal the diagnosis.

"If you can actually illicit their attacks, it’s much easier for [patients] to buy into treatment," which includes breathing exercises, Dr. Rao said.

Vocal cord inflammation is the underlying problem in VCD, and the conditions that cause it, including gastroesophageal reflux (GERD), allergic rhinitis, and asthma – properly diagnosed – were common among patients. Treatment of those conditions can also help VCD.

GERD likely explains at least part of the link with obesity, but it remains unclear why women and people with anxiety and other psychiatric problems seem predisposed, Dr. Rao said.

Proper diagnosis is important. "If [attacks are] severe enough that [patients] go to the ER, they are going to get frequent steroids, which are not going to help them," Dr. Rao said.

"In severe cases, people who are not familiar with this disease may actually intubate [patients], and that’s actually counterproductive. It’s very difficult to extubate them because the whole underlying process is inflammation of the vocal chords. When you put in a breathing tube, it actually makes the symptoms worse," she said.

Dr. Rao said she has nothing to disclose.

SAN FRANCISCO – Beware of vocal cord dysfunction mimicking asthma and other respiratory problems, especially in women, the overweight, and in patients with psychiatric diagnoses, according to a retrospective chart review of patients with the condition.

Of 100 patients diagnosed with vocal cord dysfunction at the University of Pittsburgh Medical Center’s outpatient adult allergy and immunology clinic, 86 were female, 68 were overweight, and 50 had psychiatric conditions.

For those patients especially, the possibility of vocal cord dysfunction (VCD) must be kept in mind when working up airway problems, said lead investigator Dr. Chitra Rao, an internal medicine resident at the medical center.

The reason is that VCD – in which the vocal cords spasm or even, to some extent, close on inspiration – is a notorious mimic of asthma, anaphylaxis, and other respiratory problems. Identifying it quickly not only speeds treatment but also prevents mistreatment for conditions patients do not have.

"I think it should definitely be on the differential, especially of severe or poorly controlled asthma. It can very much act like asthma," Dr. Rao said.

Dr. Rao and her colleagues reviewed the charts of 100 VCD patients and found that 26 had been misdiagnosed with asthma before presenting or being referred to the clinic; 9 were misdiagnosed with angioedema, 7 with anaphylaxis, and 3 with drug allergies.

In one, VCD had been mistaken for a reaction to omalizumab (Xolair). "While we were doing a desensitization challenge, [the patient] complained of the symptoms. We had a scope there and looked, and her vocal chords were spasming," Dr. Rao said.

The remaining 55 patients came to the clinic with undiagnosed respiratory complaints, including shortness of breath, wheezing, chest tightness, and throat tightness.

History and laryngoscopy ruled out asthma in half (13) of the patients mistakenly diagnosed with it; methacholine challenge testing excluded the other half.

Most patients were diagnosed with VCD by laryngoscopy, the remainder by history. Paradoxical vocal cord motion or other abnormalities were found by laryngoscope in 61 asymptomatic patients, without trigger maneuvers. A strong scent – Christian Dior’s "Poison" – was used to trigger an attack in some other patients to help seal the diagnosis.

"If you can actually illicit their attacks, it’s much easier for [patients] to buy into treatment," which includes breathing exercises, Dr. Rao said.

Vocal cord inflammation is the underlying problem in VCD, and the conditions that cause it, including gastroesophageal reflux (GERD), allergic rhinitis, and asthma – properly diagnosed – were common among patients. Treatment of those conditions can also help VCD.

GERD likely explains at least part of the link with obesity, but it remains unclear why women and people with anxiety and other psychiatric problems seem predisposed, Dr. Rao said.

Proper diagnosis is important. "If [attacks are] severe enough that [patients] go to the ER, they are going to get frequent steroids, which are not going to help them," Dr. Rao said.

"In severe cases, people who are not familiar with this disease may actually intubate [patients], and that’s actually counterproductive. It’s very difficult to extubate them because the whole underlying process is inflammation of the vocal chords. When you put in a breathing tube, it actually makes the symptoms worse," she said.

Dr. Rao said she has nothing to disclose.

SAN FRANCISCO – Beware of vocal cord dysfunction mimicking asthma and other respiratory problems, especially in women, the overweight, and in patients with psychiatric diagnoses, according to a retrospective chart review of patients with the condition.

Of 100 patients diagnosed with vocal cord dysfunction at the University of Pittsburgh Medical Center’s outpatient adult allergy and immunology clinic, 86 were female, 68 were overweight, and 50 had psychiatric conditions.

For those patients especially, the possibility of vocal cord dysfunction (VCD) must be kept in mind when working up airway problems, said lead investigator Dr. Chitra Rao, an internal medicine resident at the medical center.

The reason is that VCD – in which the vocal cords spasm or even, to some extent, close on inspiration – is a notorious mimic of asthma, anaphylaxis, and other respiratory problems. Identifying it quickly not only speeds treatment but also prevents mistreatment for conditions patients do not have.

"I think it should definitely be on the differential, especially of severe or poorly controlled asthma. It can very much act like asthma," Dr. Rao said.

Dr. Rao and her colleagues reviewed the charts of 100 VCD patients and found that 26 had been misdiagnosed with asthma before presenting or being referred to the clinic; 9 were misdiagnosed with angioedema, 7 with anaphylaxis, and 3 with drug allergies.

In one, VCD had been mistaken for a reaction to omalizumab (Xolair). "While we were doing a desensitization challenge, [the patient] complained of the symptoms. We had a scope there and looked, and her vocal chords were spasming," Dr. Rao said.

The remaining 55 patients came to the clinic with undiagnosed respiratory complaints, including shortness of breath, wheezing, chest tightness, and throat tightness.

History and laryngoscopy ruled out asthma in half (13) of the patients mistakenly diagnosed with it; methacholine challenge testing excluded the other half.

Most patients were diagnosed with VCD by laryngoscopy, the remainder by history. Paradoxical vocal cord motion or other abnormalities were found by laryngoscope in 61 asymptomatic patients, without trigger maneuvers. A strong scent – Christian Dior’s "Poison" – was used to trigger an attack in some other patients to help seal the diagnosis.

"If you can actually illicit their attacks, it’s much easier for [patients] to buy into treatment," which includes breathing exercises, Dr. Rao said.

Vocal cord inflammation is the underlying problem in VCD, and the conditions that cause it, including gastroesophageal reflux (GERD), allergic rhinitis, and asthma – properly diagnosed – were common among patients. Treatment of those conditions can also help VCD.

GERD likely explains at least part of the link with obesity, but it remains unclear why women and people with anxiety and other psychiatric problems seem predisposed, Dr. Rao said.

Proper diagnosis is important. "If [attacks are] severe enough that [patients] go to the ER, they are going to get frequent steroids, which are not going to help them," Dr. Rao said.

"In severe cases, people who are not familiar with this disease may actually intubate [patients], and that’s actually counterproductive. It’s very difficult to extubate them because the whole underlying process is inflammation of the vocal chords. When you put in a breathing tube, it actually makes the symptoms worse," she said.

Dr. Rao said she has nothing to disclose.

SAN FRANCISCO – Beware of vocal cord dysfunction mimicking asthma and other respiratory problems, especially in women, the overweight, and in patients with psychiatric diagnoses, according to a retrospective chart review of patients with the condition.

Of 100 patients diagnosed with vocal cord dysfunction at the University of Pittsburgh Medical Center’s outpatient adult allergy and immunology clinic, 86 were female, 68 were overweight, and 50 had psychiatric conditions.

For those patients especially, the possibility of vocal cord dysfunction (VCD) must be kept in mind when working up airway problems, said lead investigator Dr. Chitra Rao, an internal medicine resident at the medical center.

The reason is that VCD – in which the vocal cords spasm or even, to some extent, close on inspiration – is a notorious mimic of asthma, anaphylaxis, and other respiratory problems. Identifying it quickly not only speeds treatment but also prevents mistreatment for conditions patients do not have.

"I think it should definitely be on the differential, especially of severe or poorly controlled asthma. It can very much act like asthma," Dr. Rao said.

Dr. Rao and her colleagues reviewed the charts of 100 VCD patients and found that 26 had been misdiagnosed with asthma before presenting or being referred to the clinic; 9 were misdiagnosed with angioedema, 7 with anaphylaxis, and 3 with drug allergies.

In one, VCD had been mistaken for a reaction to omalizumab (Xolair). "While we were doing a desensitization challenge, [the patient] complained of the symptoms. We had a scope there and looked, and her vocal chords were spasming," Dr. Rao said.

The remaining 55 patients came to the clinic with undiagnosed respiratory complaints, including shortness of breath, wheezing, chest tightness, and throat tightness.

History and laryngoscopy ruled out asthma in half (13) of the patients mistakenly diagnosed with it; methacholine challenge testing excluded the other half.

Most patients were diagnosed with VCD by laryngoscopy, the remainder by history. Paradoxical vocal cord motion or other abnormalities were found by laryngoscope in 61 asymptomatic patients, without trigger maneuvers. A strong scent – Christian Dior’s "Poison" – was used to trigger an attack in some other patients to help seal the diagnosis.

"If you can actually illicit their attacks, it’s much easier for [patients] to buy into treatment," which includes breathing exercises, Dr. Rao said.

Vocal cord inflammation is the underlying problem in VCD, and the conditions that cause it, including gastroesophageal reflux (GERD), allergic rhinitis, and asthma – properly diagnosed – were common among patients. Treatment of those conditions can also help VCD.

GERD likely explains at least part of the link with obesity, but it remains unclear why women and people with anxiety and other psychiatric problems seem predisposed, Dr. Rao said.

Proper diagnosis is important. "If [attacks are] severe enough that [patients] go to the ER, they are going to get frequent steroids, which are not going to help them," Dr. Rao said.

"In severe cases, people who are not familiar with this disease may actually intubate [patients], and that’s actually counterproductive. It’s very difficult to extubate them because the whole underlying process is inflammation of the vocal chords. When you put in a breathing tube, it actually makes the symptoms worse," she said.

Dr. Rao said she has nothing to disclose.

SAN FRANCISCO – Beware of vocal cord dysfunction mimicking asthma and other respiratory problems, especially in women, the overweight, and in patients with psychiatric diagnoses, according to a retrospective chart review of patients with the condition.

Of 100 patients diagnosed with vocal cord dysfunction at the University of Pittsburgh Medical Center’s outpatient adult allergy and immunology clinic, 86 were female, 68 were overweight, and 50 had psychiatric conditions.

For those patients especially, the possibility of vocal cord dysfunction (VCD) must be kept in mind when working up airway problems, said lead investigator Dr. Chitra Rao, an internal medicine resident at the medical center.

The reason is that VCD – in which the vocal cords spasm or even, to some extent, close on inspiration – is a notorious mimic of asthma, anaphylaxis, and other respiratory problems. Identifying it quickly not only speeds treatment but also prevents mistreatment for conditions patients do not have.

"I think it should definitely be on the differential, especially of severe or poorly controlled asthma. It can very much act like asthma," Dr. Rao said.

Dr. Rao and her colleagues reviewed the charts of 100 VCD patients and found that 26 had been misdiagnosed with asthma before presenting or being referred to the clinic; 9 were misdiagnosed with angioedema, 7 with anaphylaxis, and 3 with drug allergies.

In one, VCD had been mistaken for a reaction to omalizumab (Xolair). "While we were doing a desensitization challenge, [the patient] complained of the symptoms. We had a scope there and looked, and her vocal chords were spasming," Dr. Rao said.

The remaining 55 patients came to the clinic with undiagnosed respiratory complaints, including shortness of breath, wheezing, chest tightness, and throat tightness.

History and laryngoscopy ruled out asthma in half (13) of the patients mistakenly diagnosed with it; methacholine challenge testing excluded the other half.

Most patients were diagnosed with VCD by laryngoscopy, the remainder by history. Paradoxical vocal cord motion or other abnormalities were found by laryngoscope in 61 asymptomatic patients, without trigger maneuvers. A strong scent – Christian Dior’s "Poison" – was used to trigger an attack in some other patients to help seal the diagnosis.

"If you can actually illicit their attacks, it’s much easier for [patients] to buy into treatment," which includes breathing exercises, Dr. Rao said.

Vocal cord inflammation is the underlying problem in VCD, and the conditions that cause it, including gastroesophageal reflux (GERD), allergic rhinitis, and asthma – properly diagnosed – were common among patients. Treatment of those conditions can also help VCD.

GERD likely explains at least part of the link with obesity, but it remains unclear why women and people with anxiety and other psychiatric problems seem predisposed, Dr. Rao said.

Proper diagnosis is important. "If [attacks are] severe enough that [patients] go to the ER, they are going to get frequent steroids, which are not going to help them," Dr. Rao said.

"In severe cases, people who are not familiar with this disease may actually intubate [patients], and that’s actually counterproductive. It’s very difficult to extubate them because the whole underlying process is inflammation of the vocal chords. When you put in a breathing tube, it actually makes the symptoms worse," she said.

Dr. Rao said she has nothing to disclose.

SAN FRANCISCO – Beware of vocal cord dysfunction mimicking asthma and other respiratory problems, especially in women, the overweight, and in patients with psychiatric diagnoses, according to a retrospective chart review of patients with the condition.

Of 100 patients diagnosed with vocal cord dysfunction at the University of Pittsburgh Medical Center’s outpatient adult allergy and immunology clinic, 86 were female, 68 were overweight, and 50 had psychiatric conditions.

For those patients especially, the possibility of vocal cord dysfunction (VCD) must be kept in mind when working up airway problems, said lead investigator Dr. Chitra Rao, an internal medicine resident at the medical center.

The reason is that VCD – in which the vocal cords spasm or even, to some extent, close on inspiration – is a notorious mimic of asthma, anaphylaxis, and other respiratory problems. Identifying it quickly not only speeds treatment but also prevents mistreatment for conditions patients do not have.

"I think it should definitely be on the differential, especially of severe or poorly controlled asthma. It can very much act like asthma," Dr. Rao said.

Dr. Rao and her colleagues reviewed the charts of 100 VCD patients and found that 26 had been misdiagnosed with asthma before presenting or being referred to the clinic; 9 were misdiagnosed with angioedema, 7 with anaphylaxis, and 3 with drug allergies.

In one, VCD had been mistaken for a reaction to omalizumab (Xolair). "While we were doing a desensitization challenge, [the patient] complained of the symptoms. We had a scope there and looked, and her vocal chords were spasming," Dr. Rao said.

The remaining 55 patients came to the clinic with undiagnosed respiratory complaints, including shortness of breath, wheezing, chest tightness, and throat tightness.

History and laryngoscopy ruled out asthma in half (13) of the patients mistakenly diagnosed with it; methacholine challenge testing excluded the other half.

Most patients were diagnosed with VCD by laryngoscopy, the remainder by history. Paradoxical vocal cord motion or other abnormalities were found by laryngoscope in 61 asymptomatic patients, without trigger maneuvers. A strong scent – Christian Dior’s "Poison" – was used to trigger an attack in some other patients to help seal the diagnosis.

"If you can actually illicit their attacks, it’s much easier for [patients] to buy into treatment," which includes breathing exercises, Dr. Rao said.

Vocal cord inflammation is the underlying problem in VCD, and the conditions that cause it, including gastroesophageal reflux (GERD), allergic rhinitis, and asthma – properly diagnosed – were common among patients. Treatment of those conditions can also help VCD.

GERD likely explains at least part of the link with obesity, but it remains unclear why women and people with anxiety and other psychiatric problems seem predisposed, Dr. Rao said.

Proper diagnosis is important. "If [attacks are] severe enough that [patients] go to the ER, they are going to get frequent steroids, which are not going to help them," Dr. Rao said.

"In severe cases, people who are not familiar with this disease may actually intubate [patients], and that’s actually counterproductive. It’s very difficult to extubate them because the whole underlying process is inflammation of the vocal chords. When you put in a breathing tube, it actually makes the symptoms worse," she said.

Dr. Rao said she has nothing to disclose.

SAN FRANCISCO – Beware of vocal cord dysfunction mimicking asthma and other respiratory problems, especially in women, the overweight, and in patients with psychiatric diagnoses, according to a retrospective chart review of patients with the condition.

Of 100 patients diagnosed with vocal cord dysfunction at the University of Pittsburgh Medical Center’s outpatient adult allergy and immunology clinic, 86 were female, 68 were overweight, and 50 had psychiatric conditions.

For those patients especially, the possibility of vocal cord dysfunction (VCD) must be kept in mind when working up airway problems, said lead investigator Dr. Chitra Rao, an internal medicine resident at the medical center.

The reason is that VCD – in which the vocal cords spasm or even, to some extent, close on inspiration – is a notorious mimic of asthma, anaphylaxis, and other respiratory problems. Identifying it quickly not only speeds treatment but also prevents mistreatment for conditions patients do not have.

"I think it should definitely be on the differential, especially of severe or poorly controlled asthma. It can very much act like asthma," Dr. Rao said.

Dr. Rao and her colleagues reviewed the charts of 100 VCD patients and found that 26 had been misdiagnosed with asthma before presenting or being referred to the clinic; 9 were misdiagnosed with angioedema, 7 with anaphylaxis, and 3 with drug allergies.

In one, VCD had been mistaken for a reaction to omalizumab (Xolair). "While we were doing a desensitization challenge, [the patient] complained of the symptoms. We had a scope there and looked, and her vocal chords were spasming," Dr. Rao said.

The remaining 55 patients came to the clinic with undiagnosed respiratory complaints, including shortness of breath, wheezing, chest tightness, and throat tightness.

History and laryngoscopy ruled out asthma in half (13) of the patients mistakenly diagnosed with it; methacholine challenge testing excluded the other half.

Most patients were diagnosed with VCD by laryngoscopy, the remainder by history. Paradoxical vocal cord motion or other abnormalities were found by laryngoscope in 61 asymptomatic patients, without trigger maneuvers. A strong scent – Christian Dior’s "Poison" – was used to trigger an attack in some other patients to help seal the diagnosis.

"If you can actually illicit their attacks, it’s much easier for [patients] to buy into treatment," which includes breathing exercises, Dr. Rao said.

Vocal cord inflammation is the underlying problem in VCD, and the conditions that cause it, including gastroesophageal reflux (GERD), allergic rhinitis, and asthma – properly diagnosed – were common among patients. Treatment of those conditions can also help VCD.

GERD likely explains at least part of the link with obesity, but it remains unclear why women and people with anxiety and other psychiatric problems seem predisposed, Dr. Rao said.

Proper diagnosis is important. "If [attacks are] severe enough that [patients] go to the ER, they are going to get frequent steroids, which are not going to help them," Dr. Rao said.

"In severe cases, people who are not familiar with this disease may actually intubate [patients], and that’s actually counterproductive. It’s very difficult to extubate them because the whole underlying process is inflammation of the vocal chords. When you put in a breathing tube, it actually makes the symptoms worse," she said.

Dr. Rao said she has nothing to disclose.

SAN FRANCISCO – Beware of vocal cord dysfunction mimicking asthma and other respiratory problems, especially in women, the overweight, and in patients with psychiatric diagnoses, according to a retrospective chart review of patients with the condition.

Of 100 patients diagnosed with vocal cord dysfunction at the University of Pittsburgh Medical Center’s outpatient adult allergy and immunology clinic, 86 were female, 68 were overweight, and 50 had psychiatric conditions.

For those patients especially, the possibility of vocal cord dysfunction (VCD) must be kept in mind when working up airway problems, said lead investigator Dr. Chitra Rao, an internal medicine resident at the medical center.

The reason is that VCD – in which the vocal cords spasm or even, to some extent, close on inspiration – is a notorious mimic of asthma, anaphylaxis, and other respiratory problems. Identifying it quickly not only speeds treatment but also prevents mistreatment for conditions patients do not have.

"I think it should definitely be on the differential, especially of severe or poorly controlled asthma. It can very much act like asthma," Dr. Rao said.

Dr. Rao and her colleagues reviewed the charts of 100 VCD patients and found that 26 had been misdiagnosed with asthma before presenting or being referred to the clinic; 9 were misdiagnosed with angioedema, 7 with anaphylaxis, and 3 with drug allergies.

In one, VCD had been mistaken for a reaction to omalizumab (Xolair). "While we were doing a desensitization challenge, [the patient] complained of the symptoms. We had a scope there and looked, and her vocal chords were spasming," Dr. Rao said.

The remaining 55 patients came to the clinic with undiagnosed respiratory complaints, including shortness of breath, wheezing, chest tightness, and throat tightness.

History and laryngoscopy ruled out asthma in half (13) of the patients mistakenly diagnosed with it; methacholine challenge testing excluded the other half.

Most patients were diagnosed with VCD by laryngoscopy, the remainder by history. Paradoxical vocal cord motion or other abnormalities were found by laryngoscope in 61 asymptomatic patients, without trigger maneuvers. A strong scent – Christian Dior’s "Poison" – was used to trigger an attack in some other patients to help seal the diagnosis.

"If you can actually illicit their attacks, it’s much easier for [patients] to buy into treatment," which includes breathing exercises, Dr. Rao said.

Vocal cord inflammation is the underlying problem in VCD, and the conditions that cause it, including gastroesophageal reflux (GERD), allergic rhinitis, and asthma – properly diagnosed – were common among patients. Treatment of those conditions can also help VCD.

GERD likely explains at least part of the link with obesity, but it remains unclear why women and people with anxiety and other psychiatric problems seem predisposed, Dr. Rao said.

Proper diagnosis is important. "If [attacks are] severe enough that [patients] go to the ER, they are going to get frequent steroids, which are not going to help them," Dr. Rao said.

"In severe cases, people who are not familiar with this disease may actually intubate [patients], and that’s actually counterproductive. It’s very difficult to extubate them because the whole underlying process is inflammation of the vocal chords. When you put in a breathing tube, it actually makes the symptoms worse," she said.

Dr. Rao said she has nothing to disclose.

SAN FRANCISCO – Beware of vocal cord dysfunction mimicking asthma and other respiratory problems, especially in women, the overweight, and in patients with psychiatric diagnoses, according to a retrospective chart review of patients with the condition.

Of 100 patients diagnosed with vocal cord dysfunction at the University of Pittsburgh Medical Center’s outpatient adult allergy and immunology clinic, 86 were female, 68 were overweight, and 50 had psychiatric conditions.

For those patients especially, the possibility of vocal cord dysfunction (VCD) must be kept in mind when working up airway problems, said lead investigator Dr. Chitra Rao, an internal medicine resident at the medical center.

The reason is that VCD – in which the vocal cords spasm or even, to some extent, close on inspiration – is a notorious mimic of asthma, anaphylaxis, and other respiratory problems. Identifying it quickly not only speeds treatment but also prevents mistreatment for conditions patients do not have.

"I think it should definitely be on the differential, especially of severe or poorly controlled asthma. It can very much act like asthma," Dr. Rao said.

Dr. Rao and her colleagues reviewed the charts of 100 VCD patients and found that 26 had been misdiagnosed with asthma before presenting or being referred to the clinic; 9 were misdiagnosed with angioedema, 7 with anaphylaxis, and 3 with drug allergies.

In one, VCD had been mistaken for a reaction to omalizumab (Xolair). "While we were doing a desensitization challenge, [the patient] complained of the symptoms. We had a scope there and looked, and her vocal chords were spasming," Dr. Rao said.

The remaining 55 patients came to the clinic with undiagnosed respiratory complaints, including shortness of breath, wheezing, chest tightness, and throat tightness.

History and laryngoscopy ruled out asthma in half (13) of the patients mistakenly diagnosed with it; methacholine challenge testing excluded the other half.

Most patients were diagnosed with VCD by laryngoscopy, the remainder by history. Paradoxical vocal cord motion or other abnormalities were found by laryngoscope in 61 asymptomatic patients, without trigger maneuvers. A strong scent – Christian Dior’s "Poison" – was used to trigger an attack in some other patients to help seal the diagnosis.

"If you can actually illicit their attacks, it’s much easier for [patients] to buy into treatment," which includes breathing exercises, Dr. Rao said.

Vocal cord inflammation is the underlying problem in VCD, and the conditions that cause it, including gastroesophageal reflux (GERD), allergic rhinitis, and asthma – properly diagnosed – were common among patients. Treatment of those conditions can also help VCD.

GERD likely explains at least part of the link with obesity, but it remains unclear why women and people with anxiety and other psychiatric problems seem predisposed, Dr. Rao said.

Proper diagnosis is important. "If [attacks are] severe enough that [patients] go to the ER, they are going to get frequent steroids, which are not going to help them," Dr. Rao said.

"In severe cases, people who are not familiar with this disease may actually intubate [patients], and that’s actually counterproductive. It’s very difficult to extubate them because the whole underlying process is inflammation of the vocal chords. When you put in a breathing tube, it actually makes the symptoms worse," she said.

Dr. Rao said she has nothing to disclose.

SAN FRANCISCO – Children's eczema and parents' confidence in managing it both improved when parents were given eczema action plans with stepwise instructions for treatment according to severity, a small study has shown.

The idea for the study came from asthma management, in which personalized action plans are routinely given to parents to help manage childhood asthma, according to lead author Jillian Rork, a third-year medical student at Harvard Medical School, Boston.

The eczema action plans (EAPs) developed by Ms. Rork and her colleagues at Children's Hospital Boston and Seattle Children's Hospital divided treatment into three "zones." The green zone comprises daily skin care, including use of moisturizers and cleansers, for when children have only mild redness or irritation. The yellow zone includes topical steroids for when parents begin to notice a flare, and the red zone is for severe redness, itching, and oozing, which could involve more potent topical steroids or other medications.

"The physician can actually fill in the blank as to which medication to use," Ms. Rork explained. That decision depends on the level of the child's underlying disease. The approach is "very useful, not only for allergists but for ... the whole gamut. That was the goal, to have [the EAP be] very applicable," Ms. Rork said at the annual meeting of the American Academy of Allergy, Asthma, and Immunology.

In the study, parents of 35 children ranging in age from 4 months to 17 years (mean 4 years), were given EAPs in a tertiary allergy program. Parents completed a survey regarding their child’s eczema at baseline and then again at 3-12 months' follow-up.

At follow-up, the number of parents who rated their child’s eczema as severe dropped from 51% at baseline to 3%, a significant difference. The percentage of children with mild eczema increased from 3% initially to 57%, also a significant difference. Itching and scratching levels fell in 60% of children, and sleep improved in 65%. Overall, 80% of parents said their child's eczema was less severe.

Meanwhile, 67% of parents said the EAP contributed to the improvements, and 86% said it clarified their child's medication regimen. The number of parents saying they were comfortable managing their child's eczema rose from 57% to 86%, a significant change.

Many parents said they gave copies of the EAP to day care providers or school nurses.

The approach "works really well for kids who have mild eczema - because they still need to have a green and yellow zone, and sometimes the red zone is the same - and [in] kids who have really severe skin who're going to have very different treatment methods in each zone," Ms. Rork said.

Although the utility of asthma action plans is widely supported in the literature, she noted, her study is the first to demonstrate utility for eczema.

Ms. Rork and her colleagues are considering an electronic version of the form that would allow clinicians to type instructions and print out the form for parents, in the same way that asthma action plans work in most offices. The researchers are also considering a similar approach to eczema for older patients. "We found it useful in kids. Maybe it can apply in adults, too," Ms. Rork said.

Ms. Rork said she has no disclosures.

SAN FRANCISCO – Children's eczema and parents' confidence in managing it both improved when parents were given eczema action plans with stepwise instructions for treatment according to severity, a small study has shown.

The idea for the study came from asthma management, in which personalized action plans are routinely given to parents to help manage childhood asthma, according to lead author Jillian Rork, a third-year medical student at Harvard Medical School, Boston.

The eczema action plans (EAPs) developed by Ms. Rork and her colleagues at Children's Hospital Boston and Seattle Children's Hospital divided treatment into three "zones." The green zone comprises daily skin care, including use of moisturizers and cleansers, for when children have only mild redness or irritation. The yellow zone includes topical steroids for when parents begin to notice a flare, and the red zone is for severe redness, itching, and oozing, which could involve more potent topical steroids or other medications.

"The physician can actually fill in the blank as to which medication to use," Ms. Rork explained. That decision depends on the level of the child's underlying disease. The approach is "very useful, not only for allergists but for ... the whole gamut. That was the goal, to have [the EAP be] very applicable," Ms. Rork said at the annual meeting of the American Academy of Allergy, Asthma, and Immunology.

In the study, parents of 35 children ranging in age from 4 months to 17 years (mean 4 years), were given EAPs in a tertiary allergy program. Parents completed a survey regarding their child’s eczema at baseline and then again at 3-12 months' follow-up.

At follow-up, the number of parents who rated their child’s eczema as severe dropped from 51% at baseline to 3%, a significant difference. The percentage of children with mild eczema increased from 3% initially to 57%, also a significant difference. Itching and scratching levels fell in 60% of children, and sleep improved in 65%. Overall, 80% of parents said their child's eczema was less severe.

Meanwhile, 67% of parents said the EAP contributed to the improvements, and 86% said it clarified their child's medication regimen. The number of parents saying they were comfortable managing their child's eczema rose from 57% to 86%, a significant change.

Many parents said they gave copies of the EAP to day care providers or school nurses.

The approach "works really well for kids who have mild eczema - because they still need to have a green and yellow zone, and sometimes the red zone is the same - and [in] kids who have really severe skin who're going to have very different treatment methods in each zone," Ms. Rork said.

Although the utility of asthma action plans is widely supported in the literature, she noted, her study is the first to demonstrate utility for eczema.

Ms. Rork and her colleagues are considering an electronic version of the form that would allow clinicians to type instructions and print out the form for parents, in the same way that asthma action plans work in most offices. The researchers are also considering a similar approach to eczema for older patients. "We found it useful in kids. Maybe it can apply in adults, too," Ms. Rork said.

Ms. Rork said she has no disclosures.

SAN FRANCISCO – Children's eczema and parents' confidence in managing it both improved when parents were given eczema action plans with stepwise instructions for treatment according to severity, a small study has shown.

The idea for the study came from asthma management, in which personalized action plans are routinely given to parents to help manage childhood asthma, according to lead author Jillian Rork, a third-year medical student at Harvard Medical School, Boston.

The eczema action plans (EAPs) developed by Ms. Rork and her colleagues at Children's Hospital Boston and Seattle Children's Hospital divided treatment into three "zones." The green zone comprises daily skin care, including use of moisturizers and cleansers, for when children have only mild redness or irritation. The yellow zone includes topical steroids for when parents begin to notice a flare, and the red zone is for severe redness, itching, and oozing, which could involve more potent topical steroids or other medications.

"The physician can actually fill in the blank as to which medication to use," Ms. Rork explained. That decision depends on the level of the child's underlying disease. The approach is "very useful, not only for allergists but for ... the whole gamut. That was the goal, to have [the EAP be] very applicable," Ms. Rork said at the annual meeting of the American Academy of Allergy, Asthma, and Immunology.

In the study, parents of 35 children ranging in age from 4 months to 17 years (mean 4 years), were given EAPs in a tertiary allergy program. Parents completed a survey regarding their child’s eczema at baseline and then again at 3-12 months' follow-up.

At follow-up, the number of parents who rated their child’s eczema as severe dropped from 51% at baseline to 3%, a significant difference. The percentage of children with mild eczema increased from 3% initially to 57%, also a significant difference. Itching and scratching levels fell in 60% of children, and sleep improved in 65%. Overall, 80% of parents said their child's eczema was less severe.

Meanwhile, 67% of parents said the EAP contributed to the improvements, and 86% said it clarified their child's medication regimen. The number of parents saying they were comfortable managing their child's eczema rose from 57% to 86%, a significant change.

Many parents said they gave copies of the EAP to day care providers or school nurses.

The approach "works really well for kids who have mild eczema - because they still need to have a green and yellow zone, and sometimes the red zone is the same - and [in] kids who have really severe skin who're going to have very different treatment methods in each zone," Ms. Rork said.

Although the utility of asthma action plans is widely supported in the literature, she noted, her study is the first to demonstrate utility for eczema.

Ms. Rork and her colleagues are considering an electronic version of the form that would allow clinicians to type instructions and print out the form for parents, in the same way that asthma action plans work in most offices. The researchers are also considering a similar approach to eczema for older patients. "We found it useful in kids. Maybe it can apply in adults, too," Ms. Rork said.

Ms. Rork said she has no disclosures.

SAN FRANCISCO – Children’s eczema and parents' confidence in managing it both improved when parents were given eczema action plans with stepwise instructions for treatment according to severity, a small study has shown.

The idea for the study came from asthma management, in which personalized action plans are routinely given to parents to help manage childhood asthma, according to lead author Jillian Rork, a third-year medical student at Harvard Medical School, Boston.

The eczema action plans (EAPs) developed by Ms. Rork and her colleagues at Children’s Hospital Boston and Seattle Children’s Hospital divided treatment into three "zones." The green zone comprises daily skin care, including use of moisturizers and cleansers, for when children have only mild redness or irritation. The yellow zone includes topical steroids for when parents begin to notice a flare, and the red zone is for severe redness, itching, and oozing, which could involve more potent topical steroids or other medications.

"The physician can actually fill in the blank as to which medication to use," Ms. Rork explained. That decision depends on the level of the child’s underlying disease. The approach is "very useful, not only for allergists but for primary care doctors, pediatricians, kind of the whole gamut. That was the goal, to have [the EAP be] very applicable," Ms. Rork said at the annual meeting of the American Academy of Allergy, Asthma, and Immunology.

In the study, parents of 35 children ranging in age from 4 months to 17 years (mean 4 years), were given EAPs in a tertiary allergy program. Parents completed a survey regarding their child’s eczema at baseline and then again at 3-12 months’ follow-up.

At follow-up, the number of parents who rated their child’s eczema as severe dropped from 51% at baseline to 3%, a significant difference. The percentage of children with mild eczema increased from 3% initially to 57%, also a significant difference. Itching and scratching levels fell in 60% of children, and sleep improved in 65%. Overall, 80% of parents said their child’s eczema was less severe.

Meanwhile, 67% of parents said the EAP contributed to the improvements, and 86% said it clarified their child’s medication regimen. The number of parents saying they were comfortable managing their child’s eczema rose from 57% to 86%, a significant change.

Many parents said they gave copies of the EAP to day care providers or school nurses.

The approach "works really well for kids who have mild eczema -- because they still need to have a green and yellow zone, and sometimes the red zone is the same -- and [in] kids who have really severe skin who're going to have very different treatment methods in each zone," Ms. Rork said.

Although the utility of asthma action plans is widely supported in the literature, she noted, her study is the first to demonstrate utility for eczema.

Ms. Rork and her colleagues are considering an electronic version of the form that would allow clinicians to type instructions and print out the form for parents, in the same way that asthma action plans work in most offices. The researchers are also considering a similar approach to eczema for older patients. "We found it useful in kids. Maybe it can apply in adults, too," Ms. Rork said.

Ms. Rork said she has no disclosures.

SAN FRANCISCO – Children’s eczema and parents' confidence in managing it both improved when parents were given eczema action plans with stepwise instructions for treatment according to severity, a small study has shown.

The idea for the study came from asthma management, in which personalized action plans are routinely given to parents to help manage childhood asthma, according to lead author Jillian Rork, a third-year medical student at Harvard Medical School, Boston.

The eczema action plans (EAPs) developed by Ms. Rork and her colleagues at Children’s Hospital Boston and Seattle Children’s Hospital divided treatment into three "zones." The green zone comprises daily skin care, including use of moisturizers and cleansers, for when children have only mild redness or irritation. The yellow zone includes topical steroids for when parents begin to notice a flare, and the red zone is for severe redness, itching, and oozing, which could involve more potent topical steroids or other medications.

"The physician can actually fill in the blank as to which medication to use," Ms. Rork explained. That decision depends on the level of the child’s underlying disease. The approach is "very useful, not only for allergists but for primary care doctors, pediatricians, kind of the whole gamut. That was the goal, to have [the EAP be] very applicable," Ms. Rork said at the annual meeting of the American Academy of Allergy, Asthma, and Immunology.

In the study, parents of 35 children ranging in age from 4 months to 17 years (mean 4 years), were given EAPs in a tertiary allergy program. Parents completed a survey regarding their child’s eczema at baseline and then again at 3-12 months’ follow-up.

At follow-up, the number of parents who rated their child’s eczema as severe dropped from 51% at baseline to 3%, a significant difference. The percentage of children with mild eczema increased from 3% initially to 57%, also a significant difference. Itching and scratching levels fell in 60% of children, and sleep improved in 65%. Overall, 80% of parents said their child’s eczema was less severe.

Meanwhile, 67% of parents said the EAP contributed to the improvements, and 86% said it clarified their child’s medication regimen. The number of parents saying they were comfortable managing their child’s eczema rose from 57% to 86%, a significant change.

Many parents said they gave copies of the EAP to day care providers or school nurses.

The approach "works really well for kids who have mild eczema -- because they still need to have a green and yellow zone, and sometimes the red zone is the same -- and [in] kids who have really severe skin who're going to have very different treatment methods in each zone," Ms. Rork said.

Although the utility of asthma action plans is widely supported in the literature, she noted, her study is the first to demonstrate utility for eczema.

Ms. Rork and her colleagues are considering an electronic version of the form that would allow clinicians to type instructions and print out the form for parents, in the same way that asthma action plans work in most offices. The researchers are also considering a similar approach to eczema for older patients. "We found it useful in kids. Maybe it can apply in adults, too," Ms. Rork said.

Ms. Rork said she has no disclosures.

SAN FRANCISCO – Children’s eczema and parents' confidence in managing it both improved when parents were given eczema action plans with stepwise instructions for treatment according to severity, a small study has shown.

The idea for the study came from asthma management, in which personalized action plans are routinely given to parents to help manage childhood asthma, according to lead author Jillian Rork, a third-year medical student at Harvard Medical School, Boston.

The eczema action plans (EAPs) developed by Ms. Rork and her colleagues at Children’s Hospital Boston and Seattle Children’s Hospital divided treatment into three "zones." The green zone comprises daily skin care, including use of moisturizers and cleansers, for when children have only mild redness or irritation. The yellow zone includes topical steroids for when parents begin to notice a flare, and the red zone is for severe redness, itching, and oozing, which could involve more potent topical steroids or other medications.

"The physician can actually fill in the blank as to which medication to use," Ms. Rork explained. That decision depends on the level of the child’s underlying disease. The approach is "very useful, not only for allergists but for primary care doctors, pediatricians, kind of the whole gamut. That was the goal, to have [the EAP be] very applicable," Ms. Rork said at the annual meeting of the American Academy of Allergy, Asthma, and Immunology.

In the study, parents of 35 children ranging in age from 4 months to 17 years (mean 4 years), were given EAPs in a tertiary allergy program. Parents completed a survey regarding their child’s eczema at baseline and then again at 3-12 months’ follow-up.

At follow-up, the number of parents who rated their child’s eczema as severe dropped from 51% at baseline to 3%, a significant difference. The percentage of children with mild eczema increased from 3% initially to 57%, also a significant difference. Itching and scratching levels fell in 60% of children, and sleep improved in 65%. Overall, 80% of parents said their child’s eczema was less severe.

Meanwhile, 67% of parents said the EAP contributed to the improvements, and 86% said it clarified their child’s medication regimen. The number of parents saying they were comfortable managing their child’s eczema rose from 57% to 86%, a significant change.

Many parents said they gave copies of the EAP to day care providers or school nurses.

The approach "works really well for kids who have mild eczema -- because they still need to have a green and yellow zone, and sometimes the red zone is the same -- and [in] kids who have really severe skin who're going to have very different treatment methods in each zone," Ms. Rork said.

Although the utility of asthma action plans is widely supported in the literature, she noted, her study is the first to demonstrate utility for eczema.

Ms. Rork and her colleagues are considering an electronic version of the form that would allow clinicians to type instructions and print out the form for parents, in the same way that asthma action plans work in most offices. The researchers are also considering a similar approach to eczema for older patients. "We found it useful in kids. Maybe it can apply in adults, too," Ms. Rork said.

Ms. Rork said she has no disclosures.

SAN FRANCISCO – Children’s eczema and parents' confidence in managing it both improved when parents were given eczema action plans with stepwise instructions for treatment according to severity, a small study has shown.

The idea for the study came from asthma management, in which personalized action plans are routinely given to parents to help manage childhood asthma, according to lead author Jillian Rork, a third-year medical student at Harvard Medical School, Boston.

The eczema action plans (EAPs) developed by Ms. Rork and her colleagues at Children’s Hospital Boston and Seattle Children’s Hospital divided treatment into three "zones." The green zone comprises daily skin care, including use of moisturizers and cleansers, for when children have only mild redness or irritation. The yellow zone includes topical steroids for when parents begin to notice a flare, and the red zone is for severe redness, itching, and oozing, which could involve more potent topical steroids or other medications.

"The physician can actually fill in the blank as to which medication to use," Ms. Rork explained. That decision depends on the level of the child’s underlying disease. The approach is "very useful, not only for allergists but for primary care doctors, pediatricians, kind of the whole gamut. That was the goal, to have [the EAP be] very applicable," Ms. Rork said at the annual meeting of the American Academy of Allergy, Asthma, and Immunology.

In the study, parents of 35 children ranging in age from 4 months to 17 years (mean 4 years), were given EAPs in a tertiary allergy program. Parents completed a survey regarding their child’s eczema at baseline and then again at 3-12 months’ follow-up.

At follow-up, the number of parents who rated their child’s eczema as severe dropped from 51% at baseline to 3%, a significant difference. The percentage of children with mild eczema increased from 3% initially to 57%, also a significant difference. Itching and scratching levels fell in 60% of children, and sleep improved in 65%. Overall, 80% of parents said their child’s eczema was less severe.

Meanwhile, 67% of parents said the EAP contributed to the improvements, and 86% said it clarified their child’s medication regimen. The number of parents saying they were comfortable managing their child’s eczema rose from 57% to 86%, a significant change.

Many parents said they gave copies of the EAP to day care providers or school nurses.

The approach "works really well for kids who have mild eczema - because they still need to have a green and yellow zone, and sometimes the red zone is the same - and [in] kids who have really severe skin who're going to have very different treatment methods in each zone," Ms. Rork said. 

Although the utility of asthma action plans is widely supported in the literature, she noted, her study is the first to demonstrate utility for eczema.

Ms. Rork and her colleagues are considering an electronic version of the form that would allow clinicians to type instructions and print out the form for parents, in the same way that asthma action plans work in most offices. The researchers are also considering a similar approach to eczema for older patients. "We found it useful in kids. Maybe it can apply in adults, too," Ms. Rork said.

Ms. Rork said she has no disclosures.

SAN FRANCISCO – Children’s eczema and parents' confidence in managing it both improved when parents were given eczema action plans with stepwise instructions for treatment according to severity, a small study has shown.

The idea for the study came from asthma management, in which personalized action plans are routinely given to parents to help manage childhood asthma, according to lead author Jillian Rork, a third-year medical student at Harvard Medical School, Boston.

The eczema action plans (EAPs) developed by Ms. Rork and her colleagues at Children’s Hospital Boston and Seattle Children’s Hospital divided treatment into three "zones." The green zone comprises daily skin care, including use of moisturizers and cleansers, for when children have only mild redness or irritation. The yellow zone includes topical steroids for when parents begin to notice a flare, and the red zone is for severe redness, itching, and oozing, which could involve more potent topical steroids or other medications.

"The physician can actually fill in the blank as to which medication to use," Ms. Rork explained. That decision depends on the level of the child’s underlying disease. The approach is "very useful, not only for allergists but for primary care doctors, pediatricians, kind of the whole gamut. That was the goal, to have [the EAP be] very applicable," Ms. Rork said at the annual meeting of the American Academy of Allergy, Asthma, and Immunology.

In the study, parents of 35 children ranging in age from 4 months to 17 years (mean 4 years), were given EAPs in a tertiary allergy program. Parents completed a survey regarding their child’s eczema at baseline and then again at 3-12 months’ follow-up.

At follow-up, the number of parents who rated their child’s eczema as severe dropped from 51% at baseline to 3%, a significant difference. The percentage of children with mild eczema increased from 3% initially to 57%, also a significant difference. Itching and scratching levels fell in 60% of children, and sleep improved in 65%. Overall, 80% of parents said their child’s eczema was less severe.

Meanwhile, 67% of parents said the EAP contributed to the improvements, and 86% said it clarified their child’s medication regimen. The number of parents saying they were comfortable managing their child’s eczema rose from 57% to 86%, a significant change.

Many parents said they gave copies of the EAP to day care providers or school nurses.

The approach "works really well for kids who have mild eczema - because they still need to have a green and yellow zone, and sometimes the red zone is the same - and [in] kids who have really severe skin who're going to have very different treatment methods in each zone," Ms. Rork said. 

Although the utility of asthma action plans is widely supported in the literature, she noted, her study is the first to demonstrate utility for eczema.

Ms. Rork and her colleagues are considering an electronic version of the form that would allow clinicians to type instructions and print out the form for parents, in the same way that asthma action plans work in most offices. The researchers are also considering a similar approach to eczema for older patients. "We found it useful in kids. Maybe it can apply in adults, too," Ms. Rork said.

Ms. Rork said she has no disclosures.

SAN FRANCISCO – Children’s eczema and parents' confidence in managing it both improved when parents were given eczema action plans with stepwise instructions for treatment according to severity, a small study has shown.

The idea for the study came from asthma management, in which personalized action plans are routinely given to parents to help manage childhood asthma, according to lead author Jillian Rork, a third-year medical student at Harvard Medical School, Boston.

The eczema action plans (EAPs) developed by Ms. Rork and her colleagues at Children’s Hospital Boston and Seattle Children’s Hospital divided treatment into three "zones." The green zone comprises daily skin care, including use of moisturizers and cleansers, for when children have only mild redness or irritation. The yellow zone includes topical steroids for when parents begin to notice a flare, and the red zone is for severe redness, itching, and oozing, which could involve more potent topical steroids or other medications.

"The physician can actually fill in the blank as to which medication to use," Ms. Rork explained. That decision depends on the level of the child’s underlying disease. The approach is "very useful, not only for allergists but for primary care doctors, pediatricians, kind of the whole gamut. That was the goal, to have [the EAP be] very applicable," Ms. Rork said at the annual meeting of the American Academy of Allergy, Asthma, and Immunology.

In the study, parents of 35 children ranging in age from 4 months to 17 years (mean 4 years), were given EAPs in a tertiary allergy program. Parents completed a survey regarding their child’s eczema at baseline and then again at 3-12 months’ follow-up.

At follow-up, the number of parents who rated their child’s eczema as severe dropped from 51% at baseline to 3%, a significant difference. The percentage of children with mild eczema increased from 3% initially to 57%, also a significant difference. Itching and scratching levels fell in 60% of children, and sleep improved in 65%. Overall, 80% of parents said their child’s eczema was less severe.

Meanwhile, 67% of parents said the EAP contributed to the improvements, and 86% said it clarified their child’s medication regimen. The number of parents saying they were comfortable managing their child’s eczema rose from 57% to 86%, a significant change.

Many parents said they gave copies of the EAP to day care providers or school nurses.

The approach "works really well for kids who have mild eczema - because they still need to have a green and yellow zone, and sometimes the red zone is the same - and [in] kids who have really severe skin who're going to have very different treatment methods in each zone," Ms. Rork said. 

Although the utility of asthma action plans is widely supported in the literature, she noted, her study is the first to demonstrate utility for eczema.

Ms. Rork and her colleagues are considering an electronic version of the form that would allow clinicians to type instructions and print out the form for parents, in the same way that asthma action plans work in most offices. The researchers are also considering a similar approach to eczema for older patients. "We found it useful in kids. Maybe it can apply in adults, too," Ms. Rork said.

Ms. Rork said she has no disclosures.

VANCOUVER, B.C. - To improve hospital mortality scores, clinicians should include all possible diagnoses in patient charts, according to oncologist and palliative care specialist Dr. Thomas J. Smith.

U.S. News & World Report’s "Best Hospitals," the Centers for Medicaid and Medicare Services’ Hospital Compare, and other hospital rating programs compare hospital outcomes to national averages based on how sick patients are, said Dr. Smith, medical director of palliative care at Virginia Commonwealth University Massey Cancer Center in Richmond.

"You get counted on your observed mortality rate. They compare that to how many people are expected to die" according to the averages, he said at the annual meeting of the American Academy of Hospice and Palliative Care Medicine. Deaths in excess of the averages are considered unexpected and are assumed to be caused by poor quality care, which lowers hospitals in the mortality rankings.

By listing all possible diagnoses – especially at the end of life – "[you increase] your expected mortality, so that your observed-to-expected ratio improves. Even if you ignore improving mortality, if you change [how many people are expected to die] you’ll improve your ratio" and hospital standing, he said.

The reason is that hospital coders pull the diagnoses off patient charts and include them in claims submissions, the data upon which the rankings are based.

The approach is not about "gaming the system," Dr. Smith said. "You are adequately documenting the severity of the patients that you take care of" to ensure accurate mortality scores.

The key is to list diagnoses, not "medical thoughts," he said.

For example, " ‘lytic lesion of vertebra on spine films’ does not count. Write ‘bone mets’ [because] your coders can count that. Don’t write ‘neutrophils’ with an arrow going down. It doesn’t count. You have to write ‘neutropenia.’ If you write ‘admit for chemo,’ you can write ‘admit for chemo, dehydration, chronic blood loss anemia’ [as appropriate] and your severity index will go up a lot," said Dr. Smith, adding that each site of metastases should be listed because "you get points for each one."

Similarly, " ‘chest x-ray with pneumonitis status post radiation therapy’ does not count. You have to write ‘radiation pneumonitis.’ [And] don’t put ‘total protein and albumin low.’ Put ‘cachexia or malnutrition, moderate or severe.’ Don’t write ‘admit for pain control.’ Write ‘intractable pain form malignancy,’ and you have to say ‘lung cancer, breast cancer, bone cancer, liver cancer’ [accordingly]," he said.

Such diagnoses only have to be written once during the admission to count, he noted.

The approach worked for Massey Cancer Center’s palliative care unit.

"In about an 18- to 24-month period, we paid a lot attention to having most of the attendings and the fellows write out diagnostic statements, rather than medical thoughts," Dr. Smith said.

"When we started, our actual-vs.-expected mortality ratio was 150% higher than what it was supposed to be. We didn’t change the mortality rate one bit, but we changed the expected mortality. It came down to 55%, which is still high, but, heck, it’s a palliative care unit. A lot of people are sick and they’re going to die," he said.

"The APR-DRG [All Patient Refined Diagnosis Related Groups] severity of illness doubled just by paying attention to having those diagnostic statements put in," he said.

Dr. Smith gave an example of how the strategy also increases payments: An elderly person was admitted upon diagnosis of urosepsis, dehydration, and chronic obstructive pulmonary disease, but the patient’s condition allowed for more, including urinary tract infection; malnutrition; preexisting decubitus ulcer; and shock because the patient was a bit hypotensive.

With the additional diagnoses, the patient’s severity of illness (SOI) weighting increased from 0.5973 to 3.3739, resulting in a $5,613 payment increase.

"That’s a huge difference," Dr. Smith said.

He had a final tip for improving Hospital Compare mortality scores.

The CMS counts 30-day mortality, but the 30-day clock doesn’t start until 24 hours after admission. "So if you can enroll a Medicare patient in hospice within 24 hours of them hitting your emergency room door, then they don’t count towards your 30 day mortality," Dr. Smith said.

To help, "you can post somebody in the ER and make the ER aware that this is important, so that you can see those patients in the ER. Let your social workers know that the 24 shot-clock is ticking," Dr. Smith said.

The goal is to "accelerate the process of patients and families making choices. You can push that a little bit," he said.

Dr. Smith said he has no relevant disclosures.

VANCOUVER, B.C. - To improve hospital mortality scores, clinicians should include all possible diagnoses in patient charts, according to oncologist and palliative care specialist Dr. Thomas J. Smith.

U.S. News & World Report’s "Best Hospitals," the Centers for Medicaid and Medicare Services’ Hospital Compare, and other hospital rating programs compare hospital outcomes to national averages based on how sick patients are, said Dr. Smith, medical director of palliative care at Virginia Commonwealth University Massey Cancer Center in Richmond.

"You get counted on your observed mortality rate. They compare that to how many people are expected to die" according to the averages, he said at the annual meeting of the American Academy of Hospice and Palliative Care Medicine. Deaths in excess of the averages are considered unexpected and are assumed to be caused by poor quality care, which lowers hospitals in the mortality rankings.

By listing all possible diagnoses – especially at the end of life – "[you increase] your expected mortality, so that your observed-to-expected ratio improves. Even if you ignore improving mortality, if you change [how many people are expected to die] you’ll improve your ratio" and hospital standing, he said.

The reason is that hospital coders pull the diagnoses off patient charts and include them in claims submissions, the data upon which the rankings are based.

The approach is not about "gaming the system," Dr. Smith said. "You are adequately documenting the severity of the patients that you take care of" to ensure accurate mortality scores.

The key is to list diagnoses, not "medical thoughts," he said.

For example, " ‘lytic lesion of vertebra on spine films’ does not count. Write ‘bone mets’ [because] your coders can count that. Don’t write ‘neutrophils’ with an arrow going down. It doesn’t count. You have to write ‘neutropenia.’ If you write ‘admit for chemo,’ you can write ‘admit for chemo, dehydration, chronic blood loss anemia’ [as appropriate] and your severity index will go up a lot," said Dr. Smith, adding that each site of metastases should be listed because "you get points for each one."

Similarly, " ‘chest x-ray with pneumonitis status post radiation therapy’ does not count. You have to write ‘radiation pneumonitis.’ [And] don’t put ‘total protein and albumin low.’ Put ‘cachexia or malnutrition, moderate or severe.’ Don’t write ‘admit for pain control.’ Write ‘intractable pain form malignancy,’ and you have to say ‘lung cancer, breast cancer, bone cancer, liver cancer’ [accordingly]," he said.

Such diagnoses only have to be written once during the admission to count, he noted.

The approach worked for Massey Cancer Center’s palliative care unit.

"In about an 18- to 24-month period, we paid a lot attention to having most of the attendings and the fellows write out diagnostic statements, rather than medical thoughts," Dr. Smith said.

"When we started, our actual-vs.-expected mortality ratio was 150% higher than what it was supposed to be. We didn’t change the mortality rate one bit, but we changed the expected mortality. It came down to 55%, which is still high, but, heck, it’s a palliative care unit. A lot of people are sick and they’re going to die," he said.

"The APR-DRG [All Patient Refined Diagnosis Related Groups] severity of illness doubled just by paying attention to having those diagnostic statements put in," he said.

Dr. Smith gave an example of how the strategy also increases payments: An elderly person was admitted upon diagnosis of urosepsis, dehydration, and chronic obstructive pulmonary disease, but the patient’s condition allowed for more, including urinary tract infection; malnutrition; preexisting decubitus ulcer; and shock because the patient was a bit hypotensive.

With the additional diagnoses, the patient’s severity of illness (SOI) weighting increased from 0.5973 to 3.3739, resulting in a $5,613 payment increase.

"That’s a huge difference," Dr. Smith said.

He had a final tip for improving Hospital Compare mortality scores.

The CMS counts 30-day mortality, but the 30-day clock doesn’t start until 24 hours after admission. "So if you can enroll a Medicare patient in hospice within 24 hours of them hitting your emergency room door, then they don’t count towards your 30 day mortality," Dr. Smith said.

To help, "you can post somebody in the ER and make the ER aware that this is important, so that you can see those patients in the ER. Let your social workers know that the 24 shot-clock is ticking," Dr. Smith said.

The goal is to "accelerate the process of patients and families making choices. You can push that a little bit," he said.

Dr. Smith said he has no relevant disclosures.

VANCOUVER, B.C. - To improve hospital mortality scores, clinicians should include all possible diagnoses in patient charts, according to oncologist and palliative care specialist Dr. Thomas J. Smith.

U.S. News & World Report’s "Best Hospitals," the Centers for Medicaid and Medicare Services’ Hospital Compare, and other hospital rating programs compare hospital outcomes to national averages based on how sick patients are, said Dr. Smith, medical director of palliative care at Virginia Commonwealth University Massey Cancer Center in Richmond.

"You get counted on your observed mortality rate. They compare that to how many people are expected to die" according to the averages, he said at the annual meeting of the American Academy of Hospice and Palliative Care Medicine. Deaths in excess of the averages are considered unexpected and are assumed to be caused by poor quality care, which lowers hospitals in the mortality rankings.

By listing all possible diagnoses – especially at the end of life – "[you increase] your expected mortality, so that your observed-to-expected ratio improves. Even if you ignore improving mortality, if you change [how many people are expected to die] you’ll improve your ratio" and hospital standing, he said.

The reason is that hospital coders pull the diagnoses off patient charts and include them in claims submissions, the data upon which the rankings are based.

The approach is not about "gaming the system," Dr. Smith said. "You are adequately documenting the severity of the patients that you take care of" to ensure accurate mortality scores.

The key is to list diagnoses, not "medical thoughts," he said.

For example, " ‘lytic lesion of vertebra on spine films’ does not count. Write ‘bone mets’ [because] your coders can count that. Don’t write ‘neutrophils’ with an arrow going down. It doesn’t count. You have to write ‘neutropenia.’ If you write ‘admit for chemo,’ you can write ‘admit for chemo, dehydration, chronic blood loss anemia’ [as appropriate] and your severity index will go up a lot," said Dr. Smith, adding that each site of metastases should be listed because "you get points for each one."

Similarly, " ‘chest x-ray with pneumonitis status post radiation therapy’ does not count. You have to write ‘radiation pneumonitis.’ [And] don’t put ‘total protein and albumin low.’ Put ‘cachexia or malnutrition, moderate or severe.’ Don’t write ‘admit for pain control.’ Write ‘intractable pain form malignancy,’ and you have to say ‘lung cancer, breast cancer, bone cancer, liver cancer’ [accordingly]," he said.

Such diagnoses only have to be written once during the admission to count, he noted.

The approach worked for Massey Cancer Center’s palliative care unit.

"In about an 18- to 24-month period, we paid a lot attention to having most of the attendings and the fellows write out diagnostic statements, rather than medical thoughts," Dr. Smith said.

"When we started, our actual-vs.-expected mortality ratio was 150% higher than what it was supposed to be. We didn’t change the mortality rate one bit, but we changed the expected mortality. It came down to 55%, which is still high, but, heck, it’s a palliative care unit. A lot of people are sick and they’re going to die," he said.

"The APR-DRG [All Patient Refined Diagnosis Related Groups] severity of illness doubled just by paying attention to having those diagnostic statements put in," he said.

Dr. Smith gave an example of how the strategy also increases payments: An elderly person was admitted upon diagnosis of urosepsis, dehydration, and chronic obstructive pulmonary disease, but the patient’s condition allowed for more, including urinary tract infection; malnutrition; preexisting decubitus ulcer; and shock because the patient was a bit hypotensive.

With the additional diagnoses, the patient’s severity of illness (SOI) weighting increased from 0.5973 to 3.3739, resulting in a $5,613 payment increase.

"That’s a huge difference," Dr. Smith said.

He had a final tip for improving Hospital Compare mortality scores.

The CMS counts 30-day mortality, but the 30-day clock doesn’t start until 24 hours after admission. "So if you can enroll a Medicare patient in hospice within 24 hours of them hitting your emergency room door, then they don’t count towards your 30 day mortality," Dr. Smith said.

To help, "you can post somebody in the ER and make the ER aware that this is important, so that you can see those patients in the ER. Let your social workers know that the 24 shot-clock is ticking," Dr. Smith said.

The goal is to "accelerate the process of patients and families making choices. You can push that a little bit," he said.

Dr. Smith said he has no relevant disclosures.

VANCOUVER, B.C. - To improve hospital mortality scores, clinicians should include all possible diagnoses in patient charts, according to oncologist and palliative care specialist Dr. Thomas J. Smith.

U.S. News & World Report’s "Best Hospitals," the Centers for Medicaid and Medicare Services’ Hospital Compare, and other hospital rating programs compare hospital outcomes to national averages based on how sick patients are, said Dr. Smith, medical director of palliative care at Virginia Commonwealth University Massey Cancer Center in Richmond.

"You get counted on your observed mortality rate. They compare that to how many people are expected to die" according to the averages, he said at the annual meeting of the American Academy of Hospice and Palliative Care Medicine. Deaths in excess of the averages are considered unexpected and are assumed to be caused by poor quality care, which lowers hospitals in the mortality rankings.

By listing all possible diagnoses – especially at the end of life – "[you increase] your expected mortality, so that your observed-to-expected ratio improves. Even if you ignore improving mortality, if you change [how many people are expected to die] you’ll improve your ratio" and hospital standing, he said.

The reason is that hospital coders pull the diagnoses off patient charts and include them in claims submissions, the data upon which the rankings are based.

The approach is not about "gaming the system," Dr. Smith said. "You are adequately documenting the severity of the patients that you take care of" to ensure accurate mortality scores.

The key is to list diagnoses, not "medical thoughts," he said.

For example, " ‘lytic lesion of vertebra on spine films’ does not count. Write ‘bone mets’ [because] your coders can count that. Don’t write ‘neutrophils’ with an arrow going down. It doesn’t count. You have to write ‘neutropenia.’ If you write ‘admit for chemo,’ you can write ‘admit for chemo, dehydration, chronic blood loss anemia’ [as appropriate] and your severity index will go up a lot," said Dr. Smith, adding that each site of metastases should be listed because "you get points for each one."

Similarly, " ‘chest x-ray with pneumonitis status post radiation therapy’ does not count. You have to write ‘radiation pneumonitis.’ [And] don’t put ‘total protein and albumin low.’ Put ‘cachexia or malnutrition, moderate or severe.’ Don’t write ‘admit for pain control.’ Write ‘intractable pain form malignancy,’ and you have to say ‘lung cancer, breast cancer, bone cancer, liver cancer’ [accordingly]," he said.

Such diagnoses only have to be written once during the admission to count, he noted.

The approach worked for Massey Cancer Center’s palliative care unit.

"In about an 18- to 24-month period, we paid a lot attention to having most of the attendings and the fellows write out diagnostic statements, rather than medical thoughts," Dr. Smith said.

"When we started, our actual-vs.-expected mortality ratio was 150% higher than what it was supposed to be. We didn’t change the mortality rate one bit, but we changed the expected mortality. It came down to 55%, which is still high, but, heck, it’s a palliative care unit. A lot of people are sick and they’re going to die," he said.

"The APR-DRG [All Patient Refined Diagnosis Related Groups] severity of illness doubled just by paying attention to having those diagnostic statements put in," he said.

Dr. Smith gave an example of how the strategy also increases payments: An elderly person was admitted upon diagnosis of urosepsis, dehydration, and chronic obstructive pulmonary disease, but the patient’s condition allowed for more, including urinary tract infection; malnutrition; preexisting decubitus ulcer; and shock because the patient was a bit hypotensive.

With the additional diagnoses, the patient’s severity of illness (SOI) weighting increased from 0.5973 to 3.3739, resulting in a $5,613 payment increase.

"That’s a huge difference," Dr. Smith said.

He had a final tip for improving Hospital Compare mortality scores.

The CMS counts 30-day mortality, but the 30-day clock doesn’t start until 24 hours after admission. "So if you can enroll a Medicare patient in hospice within 24 hours of them hitting your emergency room door, then they don’t count towards your 30 day mortality," Dr. Smith said.

To help, "you can post somebody in the ER and make the ER aware that this is important, so that you can see those patients in the ER. Let your social workers know that the 24 shot-clock is ticking," Dr. Smith said.

The goal is to "accelerate the process of patients and families making choices. You can push that a little bit," he said.

Dr. Smith said he has no relevant disclosures.

VANCOUVER, B.C. - To improve hospital mortality scores, clinicians should include all possible diagnoses in patient charts, according to oncologist and palliative care specialist Dr. Thomas J. Smith.

U.S. News & World Report’s "Best Hospitals," the Centers for Medicaid and Medicare Services’ Hospital Compare, and other hospital rating programs compare hospital outcomes to national averages based on how sick patients are, said Dr. Smith, medical director of palliative care at Virginia Commonwealth University Massey Cancer Center in Richmond.

"You get counted on your observed mortality rate. They compare that to how many people are expected to die" according to the averages, he said at the annual meeting of the American Academy of Hospice and Palliative Care Medicine. Deaths in excess of the averages are considered unexpected and are assumed to be caused by poor quality care, which lowers hospitals in the mortality rankings.

By listing all possible diagnoses – especially at the end of life – "[you increase] your expected mortality, so that your observed-to-expected ratio improves. Even if you ignore improving mortality, if you change [how many people are expected to die] you’ll improve your ratio" and hospital standing, he said.

The reason is that hospital coders pull the diagnoses off patient charts and include them in claims submissions, the data upon which the rankings are based.

The approach is not about "gaming the system," Dr. Smith said. "You are adequately documenting the severity of the patients that you take care of" to ensure accurate mortality scores.

The key is to list diagnoses, not "medical thoughts," he said.

For example, " ‘lytic lesion of vertebra on spine films’ does not count. Write ‘bone mets’ [because] your coders can count that. Don’t write ‘neutrophils’ with an arrow going down. It doesn’t count. You have to write ‘neutropenia.’ If you write ‘admit for chemo,’ you can write ‘admit for chemo, dehydration, chronic blood loss anemia’ [as appropriate] and your severity index will go up a lot," said Dr. Smith, adding that each site of metastases should be listed because "you get points for each one."

Similarly, " ‘chest x-ray with pneumonitis status post radiation therapy’ does not count. You have to write ‘radiation pneumonitis.’ [And] don’t put ‘total protein and albumin low.’ Put ‘cachexia or malnutrition, moderate or severe.’ Don’t write ‘admit for pain control.’ Write ‘intractable pain form malignancy,’ and you have to say ‘lung cancer, breast cancer, bone cancer, liver cancer’ [accordingly]," he said.

Such diagnoses only have to be written once during the admission to count, he noted.

The approach worked for Massey Cancer Center’s palliative care unit.

"In about an 18- to 24-month period, we paid a lot attention to having most of the attendings and the fellows write out diagnostic statements, rather than medical thoughts," Dr. Smith said.

"When we started, our actual-vs.-expected mortality ratio was 150% higher than what it was supposed to be. We didn’t change the mortality rate one bit, but we changed the expected mortality. It came down to 55%, which is still high, but, heck, it’s a palliative care unit. A lot of people are sick and they’re going to die," he said.

"The APR-DRG [All Patient Refined Diagnosis Related Groups] severity of illness doubled just by paying attention to having those diagnostic statements put in," he said.

Dr. Smith gave an example of how the strategy also increases payments: An elderly person was admitted upon diagnosis of urosepsis, dehydration, and chronic obstructive pulmonary disease, but the patient’s condition allowed for more, including urinary tract infection; malnutrition; preexisting decubitus ulcer; and shock because the patient was a bit hypotensive.

With the additional diagnoses, the patient’s severity of illness (SOI) weighting increased from 0.5973 to 3.3739, resulting in a $5,613 payment increase.

"That’s a huge difference," Dr. Smith said.

He had a final tip for improving Hospital Compare mortality scores.

The CMS counts 30-day mortality, but the 30-day clock doesn’t start until 24 hours after admission. "So if you can enroll a Medicare patient in hospice within 24 hours of them hitting your emergency room door, then they don’t count towards your 30 day mortality," Dr. Smith said.

To help, "you can post somebody in the ER and make the ER aware that this is important, so that you can see those patients in the ER. Let your social workers know that the 24 shot-clock is ticking," Dr. Smith said.

The goal is to "accelerate the process of patients and families making choices. You can push that a little bit," he said.

Dr. Smith said he has no relevant disclosures.

VANCOUVER, B.C. - To improve hospital mortality scores, clinicians should include all possible diagnoses in patient charts, according to oncologist and palliative care specialist Dr. Thomas J. Smith.

U.S. News & World Report’s "Best Hospitals," the Centers for Medicaid and Medicare Services’ Hospital Compare, and other hospital rating programs compare hospital outcomes to national averages based on how sick patients are, said Dr. Smith, medical director of palliative care at Virginia Commonwealth University Massey Cancer Center in Richmond.

"You get counted on your observed mortality rate. They compare that to how many people are expected to die" according to the averages, he said at the annual meeting of the American Academy of Hospice and Palliative Care Medicine. Deaths in excess of the averages are considered unexpected and are assumed to be caused by poor quality care, which lowers hospitals in the mortality rankings.

By listing all possible diagnoses – especially at the end of life – "[you increase] your expected mortality, so that your observed-to-expected ratio improves. Even if you ignore improving mortality, if you change [how many people are expected to die] you’ll improve your ratio" and hospital standing, he said.

The reason is that hospital coders pull the diagnoses off patient charts and include them in claims submissions, the data upon which the rankings are based.

The approach is not about "gaming the system," Dr. Smith said. "You are adequately documenting the severity of the patients that you take care of" to ensure accurate mortality scores.

The key is to list diagnoses, not "medical thoughts," he said.

For example, " ‘lytic lesion of vertebra on spine films’ does not count. Write ‘bone mets’ [because] your coders can count that. Don’t write ‘neutrophils’ with an arrow going down. It doesn’t count. You have to write ‘neutropenia.’ If you write ‘admit for chemo,’ you can write ‘admit for chemo, dehydration, chronic blood loss anemia’ [as appropriate] and your severity index will go up a lot," said Dr. Smith, adding that each site of metastases should be listed because "you get points for each one."

Similarly, " ‘chest x-ray with pneumonitis status post radiation therapy’ does not count. You have to write ‘radiation pneumonitis.’ [And] don’t put ‘total protein and albumin low.’ Put ‘cachexia or malnutrition, moderate or severe.’ Don’t write ‘admit for pain control.’ Write ‘intractable pain form malignancy,’ and you have to say ‘lung cancer, breast cancer, bone cancer, liver cancer’ [accordingly]," he said.

Such diagnoses only have to be written once during the admission to count, he noted.

The approach worked for Massey Cancer Center’s palliative care unit.

"In about an 18- to 24-month period, we paid a lot attention to having most of the attendings and the fellows write out diagnostic statements, rather than medical thoughts," Dr. Smith said.

"When we started, our actual-vs.-expected mortality ratio was 150% higher than what it was supposed to be. We didn’t change the mortality rate one bit, but we changed the expected mortality. It came down to 55%, which is still high, but, heck, it’s a palliative care unit. A lot of people are sick and they’re going to die," he said.

"The APR-DRG [All Patient Refined Diagnosis Related Groups] severity of illness doubled just by paying attention to having those diagnostic statements put in," he said.

Dr. Smith gave an example of how the strategy also increases payments: An elderly person was admitted upon diagnosis of urosepsis, dehydration, and chronic obstructive pulmonary disease, but the patient’s condition allowed for more, including urinary tract infection; malnutrition; preexisting decubitus ulcer; and shock because the patient was a bit hypotensive.

With the additional diagnoses, the patient’s severity of illness (SOI) weighting increased from 0.5973 to 3.3739, resulting in a $5,613 payment increase.

"That’s a huge difference," Dr. Smith said.

He had a final tip for improving Hospital Compare mortality scores.

The CMS counts 30-day mortality, but the 30-day clock doesn’t start until 24 hours after admission. "So if you can enroll a Medicare patient in hospice within 24 hours of them hitting your emergency room door, then they don’t count towards your 30 day mortality," Dr. Smith said.

To help, "you can post somebody in the ER and make the ER aware that this is important, so that you can see those patients in the ER. Let your social workers know that the 24 shot-clock is ticking," Dr. Smith said.

The goal is to "accelerate the process of patients and families making choices. You can push that a little bit," he said.

Dr. Smith said he has no relevant disclosures.

VANCOUVER, B.C. - To improve hospital mortality scores, clinicians should include all possible diagnoses in patient charts, according to oncologist and palliative care specialist Dr. Thomas J. Smith.

U.S. News & World Report’s "Best Hospitals," the Centers for Medicaid and Medicare Services’ Hospital Compare, and other hospital rating programs compare hospital outcomes to national averages based on how sick patients are, said Dr. Smith, medical director of palliative care at Virginia Commonwealth University Massey Cancer Center in Richmond.

"You get counted on your observed mortality rate. They compare that to how many people are expected to die" according to the averages, he said at the annual meeting of the American Academy of Hospice and Palliative Care Medicine. Deaths in excess of the averages are considered unexpected and are assumed to be caused by poor quality care, which lowers hospitals in the mortality rankings.

By listing all possible diagnoses – especially at the end of life – "[you increase] your expected mortality, so that your observed-to-expected ratio improves. Even if you ignore improving mortality, if you change [how many people are expected to die] you’ll improve your ratio" and hospital standing, he said.

The reason is that hospital coders pull the diagnoses off patient charts and include them in claims submissions, the data upon which the rankings are based.

The approach is not about "gaming the system," Dr. Smith said. "You are adequately documenting the severity of the patients that you take care of" to ensure accurate mortality scores.

The key is to list diagnoses, not "medical thoughts," he said.

For example, " ‘lytic lesion of vertebra on spine films’ does not count. Write ‘bone mets’ [because] your coders can count that. Don’t write ‘neutrophils’ with an arrow going down. It doesn’t count. You have to write ‘neutropenia.’ If you write ‘admit for chemo,’ you can write ‘admit for chemo, dehydration, chronic blood loss anemia’ [as appropriate] and your severity index will go up a lot," said Dr. Smith, adding that each site of metastases should be listed because "you get points for each one."

Similarly, " ‘chest x-ray with pneumonitis status post radiation therapy’ does not count. You have to write ‘radiation pneumonitis.’ [And] don’t put ‘total protein and albumin low.’ Put ‘cachexia or malnutrition, moderate or severe.’ Don’t write ‘admit for pain control.’ Write ‘intractable pain form malignancy,’ and you have to say ‘lung cancer, breast cancer, bone cancer, liver cancer’ [accordingly]," he said.

Such diagnoses only have to be written once during the admission to count, he noted.

The approach worked for Massey Cancer Center’s palliative care unit.

"In about an 18- to 24-month period, we paid a lot attention to having most of the attendings and the fellows write out diagnostic statements, rather than medical thoughts," Dr. Smith said.

"When we started, our actual-vs.-expected mortality ratio was 150% higher than what it was supposed to be. We didn’t change the mortality rate one bit, but we changed the expected mortality. It came down to 55%, which is still high, but, heck, it’s a palliative care unit. A lot of people are sick and they’re going to die," he said.

"The APR-DRG [All Patient Refined Diagnosis Related Groups] severity of illness doubled just by paying attention to having those diagnostic statements put in," he said.

Dr. Smith gave an example of how the strategy also increases payments: An elderly person was admitted upon diagnosis of urosepsis, dehydration, and chronic obstructive pulmonary disease, but the patient’s condition allowed for more, including urinary tract infection; malnutrition; preexisting decubitus ulcer; and shock because the patient was a bit hypotensive.

With the additional diagnoses, the patient’s severity of illness (SOI) weighting increased from 0.5973 to 3.3739, resulting in a $5,613 payment increase.

"That’s a huge difference," Dr. Smith said.

He had a final tip for improving Hospital Compare mortality scores.

The CMS counts 30-day mortality, but the 30-day clock doesn’t start until 24 hours after admission. "So if you can enroll a Medicare patient in hospice within 24 hours of them hitting your emergency room door, then they don’t count towards your 30 day mortality," Dr. Smith said.

To help, "you can post somebody in the ER and make the ER aware that this is important, so that you can see those patients in the ER. Let your social workers know that the 24 shot-clock is ticking," Dr. Smith said.

The goal is to "accelerate the process of patients and families making choices. You can push that a little bit," he said.

Dr. Smith said he has no relevant disclosures.

VANCOUVER, B.C. - To improve hospital mortality scores, clinicians should include all possible diagnoses in patient charts, according to oncologist and palliative care specialist Dr. Thomas J. Smith.

U.S. News & World Report’s "Best Hospitals," the Centers for Medicaid and Medicare Services’ Hospital Compare, and other hospital rating programs compare hospital outcomes to national averages based on how sick patients are, said Dr. Smith, medical director of palliative care at Virginia Commonwealth University Massey Cancer Center in Richmond.

"You get counted on your observed mortality rate. They compare that to how many people are expected to die" according to the averages, he said at the annual meeting of the American Academy of Hospice and Palliative Care Medicine. Deaths in excess of the averages are considered unexpected and are assumed to be caused by poor quality care, which lowers hospitals in the mortality rankings.

By listing all possible diagnoses – especially at the end of life – "[you increase] your expected mortality, so that your observed-to-expected ratio improves. Even if you ignore improving mortality, if you change [how many people are expected to die] you’ll improve your ratio" and hospital standing, he said.

The reason is that hospital coders pull the diagnoses off patient charts and include them in claims submissions, the data upon which the rankings are based.

The approach is not about "gaming the system," Dr. Smith said. "You are adequately documenting the severity of the patients that you take care of" to ensure accurate mortality scores.

The key is to list diagnoses, not "medical thoughts," he said.

For example, " ‘lytic lesion of vertebra on spine films’ does not count. Write ‘bone mets’ [because] your coders can count that. Don’t write ‘neutrophils’ with an arrow going down. It doesn’t count. You have to write ‘neutropenia.’ If you write ‘admit for chemo,’ you can write ‘admit for chemo, dehydration, chronic blood loss anemia’ [as appropriate] and your severity index will go up a lot," said Dr. Smith, adding that each site of metastases should be listed because "you get points for each one."

Similarly, " ‘chest x-ray with pneumonitis status post radiation therapy’ does not count. You have to write ‘radiation pneumonitis.’ [And] don’t put ‘total protein and albumin low.’ Put ‘cachexia or malnutrition, moderate or severe.’ Don’t write ‘admit for pain control.’ Write ‘intractable pain form malignancy,’ and you have to say ‘lung cancer, breast cancer, bone cancer, liver cancer’ [accordingly]," he said.

Such diagnoses only have to be written once during the admission to count, he noted.

The approach worked for Massey Cancer Center’s palliative care unit.

"In about an 18- to 24-month period, we paid a lot attention to having most of the attendings and the fellows write out diagnostic statements, rather than medical thoughts," Dr. Smith said.

"When we started, our actual-vs.-expected mortality ratio was 150% higher than what it was supposed to be. We didn’t change the mortality rate one bit, but we changed the expected mortality. It came down to 55%, which is still high, but, heck, it’s a palliative care unit. A lot of people are sick and they’re going to die," he said.

"The APR-DRG [All Patient Refined Diagnosis Related Groups] severity of illness doubled just by paying attention to having those diagnostic statements put in," he said.

Dr. Smith gave an example of how the strategy also increases payments: An elderly person was admitted upon diagnosis of urosepsis, dehydration, and chronic obstructive pulmonary disease, but the patient’s condition allowed for more, including urinary tract infection; malnutrition; preexisting decubitus ulcer; and shock because the patient was a bit hypotensive.

With the additional diagnoses, the patient’s severity of illness (SOI) weighting increased from 0.5973 to 3.3739, resulting in a $5,613 payment increase.

"That’s a huge difference," Dr. Smith said.

He had a final tip for improving Hospital Compare mortality scores.

The CMS counts 30-day mortality, but the 30-day clock doesn’t start until 24 hours after admission. "So if you can enroll a Medicare patient in hospice within 24 hours of them hitting your emergency room door, then they don’t count towards your 30 day mortality," Dr. Smith said.

To help, "you can post somebody in the ER and make the ER aware that this is important, so that you can see those patients in the ER. Let your social workers know that the 24 shot-clock is ticking," Dr. Smith said.

The goal is to "accelerate the process of patients and families making choices. You can push that a little bit," he said.

Dr. Smith said he has no relevant disclosures.

VANCOUVER, B.C. - To improve hospital mortality scores, clinicians should include all possible diagnoses in patient charts, according to oncologist and palliative care specialist Dr. Thomas J. Smith.

U.S. News & World Report’s "Best Hospitals," the Centers for Medicaid and Medicare Services’ Hospital Compare, and other hospital rating programs compare hospital outcomes to national averages based on how sick patients are, said Dr. Smith, medical director of palliative care at Virginia Commonwealth University Massey Cancer Center in Richmond.

"You get counted on your observed mortality rate. They compare that to how many people are expected to die" according to the averages, he said at the annual meeting of the American Academy of Hospice and Palliative Care Medicine. Deaths in excess of the averages are considered unexpected and are assumed to be caused by poor quality care, which lowers hospitals in the mortality rankings.

By listing all possible diagnoses – especially at the end of life – "[you increase] your expected mortality, so that your observed-to-expected ratio improves. Even if you ignore improving mortality, if you change [how many people are expected to die] you’ll improve your ratio" and hospital standing, he said.

The reason is that hospital coders pull the diagnoses off patient charts and include them in claims submissions, the data upon which the rankings are based.

The approach is not about "gaming the system," Dr. Smith said. "You are adequately documenting the severity of the patients that you take care of" to ensure accurate mortality scores.

The key is to list diagnoses, not "medical thoughts," he said.

For example, " ‘lytic lesion of vertebra on spine films’ does not count. Write ‘bone mets’ [because] your coders can count that. Don’t write ‘neutrophils’ with an arrow going down. It doesn’t count. You have to write ‘neutropenia.’ If you write ‘admit for chemo,’ you can write ‘admit for chemo, dehydration, chronic blood loss anemia’ [as appropriate] and your severity index will go up a lot," said Dr. Smith, adding that each site of metastases should be listed because "you get points for each one."

Similarly, " ‘chest x-ray with pneumonitis status post radiation therapy’ does not count. You have to write ‘radiation pneumonitis.’ [And] don’t put ‘total protein and albumin low.’ Put ‘cachexia or malnutrition, moderate or severe.’ Don’t write ‘admit for pain control.’ Write ‘intractable pain form malignancy,’ and you have to say ‘lung cancer, breast cancer, bone cancer, liver cancer’ [accordingly]," he said.

Such diagnoses only have to be written once during the admission to count, he noted.

The approach worked for Massey Cancer Center’s palliative care unit.

"In about an 18- to 24-month period, we paid a lot attention to having most of the attendings and the fellows write out diagnostic statements, rather than medical thoughts," Dr. Smith said.

"When we started, our actual-vs.-expected mortality ratio was 150% higher than what it was supposed to be. We didn’t change the mortality rate one bit, but we changed the expected mortality. It came down to 55%, which is still high, but, heck, it’s a palliative care unit. A lot of people are sick and they’re going to die," he said.

"The APR-DRG [All Patient Refined Diagnosis Related Groups] severity of illness doubled just by paying attention to having those diagnostic statements put in," he said.

Dr. Smith gave an example of how the strategy also increases payments: An elderly person was admitted upon diagnosis of urosepsis, dehydration, and chronic obstructive pulmonary disease, but the patient’s condition allowed for more, including urinary tract infection; malnutrition; preexisting decubitus ulcer; and shock because the patient was a bit hypotensive.

With the additional diagnoses, the patient’s severity of illness (SOI) weighting increased from 0.5973 to 3.3739, resulting in a $5,613 payment increase.

"That’s a huge difference," Dr. Smith said.

He had a final tip for improving Hospital Compare mortality scores.

The CMS counts 30-day mortality, but the 30-day clock doesn’t start until 24 hours after admission. "So if you can enroll a Medicare patient in hospice within 24 hours of them hitting your emergency room door, then they don’t count towards your 30 day mortality," Dr. Smith said.

To help, "you can post somebody in the ER and make the ER aware that this is important, so that you can see those patients in the ER. Let your social workers know that the 24 shot-clock is ticking," Dr. Smith said.

The goal is to "accelerate the process of patients and families making choices. You can push that a little bit," he said.

Dr. Smith said he has no relevant disclosures.

VANCOUVER, B.C. – Withdrawing medications at the end of life is often the right thing to do clinically, but it can make hospice patients feel abandoned, according to nurse Beverly Lunsford, Ph.D.

"People have it hammered in their heads to take their diabetes medications, their hypertension medications, and have done it faithfully for [decades]. Now you’re telling them to stop. They may have a real sense that isn’t right. Families may perceive medication discontinuation as substandard care or lack of care," said Dr. Lunsford, who coordinates the graduate program for palliative care nurse practitioners at George Washington University in Washington.

It’s important to reassure patients and families that’s not the case or, better yet, handle the situation in such a way that they don’t think so in the first place, Dr. Lunsford said at the annual meeting of the American Academy of Hospice and Palliative Care Medicine.

A review with the patient of his or her medications is a good place to start, said Dr. Robert Kaiser, associate geriatrics and palliative care professor at the university. In such "brown-bag reviews," patients bring in every medication they take, including nutritional supplements and other over-the-counter preparations. Clinicians then check whether the drugs’ original indications still apply and ask about side effects and adherence. Most hospice patients need such attention as they typically are on at least five drugs at admission to hospice, with more added for comfort care, Dr. Kaiser said.

Medication issues should also be incorporated into goals-of-care discussions, said Dr. Lunsford. When patients opt for comfort care, "you might sort out with them which medications they are taking for symptom relief and what medications they are taking for treating medical conditions" that are no longer a high priority, such as hypercholesterolemia, she said.

A patient might be more open to this discussion if a clinician points out that the person’s medical condition has changed – that he or she has lost weight, for instance – so certain drugs are less necessary. Once-tolerated doses may be too potent because of loss of kidney or liver function. Difficulty swallowing and memory loss may also make adherence increasingly burdensome, Dr. Kaiser said.

The goal is to cut unneeded medications so side effects, such as falls and confusion, and drug interactions don’t add discomfort to the dying process, he said. Picking which drugs to stop, however, is not an exact science. Life expectancy, how a drug meets care goals, and how long a drug takes to work are among some of the factors to consider.

Dr. Lunsford and Dr. Kaiser recommended several guides to withdrawing drugs at the end of life. The Medication Appropriateness Index, a 10-question tool for gauging appropriate drug use, can help, they said, as can the list of drugs and dosages to avoid in the elderly according to the Beers criteria (Arch. Intern. Med. 2006;166:605-9).

They cited other references making the point that drugs for chronic conditions may reasonably be discontinued. Statins, bisphosphonates, and cholinesterase inhibitors may be stopped in patients with advanced dementia, poor prognoses, or both, they said, and cholinesterase inhibitors and memantine may be discontinuation candidates because the evidence is marginal for their benefit in advanced dementia patients entering hospice or other palliative care (End of Life/Palliative Education Resource Center. Fast Fact and Concept #174 "Dementia Medications in Palliative Care," www.eperc.mcw.edu). Opioids, beta-blockers, clonidine, gabapentin, selective serotonin reuptake inhibitors, serotonin-norepinephrine reuptake inhibitors, and tricyclic antidepressants, among others, require tapering, said Dr. Lunsford and Dr. Kaiser, citing a recent study (JAMA 2010;304:1592-601). A drug holiday may be appropriate when there is uncertainty about withdrawing a medication, Dr. Kaiser said.

Dr. Lunsford cautioned that "many health care professionals may not feel they have the time" to decide what drugs to stop, negotiate the issue with the patient, taper doses, and monitor outcomes on subsequent visits. It’s important to do so, however, and to prevent conflict with peers by keeping them in the loop when discontinuing drugs, she said.

"You need to get them on the same page. Get the case manager involved if you’re not in direct contact with these people, or pick up the phone and [let them know] this is what your suggesting," she said.

Neither Dr. Lunsford nor Dr. Kaiser made conflict-of-interest disclosures.

VANCOUVER, B.C. – Withdrawing medications at the end of life is often the right thing to do clinically, but it can make hospice patients feel abandoned, according to nurse Beverly Lunsford, Ph.D.

"People have it hammered in their heads to take their diabetes medications, their hypertension medications, and have done it faithfully for [decades]. Now you’re telling them to stop. They may have a real sense that isn’t right. Families may perceive medication discontinuation as substandard care or lack of care," said Dr. Lunsford, who coordinates the graduate program for palliative care nurse practitioners at George Washington University in Washington.

It’s important to reassure patients and families that’s not the case or, better yet, handle the situation in such a way that they don’t think so in the first place, Dr. Lunsford said at the annual meeting of the American Academy of Hospice and Palliative Care Medicine.

A review with the patient of his or her medications is a good place to start, said Dr. Robert Kaiser, associate geriatrics and palliative care professor at the university. In such "brown-bag reviews," patients bring in every medication they take, including nutritional supplements and other over-the-counter preparations. Clinicians then check whether the drugs’ original indications still apply and ask about side effects and adherence. Most hospice patients need such attention as they typically are on at least five drugs at admission to hospice, with more added for comfort care, Dr. Kaiser said.

Medication issues should also be incorporated into goals-of-care discussions, said Dr. Lunsford. When patients opt for comfort care, "you might sort out with them which medications they are taking for symptom relief and what medications they are taking for treating medical conditions" that are no longer a high priority, such as hypercholesterolemia, she said.

A patient might be more open to this discussion if a clinician points out that the person’s medical condition has changed – that he or she has lost weight, for instance – so certain drugs are less necessary. Once-tolerated doses may be too potent because of loss of kidney or liver function. Difficulty swallowing and memory loss may also make adherence increasingly burdensome, Dr. Kaiser said.

The goal is to cut unneeded medications so side effects, such as falls and confusion, and drug interactions don’t add discomfort to the dying process, he said. Picking which drugs to stop, however, is not an exact science. Life expectancy, how a drug meets care goals, and how long a drug takes to work are among some of the factors to consider.

Dr. Lunsford and Dr. Kaiser recommended several guides to withdrawing drugs at the end of life. The Medication Appropriateness Index, a 10-question tool for gauging appropriate drug use, can help, they said, as can the list of drugs and dosages to avoid in the elderly according to the Beers criteria (Arch. Intern. Med. 2006;166:605-9).

They cited other references making the point that drugs for chronic conditions may reasonably be discontinued. Statins, bisphosphonates, and cholinesterase inhibitors may be stopped in patients with advanced dementia, poor prognoses, or both, they said, and cholinesterase inhibitors and memantine may be discontinuation candidates because the evidence is marginal for their benefit in advanced dementia patients entering hospice or other palliative care (End of Life/Palliative Education Resource Center. Fast Fact and Concept #174 "Dementia Medications in Palliative Care," www.eperc.mcw.edu). Opioids, beta-blockers, clonidine, gabapentin, selective serotonin reuptake inhibitors, serotonin-norepinephrine reuptake inhibitors, and tricyclic antidepressants, among others, require tapering, said Dr. Lunsford and Dr. Kaiser, citing a recent study (JAMA 2010;304:1592-601). A drug holiday may be appropriate when there is uncertainty about withdrawing a medication, Dr. Kaiser said.

Dr. Lunsford cautioned that "many health care professionals may not feel they have the time" to decide what drugs to stop, negotiate the issue with the patient, taper doses, and monitor outcomes on subsequent visits. It’s important to do so, however, and to prevent conflict with peers by keeping them in the loop when discontinuing drugs, she said.

"You need to get them on the same page. Get the case manager involved if you’re not in direct contact with these people, or pick up the phone and [let them know] this is what your suggesting," she said.

Neither Dr. Lunsford nor Dr. Kaiser made conflict-of-interest disclosures.

VANCOUVER, B.C. – Withdrawing medications at the end of life is often the right thing to do clinically, but it can make hospice patients feel abandoned, according to nurse Beverly Lunsford, Ph.D.

"People have it hammered in their heads to take their diabetes medications, their hypertension medications, and have done it faithfully for [decades]. Now you’re telling them to stop. They may have a real sense that isn’t right. Families may perceive medication discontinuation as substandard care or lack of care," said Dr. Lunsford, who coordinates the graduate program for palliative care nurse practitioners at George Washington University in Washington.

It’s important to reassure patients and families that’s not the case or, better yet, handle the situation in such a way that they don’t think so in the first place, Dr. Lunsford said at the annual meeting of the American Academy of Hospice and Palliative Care Medicine.

A review with the patient of his or her medications is a good place to start, said Dr. Robert Kaiser, associate geriatrics and palliative care professor at the university. In such "brown-bag reviews," patients bring in every medication they take, including nutritional supplements and other over-the-counter preparations. Clinicians then check whether the drugs’ original indications still apply and ask about side effects and adherence. Most hospice patients need such attention as they typically are on at least five drugs at admission to hospice, with more added for comfort care, Dr. Kaiser said.

Medication issues should also be incorporated into goals-of-care discussions, said Dr. Lunsford. When patients opt for comfort care, "you might sort out with them which medications they are taking for symptom relief and what medications they are taking for treating medical conditions" that are no longer a high priority, such as hypercholesterolemia, she said.

A patient might be more open to this discussion if a clinician points out that the person’s medical condition has changed – that he or she has lost weight, for instance – so certain drugs are less necessary. Once-tolerated doses may be too potent because of loss of kidney or liver function. Difficulty swallowing and memory loss may also make adherence increasingly burdensome, Dr. Kaiser said.

The goal is to cut unneeded medications so side effects, such as falls and confusion, and drug interactions don’t add discomfort to the dying process, he said. Picking which drugs to stop, however, is not an exact science. Life expectancy, how a drug meets care goals, and how long a drug takes to work are among some of the factors to consider.

Dr. Lunsford and Dr. Kaiser recommended several guides to withdrawing drugs at the end of life. The Medication Appropriateness Index, a 10-question tool for gauging appropriate drug use, can help, they said, as can the list of drugs and dosages to avoid in the elderly according to the Beers criteria (Arch. Intern. Med. 2006;166:605-9).

They cited other references making the point that drugs for chronic conditions may reasonably be discontinued. Statins, bisphosphonates, and cholinesterase inhibitors may be stopped in patients with advanced dementia, poor prognoses, or both, they said, and cholinesterase inhibitors and memantine may be discontinuation candidates because the evidence is marginal for their benefit in advanced dementia patients entering hospice or other palliative care (End of Life/Palliative Education Resource Center. Fast Fact and Concept #174 "Dementia Medications in Palliative Care," www.eperc.mcw.edu). Opioids, beta-blockers, clonidine, gabapentin, selective serotonin reuptake inhibitors, serotonin-norepinephrine reuptake inhibitors, and tricyclic antidepressants, among others, require tapering, said Dr. Lunsford and Dr. Kaiser, citing a recent study (JAMA 2010;304:1592-601). A drug holiday may be appropriate when there is uncertainty about withdrawing a medication, Dr. Kaiser said.

Dr. Lunsford cautioned that "many health care professionals may not feel they have the time" to decide what drugs to stop, negotiate the issue with the patient, taper doses, and monitor outcomes on subsequent visits. It’s important to do so, however, and to prevent conflict with peers by keeping them in the loop when discontinuing drugs, she said.

"You need to get them on the same page. Get the case manager involved if you’re not in direct contact with these people, or pick up the phone and [let them know] this is what your suggesting," she said.

Neither Dr. Lunsford nor Dr. Kaiser made conflict-of-interest disclosures.