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Mitchel is a reporter for MDedge based in the Philadelphia area. He started with the company in 1992, when it was International Medical News Group (IMNG), and has since covered a range of medical specialties. Mitchel trained as a virologist at Roswell Park Memorial Institute in Buffalo, and then worked briefly as a researcher at Boston Children's Hospital before pivoting to journalism as a AAAS Mass Media Fellow in 1980. His first reporting job was with Science Digest magazine, and from the mid-1980s to early-1990s he was a reporter with Medical World News. @mitchelzoler
Electronic Health Record Mandate Squeezes Private Practice
LAS VEGAS – The electronic health record mandate for physicians who participate in Medicare or Medicaid may have the unintended consequence of being the cudgel that drives many remaining private practice physicians out of business, Dr. Steve G. Peters said at the annual meeting of the National Association for Medical Direction of Respiratory Care.
"No one will admit it, but there is de facto pressure [from the electronic health record mandate] that there won’t be private practice in the foreseeable future," said Dr. Peters, a critical care physician and professor of medicine at the Mayo Clinic in Rochester, Minn. "Everyone will need to report measures on hundreds of patients," and to afford to do that they will likely have to become part of an organization, he said.
The challenge of meeting the electronic health record (EHR) reporting requirements will ratchet up over the next several years as the increasingly demanding stages of the Health Information Technology for Economic and Clinical Health (HITECH) Act begin to kick in.
In stage 1, which started this year, physicians using a certified EHR and participating in Medicare or Medicaid must report to the Center for Medicare and Medicaid Services (CMS) three core measures for each patient – height, weight, and blood pressure – as well as three additional measures from a list of 38 options. During the next few years, the program will expand into stages 2 and 3 with additional data reporting requirements.
"It sounds easy, but it’s not," Dr. Peters said. The way to program an EHR to report these various measures "differs from measure to measure, and when you get into it, it’s very complicated. We’re [currently] working this through at Mayo. We have a full EHR at Mayo, but extracting out the data for reporting is proving to be difficult. We have 85% of it, but the gap, the final 15%, is hard."
As an example, he cited the challenge of automatically reporting to the CMS what happens with patients who have a body mass index of 30 kg/m2 or greater. "You need to record and report an action plan of what you’ll do about this, and if not, why not. You need to somehow capture it in a file that can be reported out of your computer why you did not achieve the measure."
The EHR information demands required by the HITECH law are "overwhelming," commented Dr. Alan H. Morris, a pulmonologist and professor of medicine at the University of Utah in Salt Lake City. "It’s a huge operation. What if a physician does not have the infrastructure of the Mayo Clinic?"
Those consequences were exemplified by an attendee at the meeting, Dr. Theodore S. Ingrassia III, a pulmonologist in private practice who maintains an office cooperatively with two other pulmonologists in Rockford, Ill.
"The EHR is a disaster for us, because the cost of the hardware and software is just a fraction of the total cost. There is the expensive cost of getting an IT person to help maintain it and keep it current with all the demands. It may drive us out" of private practice, Dr. Ingrassia said during the session.
"Many predicted that the [$44,000 ] incentive from CMS will not buy much EHR for a big, complex practice. It is a sobering phenomenon," Dr. Peters said.
"The EHR is supposed to be a tool to help physicians organize their care, but it is being turned into something like an enemy," said Dr. Dennis E. Doherty, a pulmonologist and critical care medicine physician and professor of medicine at the University of Kentucky in Lexington.
The three major hospitals in Rockford recognized the information technology and cost challenges that the new EHR requirements pose, and have offered to provide Dr. Ingrassia with the IT support he needs to meet CMS reporting demands if he gives up his private practice and joins their staff. It’s a tempting proposal, he said, but he remains very reluctant to abandon the private practice he built over the past 20 years, he said in an interview. For the time being, his strategy rests on deferring the EHR with the hope that the financial penalties scheduled to start in 2015 for noncompliance may get delayed or that some other option emerges.
Dr. Peters, Dr. Morris, Dr. Ingrassia, and Dr. Doherty had no disclosures relevant to this topic.
LAS VEGAS – The electronic health record mandate for physicians who participate in Medicare or Medicaid may have the unintended consequence of being the cudgel that drives many remaining private practice physicians out of business, Dr. Steve G. Peters said at the annual meeting of the National Association for Medical Direction of Respiratory Care.
"No one will admit it, but there is de facto pressure [from the electronic health record mandate] that there won’t be private practice in the foreseeable future," said Dr. Peters, a critical care physician and professor of medicine at the Mayo Clinic in Rochester, Minn. "Everyone will need to report measures on hundreds of patients," and to afford to do that they will likely have to become part of an organization, he said.
The challenge of meeting the electronic health record (EHR) reporting requirements will ratchet up over the next several years as the increasingly demanding stages of the Health Information Technology for Economic and Clinical Health (HITECH) Act begin to kick in.
In stage 1, which started this year, physicians using a certified EHR and participating in Medicare or Medicaid must report to the Center for Medicare and Medicaid Services (CMS) three core measures for each patient – height, weight, and blood pressure – as well as three additional measures from a list of 38 options. During the next few years, the program will expand into stages 2 and 3 with additional data reporting requirements.
"It sounds easy, but it’s not," Dr. Peters said. The way to program an EHR to report these various measures "differs from measure to measure, and when you get into it, it’s very complicated. We’re [currently] working this through at Mayo. We have a full EHR at Mayo, but extracting out the data for reporting is proving to be difficult. We have 85% of it, but the gap, the final 15%, is hard."
As an example, he cited the challenge of automatically reporting to the CMS what happens with patients who have a body mass index of 30 kg/m2 or greater. "You need to record and report an action plan of what you’ll do about this, and if not, why not. You need to somehow capture it in a file that can be reported out of your computer why you did not achieve the measure."
The EHR information demands required by the HITECH law are "overwhelming," commented Dr. Alan H. Morris, a pulmonologist and professor of medicine at the University of Utah in Salt Lake City. "It’s a huge operation. What if a physician does not have the infrastructure of the Mayo Clinic?"
Those consequences were exemplified by an attendee at the meeting, Dr. Theodore S. Ingrassia III, a pulmonologist in private practice who maintains an office cooperatively with two other pulmonologists in Rockford, Ill.
"The EHR is a disaster for us, because the cost of the hardware and software is just a fraction of the total cost. There is the expensive cost of getting an IT person to help maintain it and keep it current with all the demands. It may drive us out" of private practice, Dr. Ingrassia said during the session.
"Many predicted that the [$44,000 ] incentive from CMS will not buy much EHR for a big, complex practice. It is a sobering phenomenon," Dr. Peters said.
"The EHR is supposed to be a tool to help physicians organize their care, but it is being turned into something like an enemy," said Dr. Dennis E. Doherty, a pulmonologist and critical care medicine physician and professor of medicine at the University of Kentucky in Lexington.
The three major hospitals in Rockford recognized the information technology and cost challenges that the new EHR requirements pose, and have offered to provide Dr. Ingrassia with the IT support he needs to meet CMS reporting demands if he gives up his private practice and joins their staff. It’s a tempting proposal, he said, but he remains very reluctant to abandon the private practice he built over the past 20 years, he said in an interview. For the time being, his strategy rests on deferring the EHR with the hope that the financial penalties scheduled to start in 2015 for noncompliance may get delayed or that some other option emerges.
Dr. Peters, Dr. Morris, Dr. Ingrassia, and Dr. Doherty had no disclosures relevant to this topic.
LAS VEGAS – The electronic health record mandate for physicians who participate in Medicare or Medicaid may have the unintended consequence of being the cudgel that drives many remaining private practice physicians out of business, Dr. Steve G. Peters said at the annual meeting of the National Association for Medical Direction of Respiratory Care.
"No one will admit it, but there is de facto pressure [from the electronic health record mandate] that there won’t be private practice in the foreseeable future," said Dr. Peters, a critical care physician and professor of medicine at the Mayo Clinic in Rochester, Minn. "Everyone will need to report measures on hundreds of patients," and to afford to do that they will likely have to become part of an organization, he said.
The challenge of meeting the electronic health record (EHR) reporting requirements will ratchet up over the next several years as the increasingly demanding stages of the Health Information Technology for Economic and Clinical Health (HITECH) Act begin to kick in.
In stage 1, which started this year, physicians using a certified EHR and participating in Medicare or Medicaid must report to the Center for Medicare and Medicaid Services (CMS) three core measures for each patient – height, weight, and blood pressure – as well as three additional measures from a list of 38 options. During the next few years, the program will expand into stages 2 and 3 with additional data reporting requirements.
"It sounds easy, but it’s not," Dr. Peters said. The way to program an EHR to report these various measures "differs from measure to measure, and when you get into it, it’s very complicated. We’re [currently] working this through at Mayo. We have a full EHR at Mayo, but extracting out the data for reporting is proving to be difficult. We have 85% of it, but the gap, the final 15%, is hard."
As an example, he cited the challenge of automatically reporting to the CMS what happens with patients who have a body mass index of 30 kg/m2 or greater. "You need to record and report an action plan of what you’ll do about this, and if not, why not. You need to somehow capture it in a file that can be reported out of your computer why you did not achieve the measure."
The EHR information demands required by the HITECH law are "overwhelming," commented Dr. Alan H. Morris, a pulmonologist and professor of medicine at the University of Utah in Salt Lake City. "It’s a huge operation. What if a physician does not have the infrastructure of the Mayo Clinic?"
Those consequences were exemplified by an attendee at the meeting, Dr. Theodore S. Ingrassia III, a pulmonologist in private practice who maintains an office cooperatively with two other pulmonologists in Rockford, Ill.
"The EHR is a disaster for us, because the cost of the hardware and software is just a fraction of the total cost. There is the expensive cost of getting an IT person to help maintain it and keep it current with all the demands. It may drive us out" of private practice, Dr. Ingrassia said during the session.
"Many predicted that the [$44,000 ] incentive from CMS will not buy much EHR for a big, complex practice. It is a sobering phenomenon," Dr. Peters said.
"The EHR is supposed to be a tool to help physicians organize their care, but it is being turned into something like an enemy," said Dr. Dennis E. Doherty, a pulmonologist and critical care medicine physician and professor of medicine at the University of Kentucky in Lexington.
The three major hospitals in Rockford recognized the information technology and cost challenges that the new EHR requirements pose, and have offered to provide Dr. Ingrassia with the IT support he needs to meet CMS reporting demands if he gives up his private practice and joins their staff. It’s a tempting proposal, he said, but he remains very reluctant to abandon the private practice he built over the past 20 years, he said in an interview. For the time being, his strategy rests on deferring the EHR with the hope that the financial penalties scheduled to start in 2015 for noncompliance may get delayed or that some other option emerges.
Dr. Peters, Dr. Morris, Dr. Ingrassia, and Dr. Doherty had no disclosures relevant to this topic.
FROM THE ANNUAL MEETING OF THE NATIONAL ASSOCIATION FOR MEDICAL DIRECTION OF RESPIRATORY CARE
Electronic Health Record Mandate Squeezes Private Practice
LAS VEGAS – The electronic health record mandate for physicians who participate in Medicare or Medicaid may have the unintended consequence of being the cudgel that drives many remaining private practice physicians out of business, Dr. Steve G. Peters said at the annual meeting of the National Association for Medical Direction of Respiratory Care.
"No one will admit it, but there is de facto pressure [from the electronic health record mandate] that there won’t be private practice in the foreseeable future," said Dr. Peters, a critical care physician and professor of medicine at the Mayo Clinic in Rochester, Minn. "Everyone will need to report measures on hundreds of patients," and to afford to do that they will likely have to become part of an organization, he said.
The challenge of meeting the electronic health record (EHR) reporting requirements will ratchet up over the next several years as the increasingly demanding stages of the Health Information Technology for Economic and Clinical Health (HITECH) Act begin to kick in.
In stage 1, which started this year, physicians using a certified EHR and participating in Medicare or Medicaid must report to the Center for Medicare and Medicaid Services (CMS) three core measures for each patient – height, weight, and blood pressure – as well as three additional measures from a list of 38 options. During the next few years, the program will expand into stages 2 and 3 with additional data reporting requirements.
"It sounds easy, but it’s not," Dr. Peters said. The way to program an EHR to report these various measures "differs from measure to measure, and when you get into it, it’s very complicated. We’re [currently] working this through at Mayo. We have a full EHR at Mayo, but extracting out the data for reporting is proving to be difficult. We have 85% of it, but the gap, the final 15%, is hard."
As an example, he cited the challenge of automatically reporting to the CMS what happens with patients who have a body mass index of 30 kg/m2 or greater. "You need to record and report an action plan of what you’ll do about this, and if not, why not. You need to somehow capture it in a file that can be reported out of your computer why you did not achieve the measure."
The EHR information demands required by the HITECH law are "overwhelming," commented Dr. Alan H. Morris, a pulmonologist and professor of medicine at the University of Utah in Salt Lake City. "It’s a huge operation. What if a physician does not have the infrastructure of the Mayo Clinic?"
Those consequences were exemplified by an attendee at the meeting, Dr. Theodore S. Ingrassia III, a pulmonologist in private practice who maintains an office cooperatively with two other pulmonologists in Rockford, Ill.
"The EHR is a disaster for us, because the cost of the hardware and software is just a fraction of the total cost. There is the expensive cost of getting an IT person to help maintain it and keep it current with all the demands. It may drive us out" of private practice, Dr. Ingrassia said during the session.
"Many predicted that the [$44,000 ] incentive from CMS will not buy much EHR for a big, complex practice. It is a sobering phenomenon," Dr. Peters said.
"The EHR is supposed to be a tool to help physicians organize their care, but it is being turned into something like an enemy," said Dr. Dennis E. Doherty, a pulmonologist and critical care medicine physician and professor of medicine at the University of Kentucky in Lexington.
The three major hospitals in Rockford recognized the information technology and cost challenges that the new EHR requirements pose, and have offered to provide Dr. Ingrassia with the IT support he needs to meet CMS reporting demands if he gives up his private practice and joins their staff. It’s a tempting proposal, he said, but he remains very reluctant to abandon the private practice he built over the past 20 years, he said in an interview. For the time being, his strategy rests on deferring the EHR with the hope that the financial penalties scheduled to start in 2015 for noncompliance may get delayed or that some other option emerges.
Dr. Peters, Dr. Morris, Dr. Ingrassia, and Dr. Doherty had no disclosures relevant to this topic.
LAS VEGAS – The electronic health record mandate for physicians who participate in Medicare or Medicaid may have the unintended consequence of being the cudgel that drives many remaining private practice physicians out of business, Dr. Steve G. Peters said at the annual meeting of the National Association for Medical Direction of Respiratory Care.
"No one will admit it, but there is de facto pressure [from the electronic health record mandate] that there won’t be private practice in the foreseeable future," said Dr. Peters, a critical care physician and professor of medicine at the Mayo Clinic in Rochester, Minn. "Everyone will need to report measures on hundreds of patients," and to afford to do that they will likely have to become part of an organization, he said.
The challenge of meeting the electronic health record (EHR) reporting requirements will ratchet up over the next several years as the increasingly demanding stages of the Health Information Technology for Economic and Clinical Health (HITECH) Act begin to kick in.
In stage 1, which started this year, physicians using a certified EHR and participating in Medicare or Medicaid must report to the Center for Medicare and Medicaid Services (CMS) three core measures for each patient – height, weight, and blood pressure – as well as three additional measures from a list of 38 options. During the next few years, the program will expand into stages 2 and 3 with additional data reporting requirements.
"It sounds easy, but it’s not," Dr. Peters said. The way to program an EHR to report these various measures "differs from measure to measure, and when you get into it, it’s very complicated. We’re [currently] working this through at Mayo. We have a full EHR at Mayo, but extracting out the data for reporting is proving to be difficult. We have 85% of it, but the gap, the final 15%, is hard."
As an example, he cited the challenge of automatically reporting to the CMS what happens with patients who have a body mass index of 30 kg/m2 or greater. "You need to record and report an action plan of what you’ll do about this, and if not, why not. You need to somehow capture it in a file that can be reported out of your computer why you did not achieve the measure."
The EHR information demands required by the HITECH law are "overwhelming," commented Dr. Alan H. Morris, a pulmonologist and professor of medicine at the University of Utah in Salt Lake City. "It’s a huge operation. What if a physician does not have the infrastructure of the Mayo Clinic?"
Those consequences were exemplified by an attendee at the meeting, Dr. Theodore S. Ingrassia III, a pulmonologist in private practice who maintains an office cooperatively with two other pulmonologists in Rockford, Ill.
"The EHR is a disaster for us, because the cost of the hardware and software is just a fraction of the total cost. There is the expensive cost of getting an IT person to help maintain it and keep it current with all the demands. It may drive us out" of private practice, Dr. Ingrassia said during the session.
"Many predicted that the [$44,000 ] incentive from CMS will not buy much EHR for a big, complex practice. It is a sobering phenomenon," Dr. Peters said.
"The EHR is supposed to be a tool to help physicians organize their care, but it is being turned into something like an enemy," said Dr. Dennis E. Doherty, a pulmonologist and critical care medicine physician and professor of medicine at the University of Kentucky in Lexington.
The three major hospitals in Rockford recognized the information technology and cost challenges that the new EHR requirements pose, and have offered to provide Dr. Ingrassia with the IT support he needs to meet CMS reporting demands if he gives up his private practice and joins their staff. It’s a tempting proposal, he said, but he remains very reluctant to abandon the private practice he built over the past 20 years, he said in an interview. For the time being, his strategy rests on deferring the EHR with the hope that the financial penalties scheduled to start in 2015 for noncompliance may get delayed or that some other option emerges.
Dr. Peters, Dr. Morris, Dr. Ingrassia, and Dr. Doherty had no disclosures relevant to this topic.
LAS VEGAS – The electronic health record mandate for physicians who participate in Medicare or Medicaid may have the unintended consequence of being the cudgel that drives many remaining private practice physicians out of business, Dr. Steve G. Peters said at the annual meeting of the National Association for Medical Direction of Respiratory Care.
"No one will admit it, but there is de facto pressure [from the electronic health record mandate] that there won’t be private practice in the foreseeable future," said Dr. Peters, a critical care physician and professor of medicine at the Mayo Clinic in Rochester, Minn. "Everyone will need to report measures on hundreds of patients," and to afford to do that they will likely have to become part of an organization, he said.
The challenge of meeting the electronic health record (EHR) reporting requirements will ratchet up over the next several years as the increasingly demanding stages of the Health Information Technology for Economic and Clinical Health (HITECH) Act begin to kick in.
In stage 1, which started this year, physicians using a certified EHR and participating in Medicare or Medicaid must report to the Center for Medicare and Medicaid Services (CMS) three core measures for each patient – height, weight, and blood pressure – as well as three additional measures from a list of 38 options. During the next few years, the program will expand into stages 2 and 3 with additional data reporting requirements.
"It sounds easy, but it’s not," Dr. Peters said. The way to program an EHR to report these various measures "differs from measure to measure, and when you get into it, it’s very complicated. We’re [currently] working this through at Mayo. We have a full EHR at Mayo, but extracting out the data for reporting is proving to be difficult. We have 85% of it, but the gap, the final 15%, is hard."
As an example, he cited the challenge of automatically reporting to the CMS what happens with patients who have a body mass index of 30 kg/m2 or greater. "You need to record and report an action plan of what you’ll do about this, and if not, why not. You need to somehow capture it in a file that can be reported out of your computer why you did not achieve the measure."
The EHR information demands required by the HITECH law are "overwhelming," commented Dr. Alan H. Morris, a pulmonologist and professor of medicine at the University of Utah in Salt Lake City. "It’s a huge operation. What if a physician does not have the infrastructure of the Mayo Clinic?"
Those consequences were exemplified by an attendee at the meeting, Dr. Theodore S. Ingrassia III, a pulmonologist in private practice who maintains an office cooperatively with two other pulmonologists in Rockford, Ill.
"The EHR is a disaster for us, because the cost of the hardware and software is just a fraction of the total cost. There is the expensive cost of getting an IT person to help maintain it and keep it current with all the demands. It may drive us out" of private practice, Dr. Ingrassia said during the session.
"Many predicted that the [$44,000 ] incentive from CMS will not buy much EHR for a big, complex practice. It is a sobering phenomenon," Dr. Peters said.
"The EHR is supposed to be a tool to help physicians organize their care, but it is being turned into something like an enemy," said Dr. Dennis E. Doherty, a pulmonologist and critical care medicine physician and professor of medicine at the University of Kentucky in Lexington.
The three major hospitals in Rockford recognized the information technology and cost challenges that the new EHR requirements pose, and have offered to provide Dr. Ingrassia with the IT support he needs to meet CMS reporting demands if he gives up his private practice and joins their staff. It’s a tempting proposal, he said, but he remains very reluctant to abandon the private practice he built over the past 20 years, he said in an interview. For the time being, his strategy rests on deferring the EHR with the hope that the financial penalties scheduled to start in 2015 for noncompliance may get delayed or that some other option emerges.
Dr. Peters, Dr. Morris, Dr. Ingrassia, and Dr. Doherty had no disclosures relevant to this topic.
FROM THE ANNUAL MEETING OF THE NATIONAL ASSOCIATION FOR MEDICAL DIRECTION OF RESPIRATORY CARE
Revised Lung Allocation System Transformed Transplantation Dynamics
LAS VEGAS – The 2005 revision of the lung allocation system for U.S. lung transplants succeeded, resulting in fewer patients dying while on the lung waiting list, Dr. Robert M. Kotloff said at the annual meeting of the National Association for Medical Direction of Respiratory Care.
Reduced deaths in wait-listed patients "was the major goal" of the revision, "so the LAS [lung allocation system] worked," said Dr. Kotloff, professor of medicine and chief of the section of advanced lung disease and lung transplantation at the University of Pennsylvania in Philadelphia.
The new LAS also triggered other changes in the pattern of U.S. lung transplantations during the subsequent 5 years, some of which took several years to become apparent.
The revised system for allocation of donor lungs shifted the weight of the different pulmonary diseases that lead to lung transplantation, reducing the priority of chronic obstructive pulmonary disease (COPD) and boosting the importance of idiopathic pulmonary fibrosis (IPF). As recently as a decade ago, 45% of U.S. lung transplantations were done in patients with COPD and 20% in those with IPF. Although the gap between the two had narrowed considerably by 2005, that year COPD still remained the leading indication. But by 2007, IPF inched ahead of COPD, and today IPF is the leading reason why U.S. patients receive a lung transplant, Dr. Kotloff said.
"IPF is a no-brainer for listing," with a median survival of 3-4 years, and with half of IPF deaths occurring after a sudden patient decline, he said. Although some patients have an indolent form of IPF, "what’s unsettling is that half of IPF deaths are sudden and unpredictable, occurring in patients who recently had stable or mild disease. We have all had IPF patients who were told they weren’t sick enough to list and to return in 6 months – who then show up in the ICU on a ventilator, a missed opportunity" for transplantation. Because of experiences like these, IPF patients now undergo a thorough evaluation for transplantation so that if they suddenly wind up in the ICU, it’s easier to get them a transplant quickly.
Patients who receive a lung transplant have a median 5-year survival rate of 50%, which means that patients with a disease that has a similar or better prognosis are not good candidates. The poorer average survival rate of IPF patients helps explain why they are good transplant candidates.
The U.S. Department of Health and Human Services mandated a 2005 revision of the allocation systems for all organs based on medical urgency rather than time on the waiting list, a system biased against patients with more aggressive disease such as IPF. The LAS scoring formula put in place by the Organ Procurement and Transplantation Network took into account both the urgency of a patient’s need for a lung transplant and the patient’s likelihood of survival following transplantation (Chest 2007;132:1954-61). Two patient features carry the most weight in the formula: the patient’s underlying disease, and whether the patient requires mechanical ventilation and how much oxygen he or she needs. Today, about the only way for a patient to have a really high LAS score of 80 or greater is to be on a ventilator with high-flow oxygen.
The 2005 LAS revision led to a dramatic shortening of the U.S. waiting list for lungs – from more than 2,000 patients before 2005 to roughly 1,000 patients today – largely because it deemphasized time on the list and made "time banking" unnecessary. Time banking had been a practice by which potential lung transplant candidates without an immediate need got listed in case they needed a transplant in the future. If they did eventually need a transplant, they had accumulated time on the list, which boosted their chances of getting the transplant more quickly. If they eventually got a call for a transplant but still did not immediately need it, they could withdraw from accepting that organ but still retain their relatively high priority on the list, Dr. Kotloff explained.
With the new allocation formula, patients with no immediate need and an uncertain future need for a transplant, such as many COPD patients, are simply kept off the list until their transplant need becomes clear. The downside to the current system is that many patients with potentially severe and unstable lung disease, such as many IPF patients, move from referral to listing to transplantation in just a few weeks – so rapidly that they do not have time to receive adequate counseling about the consequences and possible drawbacks of lung transplantation, Dr. Kotloff said.
Dr. Kotloff said that he had no disclosures.
LAS VEGAS – The 2005 revision of the lung allocation system for U.S. lung transplants succeeded, resulting in fewer patients dying while on the lung waiting list, Dr. Robert M. Kotloff said at the annual meeting of the National Association for Medical Direction of Respiratory Care.
Reduced deaths in wait-listed patients "was the major goal" of the revision, "so the LAS [lung allocation system] worked," said Dr. Kotloff, professor of medicine and chief of the section of advanced lung disease and lung transplantation at the University of Pennsylvania in Philadelphia.
The new LAS also triggered other changes in the pattern of U.S. lung transplantations during the subsequent 5 years, some of which took several years to become apparent.
The revised system for allocation of donor lungs shifted the weight of the different pulmonary diseases that lead to lung transplantation, reducing the priority of chronic obstructive pulmonary disease (COPD) and boosting the importance of idiopathic pulmonary fibrosis (IPF). As recently as a decade ago, 45% of U.S. lung transplantations were done in patients with COPD and 20% in those with IPF. Although the gap between the two had narrowed considerably by 2005, that year COPD still remained the leading indication. But by 2007, IPF inched ahead of COPD, and today IPF is the leading reason why U.S. patients receive a lung transplant, Dr. Kotloff said.
"IPF is a no-brainer for listing," with a median survival of 3-4 years, and with half of IPF deaths occurring after a sudden patient decline, he said. Although some patients have an indolent form of IPF, "what’s unsettling is that half of IPF deaths are sudden and unpredictable, occurring in patients who recently had stable or mild disease. We have all had IPF patients who were told they weren’t sick enough to list and to return in 6 months – who then show up in the ICU on a ventilator, a missed opportunity" for transplantation. Because of experiences like these, IPF patients now undergo a thorough evaluation for transplantation so that if they suddenly wind up in the ICU, it’s easier to get them a transplant quickly.
Patients who receive a lung transplant have a median 5-year survival rate of 50%, which means that patients with a disease that has a similar or better prognosis are not good candidates. The poorer average survival rate of IPF patients helps explain why they are good transplant candidates.
The U.S. Department of Health and Human Services mandated a 2005 revision of the allocation systems for all organs based on medical urgency rather than time on the waiting list, a system biased against patients with more aggressive disease such as IPF. The LAS scoring formula put in place by the Organ Procurement and Transplantation Network took into account both the urgency of a patient’s need for a lung transplant and the patient’s likelihood of survival following transplantation (Chest 2007;132:1954-61). Two patient features carry the most weight in the formula: the patient’s underlying disease, and whether the patient requires mechanical ventilation and how much oxygen he or she needs. Today, about the only way for a patient to have a really high LAS score of 80 or greater is to be on a ventilator with high-flow oxygen.
The 2005 LAS revision led to a dramatic shortening of the U.S. waiting list for lungs – from more than 2,000 patients before 2005 to roughly 1,000 patients today – largely because it deemphasized time on the list and made "time banking" unnecessary. Time banking had been a practice by which potential lung transplant candidates without an immediate need got listed in case they needed a transplant in the future. If they did eventually need a transplant, they had accumulated time on the list, which boosted their chances of getting the transplant more quickly. If they eventually got a call for a transplant but still did not immediately need it, they could withdraw from accepting that organ but still retain their relatively high priority on the list, Dr. Kotloff explained.
With the new allocation formula, patients with no immediate need and an uncertain future need for a transplant, such as many COPD patients, are simply kept off the list until their transplant need becomes clear. The downside to the current system is that many patients with potentially severe and unstable lung disease, such as many IPF patients, move from referral to listing to transplantation in just a few weeks – so rapidly that they do not have time to receive adequate counseling about the consequences and possible drawbacks of lung transplantation, Dr. Kotloff said.
Dr. Kotloff said that he had no disclosures.
LAS VEGAS – The 2005 revision of the lung allocation system for U.S. lung transplants succeeded, resulting in fewer patients dying while on the lung waiting list, Dr. Robert M. Kotloff said at the annual meeting of the National Association for Medical Direction of Respiratory Care.
Reduced deaths in wait-listed patients "was the major goal" of the revision, "so the LAS [lung allocation system] worked," said Dr. Kotloff, professor of medicine and chief of the section of advanced lung disease and lung transplantation at the University of Pennsylvania in Philadelphia.
The new LAS also triggered other changes in the pattern of U.S. lung transplantations during the subsequent 5 years, some of which took several years to become apparent.
The revised system for allocation of donor lungs shifted the weight of the different pulmonary diseases that lead to lung transplantation, reducing the priority of chronic obstructive pulmonary disease (COPD) and boosting the importance of idiopathic pulmonary fibrosis (IPF). As recently as a decade ago, 45% of U.S. lung transplantations were done in patients with COPD and 20% in those with IPF. Although the gap between the two had narrowed considerably by 2005, that year COPD still remained the leading indication. But by 2007, IPF inched ahead of COPD, and today IPF is the leading reason why U.S. patients receive a lung transplant, Dr. Kotloff said.
"IPF is a no-brainer for listing," with a median survival of 3-4 years, and with half of IPF deaths occurring after a sudden patient decline, he said. Although some patients have an indolent form of IPF, "what’s unsettling is that half of IPF deaths are sudden and unpredictable, occurring in patients who recently had stable or mild disease. We have all had IPF patients who were told they weren’t sick enough to list and to return in 6 months – who then show up in the ICU on a ventilator, a missed opportunity" for transplantation. Because of experiences like these, IPF patients now undergo a thorough evaluation for transplantation so that if they suddenly wind up in the ICU, it’s easier to get them a transplant quickly.
Patients who receive a lung transplant have a median 5-year survival rate of 50%, which means that patients with a disease that has a similar or better prognosis are not good candidates. The poorer average survival rate of IPF patients helps explain why they are good transplant candidates.
The U.S. Department of Health and Human Services mandated a 2005 revision of the allocation systems for all organs based on medical urgency rather than time on the waiting list, a system biased against patients with more aggressive disease such as IPF. The LAS scoring formula put in place by the Organ Procurement and Transplantation Network took into account both the urgency of a patient’s need for a lung transplant and the patient’s likelihood of survival following transplantation (Chest 2007;132:1954-61). Two patient features carry the most weight in the formula: the patient’s underlying disease, and whether the patient requires mechanical ventilation and how much oxygen he or she needs. Today, about the only way for a patient to have a really high LAS score of 80 or greater is to be on a ventilator with high-flow oxygen.
The 2005 LAS revision led to a dramatic shortening of the U.S. waiting list for lungs – from more than 2,000 patients before 2005 to roughly 1,000 patients today – largely because it deemphasized time on the list and made "time banking" unnecessary. Time banking had been a practice by which potential lung transplant candidates without an immediate need got listed in case they needed a transplant in the future. If they did eventually need a transplant, they had accumulated time on the list, which boosted their chances of getting the transplant more quickly. If they eventually got a call for a transplant but still did not immediately need it, they could withdraw from accepting that organ but still retain their relatively high priority on the list, Dr. Kotloff explained.
With the new allocation formula, patients with no immediate need and an uncertain future need for a transplant, such as many COPD patients, are simply kept off the list until their transplant need becomes clear. The downside to the current system is that many patients with potentially severe and unstable lung disease, such as many IPF patients, move from referral to listing to transplantation in just a few weeks – so rapidly that they do not have time to receive adequate counseling about the consequences and possible drawbacks of lung transplantation, Dr. Kotloff said.
Dr. Kotloff said that he had no disclosures.
Revised Lung Allocation System Transformed Transplantation Dynamics
LAS VEGAS – The 2005 revision of the lung allocation system for U.S. lung transplants succeeded, resulting in fewer patients dying while on the lung waiting list, Dr. Robert M. Kotloff said at the annual meeting of the National Association for Medical Direction of Respiratory Care.
Reduced deaths in wait-listed patients "was the major goal" of the revision, "so the LAS [lung allocation system] worked," said Dr. Kotloff, professor of medicine and chief of the section of advanced lung disease and lung transplantation at the University of Pennsylvania in Philadelphia.
The new LAS also triggered other changes in the pattern of U.S. lung transplantations during the subsequent 5 years, some of which took several years to become apparent.
The revised system for allocation of donor lungs shifted the weight of the different pulmonary diseases that lead to lung transplantation, reducing the priority of chronic obstructive pulmonary disease (COPD) and boosting the importance of idiopathic pulmonary fibrosis (IPF). As recently as a decade ago, 45% of U.S. lung transplantations were done in patients with COPD and 20% in those with IPF. Although the gap between the two had narrowed considerably by 2005, that year COPD still remained the leading indication. But by 2007, IPF inched ahead of COPD, and today IPF is the leading reason why U.S. patients receive a lung transplant, Dr. Kotloff said.
"IPF is a no-brainer for listing," with a median survival of 3-4 years, and with half of IPF deaths occurring after a sudden patient decline, he said. Although some patients have an indolent form of IPF, "what’s unsettling is that half of IPF deaths are sudden and unpredictable, occurring in patients who recently had stable or mild disease. We have all had IPF patients who were told they weren’t sick enough to list and to return in 6 months – who then show up in the ICU on a ventilator, a missed opportunity" for transplantation. Because of experiences like these, IPF patients now undergo a thorough evaluation for transplantation so that if they suddenly wind up in the ICU, it’s easier to get them a transplant quickly.
Patients who receive a lung transplant have a median 5-year survival rate of 50%, which means that patients with a disease that has a similar or better prognosis are not good candidates. The poorer average survival rate of IPF patients helps explain why they are good transplant candidates.
The U.S. Department of Health and Human Services mandated a 2005 revision of the allocation systems for all organs based on medical urgency rather than time on the waiting list, a system biased against patients with more aggressive disease such as IPF. The LAS scoring formula put in place by the Organ Procurement and Transplantation Network took into account both the urgency of a patient’s need for a lung transplant and the patient’s likelihood of survival following transplantation (Chest 2007;132:1954-61). Two patient features carry the most weight in the formula: the patient’s underlying disease, and whether the patient requires mechanical ventilation and how much oxygen he or she needs. Today, about the only way for a patient to have a really high LAS score of 80 or greater is to be on a ventilator with high-flow oxygen.
The 2005 LAS revision led to a dramatic shortening of the U.S. waiting list for lungs – from more than 2,000 patients before 2005 to roughly 1,000 patients today – largely because it deemphasized time on the list and made "time banking" unnecessary. Time banking had been a practice by which potential lung transplant candidates without an immediate need got listed in case they needed a transplant in the future. If they did eventually need a transplant, they had accumulated time on the list, which boosted their chances of getting the transplant more quickly. If they eventually got a call for a transplant but still did not immediately need it, they could withdraw from accepting that organ but still retain their relatively high priority on the list, Dr. Kotloff explained.
With the new allocation formula, patients with no immediate need and an uncertain future need for a transplant, such as many COPD patients, are simply kept off the list until their transplant need becomes clear. The downside to the current system is that many patients with potentially severe and unstable lung disease, such as many IPF patients, move from referral to listing to transplantation in just a few weeks – so rapidly that they do not have time to receive adequate counseling about the consequences and possible drawbacks of lung transplantation, Dr. Kotloff said.
Dr. Kotloff said that he had no disclosures.
LAS VEGAS – The 2005 revision of the lung allocation system for U.S. lung transplants succeeded, resulting in fewer patients dying while on the lung waiting list, Dr. Robert M. Kotloff said at the annual meeting of the National Association for Medical Direction of Respiratory Care.
Reduced deaths in wait-listed patients "was the major goal" of the revision, "so the LAS [lung allocation system] worked," said Dr. Kotloff, professor of medicine and chief of the section of advanced lung disease and lung transplantation at the University of Pennsylvania in Philadelphia.
The new LAS also triggered other changes in the pattern of U.S. lung transplantations during the subsequent 5 years, some of which took several years to become apparent.
The revised system for allocation of donor lungs shifted the weight of the different pulmonary diseases that lead to lung transplantation, reducing the priority of chronic obstructive pulmonary disease (COPD) and boosting the importance of idiopathic pulmonary fibrosis (IPF). As recently as a decade ago, 45% of U.S. lung transplantations were done in patients with COPD and 20% in those with IPF. Although the gap between the two had narrowed considerably by 2005, that year COPD still remained the leading indication. But by 2007, IPF inched ahead of COPD, and today IPF is the leading reason why U.S. patients receive a lung transplant, Dr. Kotloff said.
"IPF is a no-brainer for listing," with a median survival of 3-4 years, and with half of IPF deaths occurring after a sudden patient decline, he said. Although some patients have an indolent form of IPF, "what’s unsettling is that half of IPF deaths are sudden and unpredictable, occurring in patients who recently had stable or mild disease. We have all had IPF patients who were told they weren’t sick enough to list and to return in 6 months – who then show up in the ICU on a ventilator, a missed opportunity" for transplantation. Because of experiences like these, IPF patients now undergo a thorough evaluation for transplantation so that if they suddenly wind up in the ICU, it’s easier to get them a transplant quickly.
Patients who receive a lung transplant have a median 5-year survival rate of 50%, which means that patients with a disease that has a similar or better prognosis are not good candidates. The poorer average survival rate of IPF patients helps explain why they are good transplant candidates.
The U.S. Department of Health and Human Services mandated a 2005 revision of the allocation systems for all organs based on medical urgency rather than time on the waiting list, a system biased against patients with more aggressive disease such as IPF. The LAS scoring formula put in place by the Organ Procurement and Transplantation Network took into account both the urgency of a patient’s need for a lung transplant and the patient’s likelihood of survival following transplantation (Chest 2007;132:1954-61). Two patient features carry the most weight in the formula: the patient’s underlying disease, and whether the patient requires mechanical ventilation and how much oxygen he or she needs. Today, about the only way for a patient to have a really high LAS score of 80 or greater is to be on a ventilator with high-flow oxygen.
The 2005 LAS revision led to a dramatic shortening of the U.S. waiting list for lungs – from more than 2,000 patients before 2005 to roughly 1,000 patients today – largely because it deemphasized time on the list and made "time banking" unnecessary. Time banking had been a practice by which potential lung transplant candidates without an immediate need got listed in case they needed a transplant in the future. If they did eventually need a transplant, they had accumulated time on the list, which boosted their chances of getting the transplant more quickly. If they eventually got a call for a transplant but still did not immediately need it, they could withdraw from accepting that organ but still retain their relatively high priority on the list, Dr. Kotloff explained.
With the new allocation formula, patients with no immediate need and an uncertain future need for a transplant, such as many COPD patients, are simply kept off the list until their transplant need becomes clear. The downside to the current system is that many patients with potentially severe and unstable lung disease, such as many IPF patients, move from referral to listing to transplantation in just a few weeks – so rapidly that they do not have time to receive adequate counseling about the consequences and possible drawbacks of lung transplantation, Dr. Kotloff said.
Dr. Kotloff said that he had no disclosures.
LAS VEGAS – The 2005 revision of the lung allocation system for U.S. lung transplants succeeded, resulting in fewer patients dying while on the lung waiting list, Dr. Robert M. Kotloff said at the annual meeting of the National Association for Medical Direction of Respiratory Care.
Reduced deaths in wait-listed patients "was the major goal" of the revision, "so the LAS [lung allocation system] worked," said Dr. Kotloff, professor of medicine and chief of the section of advanced lung disease and lung transplantation at the University of Pennsylvania in Philadelphia.
The new LAS also triggered other changes in the pattern of U.S. lung transplantations during the subsequent 5 years, some of which took several years to become apparent.
The revised system for allocation of donor lungs shifted the weight of the different pulmonary diseases that lead to lung transplantation, reducing the priority of chronic obstructive pulmonary disease (COPD) and boosting the importance of idiopathic pulmonary fibrosis (IPF). As recently as a decade ago, 45% of U.S. lung transplantations were done in patients with COPD and 20% in those with IPF. Although the gap between the two had narrowed considerably by 2005, that year COPD still remained the leading indication. But by 2007, IPF inched ahead of COPD, and today IPF is the leading reason why U.S. patients receive a lung transplant, Dr. Kotloff said.
"IPF is a no-brainer for listing," with a median survival of 3-4 years, and with half of IPF deaths occurring after a sudden patient decline, he said. Although some patients have an indolent form of IPF, "what’s unsettling is that half of IPF deaths are sudden and unpredictable, occurring in patients who recently had stable or mild disease. We have all had IPF patients who were told they weren’t sick enough to list and to return in 6 months – who then show up in the ICU on a ventilator, a missed opportunity" for transplantation. Because of experiences like these, IPF patients now undergo a thorough evaluation for transplantation so that if they suddenly wind up in the ICU, it’s easier to get them a transplant quickly.
Patients who receive a lung transplant have a median 5-year survival rate of 50%, which means that patients with a disease that has a similar or better prognosis are not good candidates. The poorer average survival rate of IPF patients helps explain why they are good transplant candidates.
The U.S. Department of Health and Human Services mandated a 2005 revision of the allocation systems for all organs based on medical urgency rather than time on the waiting list, a system biased against patients with more aggressive disease such as IPF. The LAS scoring formula put in place by the Organ Procurement and Transplantation Network took into account both the urgency of a patient’s need for a lung transplant and the patient’s likelihood of survival following transplantation (Chest 2007;132:1954-61). Two patient features carry the most weight in the formula: the patient’s underlying disease, and whether the patient requires mechanical ventilation and how much oxygen he or she needs. Today, about the only way for a patient to have a really high LAS score of 80 or greater is to be on a ventilator with high-flow oxygen.
The 2005 LAS revision led to a dramatic shortening of the U.S. waiting list for lungs – from more than 2,000 patients before 2005 to roughly 1,000 patients today – largely because it deemphasized time on the list and made "time banking" unnecessary. Time banking had been a practice by which potential lung transplant candidates without an immediate need got listed in case they needed a transplant in the future. If they did eventually need a transplant, they had accumulated time on the list, which boosted their chances of getting the transplant more quickly. If they eventually got a call for a transplant but still did not immediately need it, they could withdraw from accepting that organ but still retain their relatively high priority on the list, Dr. Kotloff explained.
With the new allocation formula, patients with no immediate need and an uncertain future need for a transplant, such as many COPD patients, are simply kept off the list until their transplant need becomes clear. The downside to the current system is that many patients with potentially severe and unstable lung disease, such as many IPF patients, move from referral to listing to transplantation in just a few weeks – so rapidly that they do not have time to receive adequate counseling about the consequences and possible drawbacks of lung transplantation, Dr. Kotloff said.
Dr. Kotloff said that he had no disclosures.
Revised Lung Allocation System Transformed Transplantation Dynamics
LAS VEGAS – The 2005 revision of the lung allocation system for U.S. lung transplants succeeded, resulting in fewer patients dying while on the lung waiting list, Dr. Robert M. Kotloff said at the annual meeting of the National Association for Medical Direction of Respiratory Care.
Reduced deaths in wait-listed patients "was the major goal" of the revision, "so the LAS [lung allocation system] worked," said Dr. Kotloff, professor of medicine and chief of the section of advanced lung disease and lung transplantation at the University of Pennsylvania in Philadelphia.
The new LAS also triggered other changes in the pattern of U.S. lung transplantations during the subsequent 5 years, some of which took several years to become apparent.
The revised system for allocation of donor lungs shifted the weight of the different pulmonary diseases that lead to lung transplantation, reducing the priority of chronic obstructive pulmonary disease (COPD) and boosting the importance of idiopathic pulmonary fibrosis (IPF). As recently as a decade ago, 45% of U.S. lung transplantations were done in patients with COPD and 20% in those with IPF. Although the gap between the two had narrowed considerably by 2005, that year COPD still remained the leading indication. But by 2007, IPF inched ahead of COPD, and today IPF is the leading reason why U.S. patients receive a lung transplant, Dr. Kotloff said.
"IPF is a no-brainer for listing," with a median survival of 3-4 years, and with half of IPF deaths occurring after a sudden patient decline, he said. Although some patients have an indolent form of IPF, "what’s unsettling is that half of IPF deaths are sudden and unpredictable, occurring in patients who recently had stable or mild disease. We have all had IPF patients who were told they weren’t sick enough to list and to return in 6 months – who then show up in the ICU on a ventilator, a missed opportunity" for transplantation. Because of experiences like these, IPF patients now undergo a thorough evaluation for transplantation so that if they suddenly wind up in the ICU, it’s easier to get them a transplant quickly.
Patients who receive a lung transplant have a median 5-year survival rate of 50%, which means that patients with a disease that has a similar or better prognosis are not good candidates. The poorer average survival rate of IPF patients helps explain why they are good transplant candidates.
The U.S. Department of Health and Human Services mandated a 2005 revision of the allocation systems for all organs based on medical urgency rather than time on the waiting list, a system biased against patients with more aggressive disease such as IPF. The LAS scoring formula put in place by the Organ Procurement and Transplantation Network took into account both the urgency of a patient’s need for a lung transplant and the patient’s likelihood of survival following transplantation (Chest 2007;132:1954-61). Two patient features carry the most weight in the formula: the patient’s underlying disease, and whether the patient requires mechanical ventilation and how much oxygen he or she needs. Today, about the only way for a patient to have a really high LAS score of 80 or greater is to be on a ventilator with high-flow oxygen.
The 2005 LAS revision led to a dramatic shortening of the U.S. waiting list for lungs – from more than 2,000 patients before 2005 to roughly 1,000 patients today – largely because it deemphasized time on the list and made "time banking" unnecessary. Time banking had been a practice by which potential lung transplant candidates without an immediate need got listed in case they needed a transplant in the future. If they did eventually need a transplant, they had accumulated time on the list, which boosted their chances of getting the transplant more quickly. If they eventually got a call for a transplant but still did not immediately need it, they could withdraw from accepting that organ but still retain their relatively high priority on the list, Dr. Kotloff explained.
With the new allocation formula, patients with no immediate need and an uncertain future need for a transplant, such as many COPD patients, are simply kept off the list until their transplant need becomes clear. The downside to the current system is that many patients with potentially severe and unstable lung disease, such as many IPF patients, move from referral to listing to transplantation in just a few weeks – so rapidly that they do not have time to receive adequate counseling about the consequences and possible drawbacks of lung transplantation, Dr. Kotloff said.
Dr. Kotloff said that he had no disclosures.
LAS VEGAS – The 2005 revision of the lung allocation system for U.S. lung transplants succeeded, resulting in fewer patients dying while on the lung waiting list, Dr. Robert M. Kotloff said at the annual meeting of the National Association for Medical Direction of Respiratory Care.
Reduced deaths in wait-listed patients "was the major goal" of the revision, "so the LAS [lung allocation system] worked," said Dr. Kotloff, professor of medicine and chief of the section of advanced lung disease and lung transplantation at the University of Pennsylvania in Philadelphia.
The new LAS also triggered other changes in the pattern of U.S. lung transplantations during the subsequent 5 years, some of which took several years to become apparent.
The revised system for allocation of donor lungs shifted the weight of the different pulmonary diseases that lead to lung transplantation, reducing the priority of chronic obstructive pulmonary disease (COPD) and boosting the importance of idiopathic pulmonary fibrosis (IPF). As recently as a decade ago, 45% of U.S. lung transplantations were done in patients with COPD and 20% in those with IPF. Although the gap between the two had narrowed considerably by 2005, that year COPD still remained the leading indication. But by 2007, IPF inched ahead of COPD, and today IPF is the leading reason why U.S. patients receive a lung transplant, Dr. Kotloff said.
"IPF is a no-brainer for listing," with a median survival of 3-4 years, and with half of IPF deaths occurring after a sudden patient decline, he said. Although some patients have an indolent form of IPF, "what’s unsettling is that half of IPF deaths are sudden and unpredictable, occurring in patients who recently had stable or mild disease. We have all had IPF patients who were told they weren’t sick enough to list and to return in 6 months – who then show up in the ICU on a ventilator, a missed opportunity" for transplantation. Because of experiences like these, IPF patients now undergo a thorough evaluation for transplantation so that if they suddenly wind up in the ICU, it’s easier to get them a transplant quickly.
Patients who receive a lung transplant have a median 5-year survival rate of 50%, which means that patients with a disease that has a similar or better prognosis are not good candidates. The poorer average survival rate of IPF patients helps explain why they are good transplant candidates.
The U.S. Department of Health and Human Services mandated a 2005 revision of the allocation systems for all organs based on medical urgency rather than time on the waiting list, a system biased against patients with more aggressive disease such as IPF. The LAS scoring formula put in place by the Organ Procurement and Transplantation Network took into account both the urgency of a patient’s need for a lung transplant and the patient’s likelihood of survival following transplantation (Chest 2007;132:1954-61). Two patient features carry the most weight in the formula: the patient’s underlying disease, and whether the patient requires mechanical ventilation and how much oxygen he or she needs. Today, about the only way for a patient to have a really high LAS score of 80 or greater is to be on a ventilator with high-flow oxygen.
The 2005 LAS revision led to a dramatic shortening of the U.S. waiting list for lungs – from more than 2,000 patients before 2005 to roughly 1,000 patients today – largely because it deemphasized time on the list and made "time banking" unnecessary. Time banking had been a practice by which potential lung transplant candidates without an immediate need got listed in case they needed a transplant in the future. If they did eventually need a transplant, they had accumulated time on the list, which boosted their chances of getting the transplant more quickly. If they eventually got a call for a transplant but still did not immediately need it, they could withdraw from accepting that organ but still retain their relatively high priority on the list, Dr. Kotloff explained.
With the new allocation formula, patients with no immediate need and an uncertain future need for a transplant, such as many COPD patients, are simply kept off the list until their transplant need becomes clear. The downside to the current system is that many patients with potentially severe and unstable lung disease, such as many IPF patients, move from referral to listing to transplantation in just a few weeks – so rapidly that they do not have time to receive adequate counseling about the consequences and possible drawbacks of lung transplantation, Dr. Kotloff said.
Dr. Kotloff said that he had no disclosures.
LAS VEGAS – The 2005 revision of the lung allocation system for U.S. lung transplants succeeded, resulting in fewer patients dying while on the lung waiting list, Dr. Robert M. Kotloff said at the annual meeting of the National Association for Medical Direction of Respiratory Care.
Reduced deaths in wait-listed patients "was the major goal" of the revision, "so the LAS [lung allocation system] worked," said Dr. Kotloff, professor of medicine and chief of the section of advanced lung disease and lung transplantation at the University of Pennsylvania in Philadelphia.
The new LAS also triggered other changes in the pattern of U.S. lung transplantations during the subsequent 5 years, some of which took several years to become apparent.
The revised system for allocation of donor lungs shifted the weight of the different pulmonary diseases that lead to lung transplantation, reducing the priority of chronic obstructive pulmonary disease (COPD) and boosting the importance of idiopathic pulmonary fibrosis (IPF). As recently as a decade ago, 45% of U.S. lung transplantations were done in patients with COPD and 20% in those with IPF. Although the gap between the two had narrowed considerably by 2005, that year COPD still remained the leading indication. But by 2007, IPF inched ahead of COPD, and today IPF is the leading reason why U.S. patients receive a lung transplant, Dr. Kotloff said.
"IPF is a no-brainer for listing," with a median survival of 3-4 years, and with half of IPF deaths occurring after a sudden patient decline, he said. Although some patients have an indolent form of IPF, "what’s unsettling is that half of IPF deaths are sudden and unpredictable, occurring in patients who recently had stable or mild disease. We have all had IPF patients who were told they weren’t sick enough to list and to return in 6 months – who then show up in the ICU on a ventilator, a missed opportunity" for transplantation. Because of experiences like these, IPF patients now undergo a thorough evaluation for transplantation so that if they suddenly wind up in the ICU, it’s easier to get them a transplant quickly.
Patients who receive a lung transplant have a median 5-year survival rate of 50%, which means that patients with a disease that has a similar or better prognosis are not good candidates. The poorer average survival rate of IPF patients helps explain why they are good transplant candidates.
The U.S. Department of Health and Human Services mandated a 2005 revision of the allocation systems for all organs based on medical urgency rather than time on the waiting list, a system biased against patients with more aggressive disease such as IPF. The LAS scoring formula put in place by the Organ Procurement and Transplantation Network took into account both the urgency of a patient’s need for a lung transplant and the patient’s likelihood of survival following transplantation (Chest 2007;132:1954-61). Two patient features carry the most weight in the formula: the patient’s underlying disease, and whether the patient requires mechanical ventilation and how much oxygen he or she needs. Today, about the only way for a patient to have a really high LAS score of 80 or greater is to be on a ventilator with high-flow oxygen.
The 2005 LAS revision led to a dramatic shortening of the U.S. waiting list for lungs – from more than 2,000 patients before 2005 to roughly 1,000 patients today – largely because it deemphasized time on the list and made "time banking" unnecessary. Time banking had been a practice by which potential lung transplant candidates without an immediate need got listed in case they needed a transplant in the future. If they did eventually need a transplant, they had accumulated time on the list, which boosted their chances of getting the transplant more quickly. If they eventually got a call for a transplant but still did not immediately need it, they could withdraw from accepting that organ but still retain their relatively high priority on the list, Dr. Kotloff explained.
With the new allocation formula, patients with no immediate need and an uncertain future need for a transplant, such as many COPD patients, are simply kept off the list until their transplant need becomes clear. The downside to the current system is that many patients with potentially severe and unstable lung disease, such as many IPF patients, move from referral to listing to transplantation in just a few weeks – so rapidly that they do not have time to receive adequate counseling about the consequences and possible drawbacks of lung transplantation, Dr. Kotloff said.
Dr. Kotloff said that he had no disclosures.
Gastric Bypass Tied to Higher Hypoglycemia Risk
NEW YORK – Obese patients without diabetes who underwent gastric bypass showed a surprisingly high prevalence of hyperinsulinemic hypoglycemia starting about a year following bariatric surgery, based on anecdotal experience at one U.S. center.
“We have no data on the prevalence, but it is turning out to be a very prevalent side effect of gastric bypass. All of a sudden at the University of Minnesota these patients are queued up to get into our clinic,” Dr. John P. Bantle said at the meeting.
“I know of about 25 or 30 cases reported in the literature, but I've seen more than that many cases myself. They're taking over my clinic,” said Dr. Bantle, an endocrinologist and professor of medicine at the University of Minnesota in Minneapolis.
“The only thing that protects against patients developing this is preexisting diabetes. Patients who had diabetes [before undergoing gastric bypass surgery] don't get this because there needs to be a strong insulin response” to ingestion of carbohydrates, something that patients with a history of inadequate insulin production don't mount. “It happens in people who have healthy insulin-producing beta cells and can make a robust response to postprandial hyperglycemia,” he said.
The likely cause is the rapid transit of food between the stomach and small intestine that gastric bypass creates. “Carbohydrates are absorbed much more quickly than nature intended,” producing an acute hyperglycemic episode that provokes a strong hyperinsulinemia. That, in turn, brings on a sharp hypoglycemia that can cause the patient to pass out. It is a form of dumping syndrome that does not appear as quickly following bariatric surgery as other manifestations of dumping syndrome, he said.
An alternative explanation, which Dr. Bantle calls much less likely, is that gastric bypass changes the blood level of glucagonlike peptide–1, leading to beta-cell hyperplasia and hyperinsulinemia.
This type of hypoglycemia does not occur in patients who have their pylorus intact following bariatric surgery, such as those who undergo gastric banding or receive a gastric sleeve, he said.
In addition to a delay of more than a year following surgery before it appears, other features that characterize this postprandial hypoglycemia include normal fasting glucose and serum insulin levels, and a carbohydrate-triggered plasma glucose level of less than 50 mg/dL accompanied by a serum insulin level that exceeds 50 microU/mL.
The best treatment is carbohydrate avoidance or restriction, Dr. Bantle said. If that proves impossible, patients can try taking acarbose with a meal that contains carbohydrates. They can also have one or two glucose pills ready to take at the first sign of hypoglycemic symptoms, he said.
Dr. Bantle said that he is a consultant to Unilever, and serves as a speaker for Eli Lilly, Merck, and Novo Nordisk.
The only thing that protects these obese patients from developing hypoglycemia is preexisting diabetes.
Source DR. BANTLE
NEW YORK – Obese patients without diabetes who underwent gastric bypass showed a surprisingly high prevalence of hyperinsulinemic hypoglycemia starting about a year following bariatric surgery, based on anecdotal experience at one U.S. center.
“We have no data on the prevalence, but it is turning out to be a very prevalent side effect of gastric bypass. All of a sudden at the University of Minnesota these patients are queued up to get into our clinic,” Dr. John P. Bantle said at the meeting.
“I know of about 25 or 30 cases reported in the literature, but I've seen more than that many cases myself. They're taking over my clinic,” said Dr. Bantle, an endocrinologist and professor of medicine at the University of Minnesota in Minneapolis.
“The only thing that protects against patients developing this is preexisting diabetes. Patients who had diabetes [before undergoing gastric bypass surgery] don't get this because there needs to be a strong insulin response” to ingestion of carbohydrates, something that patients with a history of inadequate insulin production don't mount. “It happens in people who have healthy insulin-producing beta cells and can make a robust response to postprandial hyperglycemia,” he said.
The likely cause is the rapid transit of food between the stomach and small intestine that gastric bypass creates. “Carbohydrates are absorbed much more quickly than nature intended,” producing an acute hyperglycemic episode that provokes a strong hyperinsulinemia. That, in turn, brings on a sharp hypoglycemia that can cause the patient to pass out. It is a form of dumping syndrome that does not appear as quickly following bariatric surgery as other manifestations of dumping syndrome, he said.
An alternative explanation, which Dr. Bantle calls much less likely, is that gastric bypass changes the blood level of glucagonlike peptide–1, leading to beta-cell hyperplasia and hyperinsulinemia.
This type of hypoglycemia does not occur in patients who have their pylorus intact following bariatric surgery, such as those who undergo gastric banding or receive a gastric sleeve, he said.
In addition to a delay of more than a year following surgery before it appears, other features that characterize this postprandial hypoglycemia include normal fasting glucose and serum insulin levels, and a carbohydrate-triggered plasma glucose level of less than 50 mg/dL accompanied by a serum insulin level that exceeds 50 microU/mL.
The best treatment is carbohydrate avoidance or restriction, Dr. Bantle said. If that proves impossible, patients can try taking acarbose with a meal that contains carbohydrates. They can also have one or two glucose pills ready to take at the first sign of hypoglycemic symptoms, he said.
Dr. Bantle said that he is a consultant to Unilever, and serves as a speaker for Eli Lilly, Merck, and Novo Nordisk.
The only thing that protects these obese patients from developing hypoglycemia is preexisting diabetes.
Source DR. BANTLE
NEW YORK – Obese patients without diabetes who underwent gastric bypass showed a surprisingly high prevalence of hyperinsulinemic hypoglycemia starting about a year following bariatric surgery, based on anecdotal experience at one U.S. center.
“We have no data on the prevalence, but it is turning out to be a very prevalent side effect of gastric bypass. All of a sudden at the University of Minnesota these patients are queued up to get into our clinic,” Dr. John P. Bantle said at the meeting.
“I know of about 25 or 30 cases reported in the literature, but I've seen more than that many cases myself. They're taking over my clinic,” said Dr. Bantle, an endocrinologist and professor of medicine at the University of Minnesota in Minneapolis.
“The only thing that protects against patients developing this is preexisting diabetes. Patients who had diabetes [before undergoing gastric bypass surgery] don't get this because there needs to be a strong insulin response” to ingestion of carbohydrates, something that patients with a history of inadequate insulin production don't mount. “It happens in people who have healthy insulin-producing beta cells and can make a robust response to postprandial hyperglycemia,” he said.
The likely cause is the rapid transit of food between the stomach and small intestine that gastric bypass creates. “Carbohydrates are absorbed much more quickly than nature intended,” producing an acute hyperglycemic episode that provokes a strong hyperinsulinemia. That, in turn, brings on a sharp hypoglycemia that can cause the patient to pass out. It is a form of dumping syndrome that does not appear as quickly following bariatric surgery as other manifestations of dumping syndrome, he said.
An alternative explanation, which Dr. Bantle calls much less likely, is that gastric bypass changes the blood level of glucagonlike peptide–1, leading to beta-cell hyperplasia and hyperinsulinemia.
This type of hypoglycemia does not occur in patients who have their pylorus intact following bariatric surgery, such as those who undergo gastric banding or receive a gastric sleeve, he said.
In addition to a delay of more than a year following surgery before it appears, other features that characterize this postprandial hypoglycemia include normal fasting glucose and serum insulin levels, and a carbohydrate-triggered plasma glucose level of less than 50 mg/dL accompanied by a serum insulin level that exceeds 50 microU/mL.
The best treatment is carbohydrate avoidance or restriction, Dr. Bantle said. If that proves impossible, patients can try taking acarbose with a meal that contains carbohydrates. They can also have one or two glucose pills ready to take at the first sign of hypoglycemic symptoms, he said.
Dr. Bantle said that he is a consultant to Unilever, and serves as a speaker for Eli Lilly, Merck, and Novo Nordisk.
The only thing that protects these obese patients from developing hypoglycemia is preexisting diabetes.
Source DR. BANTLE
A Meeting Sponsored by the American Diabetes Association
Home Care Cuts Readmissions for Chronic Diseases
Major Finding: Patients aged 65 years or older with diabetes and multiple other chronic conditions had a 21% rehospitalization rate during the first 30 days following discharge from their index hospitalization when receiving home-management care, compared with a 33% rate in similar, historic control patients who did not receive such care.
Data Source: Eighty-eight patients aged 65 years or older with diabetes and multiple other chronic conditions treated during 2008–2010.
Disclosures: Dr. Rackow is an employee, stockholder, and board member of Senior Bridge.
NEW YORK – A patient-centered, medical-home approach to care for patients with multiple chronic diseases when they are discharged from the hospital and back in their own residences substantially cut their rate of hospital readmissions, suggesting that this new model of home-based medical care pays for itself by avoiding hospitalization costs.
“We think it's very important for the U.S. health care system to move its focus from hospital to home, with care management that prevents unnecessary emergency department visits and hospital admissions,” Dr. Eric C. Rackow said.
“You can alter the outcomes at home [of patients with diabetes and other chronic diseases] if you keep patients healthier and more functional at home and out of the hospital,” said Dr. Rackow, professor of medicine at New York University, and president and CEO of SeniorBridge, a company that provides medical services to patients when they are in their homes.
“We have health plan contracts where we have shown a 50% reduction in hospitalization and readmissions rates, producing a 50% drop in the cost per member per month,” Dr. Rackow said in an interview.
Although SeniorBridge is relatively unique in offering in-home services from a variety of health care professionals to patients, the model is amenable to scale up, he said. “Doctors are the captains, but it's the nurses, social workers, nutritionists, and pharmacists who actually are in the patients' homes. Physicians can manage a large number of patients. It's a cost-effective way to extend the physician's reach.”
To document the impact of home-based intervention, he presented data collected by SeniorBridge from 503 patients aged 65 years or older who the company managed during 2008–2010. Eighty-eight of these patients who had diabetes and multiple other chronic conditions had a hospital readmission rate of 21% in their first 30 days at home following discharge from their index hospitalization.
The other 415 patients managed by SeniorBridge had multiple chronic conditions but no diabetes, and they had an 11% rehospitalization rate in their first 30 days at home. In contrast, a historic control of similar elderly Americans with multiple chronic conditions who did not receive comprehensive care at home following their hospital discharge had a 33% readmission rate, Dr. Rackow said.
Another data analysis showed that 230 elderly SeniorBridge–treated patients with diabetes and multiple chronic diseases averaged 0.37 hospitalizations/year, and 1,486 elderly SeniorBridge-treated patients with multiple chronic diseases but no diabetes averaged 0.28 hospitalizations/year. By comparison, Medicare data showed a rate of 1.3 hospitalizations/year among similar patients receiving conventional care following a hospital discharge.
Multiple chronic illnesses are a hallmark of elderly patients with diabetes, affecting three-quarters of Americans 65 years or older with diabetes, Dr. Rackow said. The combination of diabetes, chronic obstructive pulmonary disease, and heart failure forms a common comorbidity constellation among elderly patients with diabetes, he noted.
Patients with several simultaneous chronic illnesses face special physical and cognitive challenges that pose problems for their self-directed care, he said. “The functional limitations [triggered by multiple chronic diseases] and the inability to self-manage tips patients and causes frequent hospitalizations.” That's why home medical services that aid a patient's self management can have such a significant impact on rehospitalization rates.
Payment for SeniorBridge's services has come from Medicaid, private insurers, and from long-term insurance policies. Medicare does not currently pay for these services, Dr. Rackow said.
'We have health plan contracts where we have shown … a 50% drop in the cost per member per month.'
Source DR. RACKOW
Major Finding: Patients aged 65 years or older with diabetes and multiple other chronic conditions had a 21% rehospitalization rate during the first 30 days following discharge from their index hospitalization when receiving home-management care, compared with a 33% rate in similar, historic control patients who did not receive such care.
Data Source: Eighty-eight patients aged 65 years or older with diabetes and multiple other chronic conditions treated during 2008–2010.
Disclosures: Dr. Rackow is an employee, stockholder, and board member of Senior Bridge.
NEW YORK – A patient-centered, medical-home approach to care for patients with multiple chronic diseases when they are discharged from the hospital and back in their own residences substantially cut their rate of hospital readmissions, suggesting that this new model of home-based medical care pays for itself by avoiding hospitalization costs.
“We think it's very important for the U.S. health care system to move its focus from hospital to home, with care management that prevents unnecessary emergency department visits and hospital admissions,” Dr. Eric C. Rackow said.
“You can alter the outcomes at home [of patients with diabetes and other chronic diseases] if you keep patients healthier and more functional at home and out of the hospital,” said Dr. Rackow, professor of medicine at New York University, and president and CEO of SeniorBridge, a company that provides medical services to patients when they are in their homes.
“We have health plan contracts where we have shown a 50% reduction in hospitalization and readmissions rates, producing a 50% drop in the cost per member per month,” Dr. Rackow said in an interview.
Although SeniorBridge is relatively unique in offering in-home services from a variety of health care professionals to patients, the model is amenable to scale up, he said. “Doctors are the captains, but it's the nurses, social workers, nutritionists, and pharmacists who actually are in the patients' homes. Physicians can manage a large number of patients. It's a cost-effective way to extend the physician's reach.”
To document the impact of home-based intervention, he presented data collected by SeniorBridge from 503 patients aged 65 years or older who the company managed during 2008–2010. Eighty-eight of these patients who had diabetes and multiple other chronic conditions had a hospital readmission rate of 21% in their first 30 days at home following discharge from their index hospitalization.
The other 415 patients managed by SeniorBridge had multiple chronic conditions but no diabetes, and they had an 11% rehospitalization rate in their first 30 days at home. In contrast, a historic control of similar elderly Americans with multiple chronic conditions who did not receive comprehensive care at home following their hospital discharge had a 33% readmission rate, Dr. Rackow said.
Another data analysis showed that 230 elderly SeniorBridge–treated patients with diabetes and multiple chronic diseases averaged 0.37 hospitalizations/year, and 1,486 elderly SeniorBridge-treated patients with multiple chronic diseases but no diabetes averaged 0.28 hospitalizations/year. By comparison, Medicare data showed a rate of 1.3 hospitalizations/year among similar patients receiving conventional care following a hospital discharge.
Multiple chronic illnesses are a hallmark of elderly patients with diabetes, affecting three-quarters of Americans 65 years or older with diabetes, Dr. Rackow said. The combination of diabetes, chronic obstructive pulmonary disease, and heart failure forms a common comorbidity constellation among elderly patients with diabetes, he noted.
Patients with several simultaneous chronic illnesses face special physical and cognitive challenges that pose problems for their self-directed care, he said. “The functional limitations [triggered by multiple chronic diseases] and the inability to self-manage tips patients and causes frequent hospitalizations.” That's why home medical services that aid a patient's self management can have such a significant impact on rehospitalization rates.
Payment for SeniorBridge's services has come from Medicaid, private insurers, and from long-term insurance policies. Medicare does not currently pay for these services, Dr. Rackow said.
'We have health plan contracts where we have shown … a 50% drop in the cost per member per month.'
Source DR. RACKOW
Major Finding: Patients aged 65 years or older with diabetes and multiple other chronic conditions had a 21% rehospitalization rate during the first 30 days following discharge from their index hospitalization when receiving home-management care, compared with a 33% rate in similar, historic control patients who did not receive such care.
Data Source: Eighty-eight patients aged 65 years or older with diabetes and multiple other chronic conditions treated during 2008–2010.
Disclosures: Dr. Rackow is an employee, stockholder, and board member of Senior Bridge.
NEW YORK – A patient-centered, medical-home approach to care for patients with multiple chronic diseases when they are discharged from the hospital and back in their own residences substantially cut their rate of hospital readmissions, suggesting that this new model of home-based medical care pays for itself by avoiding hospitalization costs.
“We think it's very important for the U.S. health care system to move its focus from hospital to home, with care management that prevents unnecessary emergency department visits and hospital admissions,” Dr. Eric C. Rackow said.
“You can alter the outcomes at home [of patients with diabetes and other chronic diseases] if you keep patients healthier and more functional at home and out of the hospital,” said Dr. Rackow, professor of medicine at New York University, and president and CEO of SeniorBridge, a company that provides medical services to patients when they are in their homes.
“We have health plan contracts where we have shown a 50% reduction in hospitalization and readmissions rates, producing a 50% drop in the cost per member per month,” Dr. Rackow said in an interview.
Although SeniorBridge is relatively unique in offering in-home services from a variety of health care professionals to patients, the model is amenable to scale up, he said. “Doctors are the captains, but it's the nurses, social workers, nutritionists, and pharmacists who actually are in the patients' homes. Physicians can manage a large number of patients. It's a cost-effective way to extend the physician's reach.”
To document the impact of home-based intervention, he presented data collected by SeniorBridge from 503 patients aged 65 years or older who the company managed during 2008–2010. Eighty-eight of these patients who had diabetes and multiple other chronic conditions had a hospital readmission rate of 21% in their first 30 days at home following discharge from their index hospitalization.
The other 415 patients managed by SeniorBridge had multiple chronic conditions but no diabetes, and they had an 11% rehospitalization rate in their first 30 days at home. In contrast, a historic control of similar elderly Americans with multiple chronic conditions who did not receive comprehensive care at home following their hospital discharge had a 33% readmission rate, Dr. Rackow said.
Another data analysis showed that 230 elderly SeniorBridge–treated patients with diabetes and multiple chronic diseases averaged 0.37 hospitalizations/year, and 1,486 elderly SeniorBridge-treated patients with multiple chronic diseases but no diabetes averaged 0.28 hospitalizations/year. By comparison, Medicare data showed a rate of 1.3 hospitalizations/year among similar patients receiving conventional care following a hospital discharge.
Multiple chronic illnesses are a hallmark of elderly patients with diabetes, affecting three-quarters of Americans 65 years or older with diabetes, Dr. Rackow said. The combination of diabetes, chronic obstructive pulmonary disease, and heart failure forms a common comorbidity constellation among elderly patients with diabetes, he noted.
Patients with several simultaneous chronic illnesses face special physical and cognitive challenges that pose problems for their self-directed care, he said. “The functional limitations [triggered by multiple chronic diseases] and the inability to self-manage tips patients and causes frequent hospitalizations.” That's why home medical services that aid a patient's self management can have such a significant impact on rehospitalization rates.
Payment for SeniorBridge's services has come from Medicaid, private insurers, and from long-term insurance policies. Medicare does not currently pay for these services, Dr. Rackow said.
'We have health plan contracts where we have shown … a 50% drop in the cost per member per month.'
Source DR. RACKOW
From a Meeting Sponsored by the American Diabetes Association
The YMCA Ventures Into Diabetes Prevention
NEW YORK – Taking an “if we build it, they will come” approach, the YMCA is rolling out a diabetes-prevention program at a Y near you. And they need primary care physicians to refer patients to these programs.
The building started last year, when the YMCA of the USA began offering lifestyle training to people with prediabetes, and by February the program had taken root at 116 sites in more than 30 U.S. communities, David G. Marrero, Ph.D., said at the annual course.
The program puts into practice lessons learned nearly a decade ago in the landmark Diabetes Prevention Program, which recruited more than 3,000 Americans who did not have diabetes but who did have elevated fasting blood glucose levels.
The findings showed that in a controlled, randomized study setting, teaching people on a one-on-one basis to exercise more and change their diet to achieve significant weight loss led to a 58% cut in the rate of new diabetes cases during 3 years of follow-up, compared with control participants (N. Engl. J. Med. 2002;346:393-403).
“The DPP showed the efficacy of lifestyle modification, but the issue remained of how to translate this powerful finding to the public,” said Dr. Marrero, professor of medicine and director of the Diabetes Translational Research Center at Indiana University in Indianapolis. “The DPP was expensive.”
By Dr. Marrero's calculations, the original DPP lifestyle intervention cost nearly $1,500 per person. With about 70 million Americans estimated to have prediabetes, it was clear that adapting the one-on-one program for a group-based program for use at YMCAs was key.
His group reported on the success of a pilot group–based version in 2008 (Am. J. Prev. Med. 2008;35:357-63). Based on this evidence – and with the backing of the Centers for Disease Control and Prevention – the YMCA moved to expand the program nationally.
By the end of this year, the program is expected to be available at 150 sites operated by about 50 different YMCAs, said Dr. Matt Longjohn, who is the senior director of chronic disease prevention at the YMCA of the USA.
The premise of the program is that people who lose 7% of their body weight and gradually increase their weekly exercise to 150 minutes can significantly lower their risk for developing frank type 2 diabetes. Candidates for the program must be overweight and either at high risk for diabetes or with a diagnosis of prediabetes.
The course that is offered at YMCAs involves an hour-long session once a week for 16 weeks. Session topics include:
▸ Ways to Eat Less Fat and Fewer Calories.
▸ Being Active: A Way of Life.
▸ Four Keys to Healthy Eating Out.
▸ Talk Back to Negative Thoughts.
▸ The Slippery Slope of Lifestyle Change.
▸ Ways to Stay Motivated.
In an effort to stay motivated, enrollees will attend monthly refresher courses for 8 months to discuss areas in which they are having trouble maintaining their new healthful habits, and reviewing the basic strategies from the original sessions.
The CDC is supporting the rollout of the program, as was mandated by the National Diabetes Prevention Program of the Patient Protection and Affordable Care Act.
For people without coverage, the year-long program costs about $300 per participant, noted Dr. Longjohn, but many Ys offer it at a reduced rate because they also receive support from the CDC. For example, YMCA of Delaware charges Y members $149 for the prevention-training course; nonmembers pay $199.
UnitedHealthcare has also signed on to cover the cost of participation for its beneficiaries who are at risk for diabetes.
Dr. Marrero said that the next step is encouraging primary care physicians to broadly screen and identify people who would benefit from a diabetes-prevention intervention. He and his associates recently began a pilot study to assess the benefits of conducting routine diabetes screening in primary care practices.
Dr. Marrero said that he had been an advisor to Eli Lilly, a consultant to Sanofi-Aventis and to YMCA of the USA, and a speaker for Taking Control of Your Diabetes. Dr. Longjohn reported having no disclosures.
The next step is to screen people for prediabetes who would benefit from the program, says David G. Marrero, Ph.D.
Source Courtesy Indiana University
NEW YORK – Taking an “if we build it, they will come” approach, the YMCA is rolling out a diabetes-prevention program at a Y near you. And they need primary care physicians to refer patients to these programs.
The building started last year, when the YMCA of the USA began offering lifestyle training to people with prediabetes, and by February the program had taken root at 116 sites in more than 30 U.S. communities, David G. Marrero, Ph.D., said at the annual course.
The program puts into practice lessons learned nearly a decade ago in the landmark Diabetes Prevention Program, which recruited more than 3,000 Americans who did not have diabetes but who did have elevated fasting blood glucose levels.
The findings showed that in a controlled, randomized study setting, teaching people on a one-on-one basis to exercise more and change their diet to achieve significant weight loss led to a 58% cut in the rate of new diabetes cases during 3 years of follow-up, compared with control participants (N. Engl. J. Med. 2002;346:393-403).
“The DPP showed the efficacy of lifestyle modification, but the issue remained of how to translate this powerful finding to the public,” said Dr. Marrero, professor of medicine and director of the Diabetes Translational Research Center at Indiana University in Indianapolis. “The DPP was expensive.”
By Dr. Marrero's calculations, the original DPP lifestyle intervention cost nearly $1,500 per person. With about 70 million Americans estimated to have prediabetes, it was clear that adapting the one-on-one program for a group-based program for use at YMCAs was key.
His group reported on the success of a pilot group–based version in 2008 (Am. J. Prev. Med. 2008;35:357-63). Based on this evidence – and with the backing of the Centers for Disease Control and Prevention – the YMCA moved to expand the program nationally.
By the end of this year, the program is expected to be available at 150 sites operated by about 50 different YMCAs, said Dr. Matt Longjohn, who is the senior director of chronic disease prevention at the YMCA of the USA.
The premise of the program is that people who lose 7% of their body weight and gradually increase their weekly exercise to 150 minutes can significantly lower their risk for developing frank type 2 diabetes. Candidates for the program must be overweight and either at high risk for diabetes or with a diagnosis of prediabetes.
The course that is offered at YMCAs involves an hour-long session once a week for 16 weeks. Session topics include:
▸ Ways to Eat Less Fat and Fewer Calories.
▸ Being Active: A Way of Life.
▸ Four Keys to Healthy Eating Out.
▸ Talk Back to Negative Thoughts.
▸ The Slippery Slope of Lifestyle Change.
▸ Ways to Stay Motivated.
In an effort to stay motivated, enrollees will attend monthly refresher courses for 8 months to discuss areas in which they are having trouble maintaining their new healthful habits, and reviewing the basic strategies from the original sessions.
The CDC is supporting the rollout of the program, as was mandated by the National Diabetes Prevention Program of the Patient Protection and Affordable Care Act.
For people without coverage, the year-long program costs about $300 per participant, noted Dr. Longjohn, but many Ys offer it at a reduced rate because they also receive support from the CDC. For example, YMCA of Delaware charges Y members $149 for the prevention-training course; nonmembers pay $199.
UnitedHealthcare has also signed on to cover the cost of participation for its beneficiaries who are at risk for diabetes.
Dr. Marrero said that the next step is encouraging primary care physicians to broadly screen and identify people who would benefit from a diabetes-prevention intervention. He and his associates recently began a pilot study to assess the benefits of conducting routine diabetes screening in primary care practices.
Dr. Marrero said that he had been an advisor to Eli Lilly, a consultant to Sanofi-Aventis and to YMCA of the USA, and a speaker for Taking Control of Your Diabetes. Dr. Longjohn reported having no disclosures.
The next step is to screen people for prediabetes who would benefit from the program, says David G. Marrero, Ph.D.
Source Courtesy Indiana University
NEW YORK – Taking an “if we build it, they will come” approach, the YMCA is rolling out a diabetes-prevention program at a Y near you. And they need primary care physicians to refer patients to these programs.
The building started last year, when the YMCA of the USA began offering lifestyle training to people with prediabetes, and by February the program had taken root at 116 sites in more than 30 U.S. communities, David G. Marrero, Ph.D., said at the annual course.
The program puts into practice lessons learned nearly a decade ago in the landmark Diabetes Prevention Program, which recruited more than 3,000 Americans who did not have diabetes but who did have elevated fasting blood glucose levels.
The findings showed that in a controlled, randomized study setting, teaching people on a one-on-one basis to exercise more and change their diet to achieve significant weight loss led to a 58% cut in the rate of new diabetes cases during 3 years of follow-up, compared with control participants (N. Engl. J. Med. 2002;346:393-403).
“The DPP showed the efficacy of lifestyle modification, but the issue remained of how to translate this powerful finding to the public,” said Dr. Marrero, professor of medicine and director of the Diabetes Translational Research Center at Indiana University in Indianapolis. “The DPP was expensive.”
By Dr. Marrero's calculations, the original DPP lifestyle intervention cost nearly $1,500 per person. With about 70 million Americans estimated to have prediabetes, it was clear that adapting the one-on-one program for a group-based program for use at YMCAs was key.
His group reported on the success of a pilot group–based version in 2008 (Am. J. Prev. Med. 2008;35:357-63). Based on this evidence – and with the backing of the Centers for Disease Control and Prevention – the YMCA moved to expand the program nationally.
By the end of this year, the program is expected to be available at 150 sites operated by about 50 different YMCAs, said Dr. Matt Longjohn, who is the senior director of chronic disease prevention at the YMCA of the USA.
The premise of the program is that people who lose 7% of their body weight and gradually increase their weekly exercise to 150 minutes can significantly lower their risk for developing frank type 2 diabetes. Candidates for the program must be overweight and either at high risk for diabetes or with a diagnosis of prediabetes.
The course that is offered at YMCAs involves an hour-long session once a week for 16 weeks. Session topics include:
▸ Ways to Eat Less Fat and Fewer Calories.
▸ Being Active: A Way of Life.
▸ Four Keys to Healthy Eating Out.
▸ Talk Back to Negative Thoughts.
▸ The Slippery Slope of Lifestyle Change.
▸ Ways to Stay Motivated.
In an effort to stay motivated, enrollees will attend monthly refresher courses for 8 months to discuss areas in which they are having trouble maintaining their new healthful habits, and reviewing the basic strategies from the original sessions.
The CDC is supporting the rollout of the program, as was mandated by the National Diabetes Prevention Program of the Patient Protection and Affordable Care Act.
For people without coverage, the year-long program costs about $300 per participant, noted Dr. Longjohn, but many Ys offer it at a reduced rate because they also receive support from the CDC. For example, YMCA of Delaware charges Y members $149 for the prevention-training course; nonmembers pay $199.
UnitedHealthcare has also signed on to cover the cost of participation for its beneficiaries who are at risk for diabetes.
Dr. Marrero said that the next step is encouraging primary care physicians to broadly screen and identify people who would benefit from a diabetes-prevention intervention. He and his associates recently began a pilot study to assess the benefits of conducting routine diabetes screening in primary care practices.
Dr. Marrero said that he had been an advisor to Eli Lilly, a consultant to Sanofi-Aventis and to YMCA of the USA, and a speaker for Taking Control of Your Diabetes. Dr. Longjohn reported having no disclosures.
The next step is to screen people for prediabetes who would benefit from the program, says David G. Marrero, Ph.D.
Source Courtesy Indiana University
From the American Diabetes Association Advanced Postgraduate Course
A Tall Order: E-Templates for Insulin Guidance
NEW YORK – Computerized systems for ordering insulin treatment are being used at some U.S. hospitals, but don't expect widespread expansion anytime soon as these systems are not easily set up, Dr. Mary T. Korytkowski said.
“We're at the early stages of using computerized ordering.” Automated systems “make it easier for nonendocrinologists to do the right thing” when administering insulin to hospitalized patients, said Dr. Korytkowski, who is director of the Center for Diabetes and Endocrinology at the University of Pittsburgh.
Setting up computerized order templates for insulin management is complicated because there is “no protocol a hospital can pull off the shelf. Every hospital has their own electronic medical record, and they need to build [an automated insulin-dose guidance algorithm] into their system. There is a lot of behind-the-scenes work that goes into building a protocol like this. At Pitt, we're working on it. We don't have it yet, but it's worth doing,” she said in an interview.
The introduction of computer-guided insulin order templates comes at a time when experts appear to have reached a consensus on managing hyperglycemia in hospitalized patients.
This began a decade ago, with the publication of the landmark study from Belgium that showed strict glucose control in intensive care patients improved survival and cut morbidity (N. Engl. J. Med. 2001;345:359-67).
Subsequent study results showed intensive glycemic control that kept blood glucose levels below 110 mg/dL resulted in no extra benefit compared with good control. Specialists now generally recommend a blood glucose range of 140–200 mg/dL for hospitalized, intensive care patients, including the guidelines published in February by the American College of Physicians (Ann. Int. Med. 2011;154:260-7).
A computerized order template would make such a goal – and the insulin treatment needed to achieve it – more automatic. “A lot of places are still struggling to get people to buy into controlling glucose levels in the hospital,” Dr. Korytkowski said.
Evidence documenting the advantages of a computerized insulin-order template appeared in an article published last October by physicians at the Massachusetts General Hospital, one of the few U.S. sites with a computerized system in place, Dr. Korytkowski said.
The study analyzed 128 patients with type 2 diabetes who received a basal-bolus insulin regimen at MGH during April 2007-May 2009, a period when the computerized system was not available to all MGH physicians.
Insulin treatment was guided by the computerized template in 63 patients, and 65 received treatment prescribed by physicians who had received a brief teaching session and a dosing pamphlet, she said.
The results showed significantly better glucose control in the group whose treatment had computerized guidance, with an average blood glucose level of 194 mg/dL, compared with an average level of 224 mg/dL in the patients who were treated without using the computer-based dosage template (Diabetes Care 2010;33:2181-3).
Dr. Korytkowski said that she has been a consultant to Eli Lilly.
'A lot of places are still struggling to get people to buy into controlling glucose levels in the hospital.'
Source DR. KORYTKOWSKI
NEW YORK – Computerized systems for ordering insulin treatment are being used at some U.S. hospitals, but don't expect widespread expansion anytime soon as these systems are not easily set up, Dr. Mary T. Korytkowski said.
“We're at the early stages of using computerized ordering.” Automated systems “make it easier for nonendocrinologists to do the right thing” when administering insulin to hospitalized patients, said Dr. Korytkowski, who is director of the Center for Diabetes and Endocrinology at the University of Pittsburgh.
Setting up computerized order templates for insulin management is complicated because there is “no protocol a hospital can pull off the shelf. Every hospital has their own electronic medical record, and they need to build [an automated insulin-dose guidance algorithm] into their system. There is a lot of behind-the-scenes work that goes into building a protocol like this. At Pitt, we're working on it. We don't have it yet, but it's worth doing,” she said in an interview.
The introduction of computer-guided insulin order templates comes at a time when experts appear to have reached a consensus on managing hyperglycemia in hospitalized patients.
This began a decade ago, with the publication of the landmark study from Belgium that showed strict glucose control in intensive care patients improved survival and cut morbidity (N. Engl. J. Med. 2001;345:359-67).
Subsequent study results showed intensive glycemic control that kept blood glucose levels below 110 mg/dL resulted in no extra benefit compared with good control. Specialists now generally recommend a blood glucose range of 140–200 mg/dL for hospitalized, intensive care patients, including the guidelines published in February by the American College of Physicians (Ann. Int. Med. 2011;154:260-7).
A computerized order template would make such a goal – and the insulin treatment needed to achieve it – more automatic. “A lot of places are still struggling to get people to buy into controlling glucose levels in the hospital,” Dr. Korytkowski said.
Evidence documenting the advantages of a computerized insulin-order template appeared in an article published last October by physicians at the Massachusetts General Hospital, one of the few U.S. sites with a computerized system in place, Dr. Korytkowski said.
The study analyzed 128 patients with type 2 diabetes who received a basal-bolus insulin regimen at MGH during April 2007-May 2009, a period when the computerized system was not available to all MGH physicians.
Insulin treatment was guided by the computerized template in 63 patients, and 65 received treatment prescribed by physicians who had received a brief teaching session and a dosing pamphlet, she said.
The results showed significantly better glucose control in the group whose treatment had computerized guidance, with an average blood glucose level of 194 mg/dL, compared with an average level of 224 mg/dL in the patients who were treated without using the computer-based dosage template (Diabetes Care 2010;33:2181-3).
Dr. Korytkowski said that she has been a consultant to Eli Lilly.
'A lot of places are still struggling to get people to buy into controlling glucose levels in the hospital.'
Source DR. KORYTKOWSKI
NEW YORK – Computerized systems for ordering insulin treatment are being used at some U.S. hospitals, but don't expect widespread expansion anytime soon as these systems are not easily set up, Dr. Mary T. Korytkowski said.
“We're at the early stages of using computerized ordering.” Automated systems “make it easier for nonendocrinologists to do the right thing” when administering insulin to hospitalized patients, said Dr. Korytkowski, who is director of the Center for Diabetes and Endocrinology at the University of Pittsburgh.
Setting up computerized order templates for insulin management is complicated because there is “no protocol a hospital can pull off the shelf. Every hospital has their own electronic medical record, and they need to build [an automated insulin-dose guidance algorithm] into their system. There is a lot of behind-the-scenes work that goes into building a protocol like this. At Pitt, we're working on it. We don't have it yet, but it's worth doing,” she said in an interview.
The introduction of computer-guided insulin order templates comes at a time when experts appear to have reached a consensus on managing hyperglycemia in hospitalized patients.
This began a decade ago, with the publication of the landmark study from Belgium that showed strict glucose control in intensive care patients improved survival and cut morbidity (N. Engl. J. Med. 2001;345:359-67).
Subsequent study results showed intensive glycemic control that kept blood glucose levels below 110 mg/dL resulted in no extra benefit compared with good control. Specialists now generally recommend a blood glucose range of 140–200 mg/dL for hospitalized, intensive care patients, including the guidelines published in February by the American College of Physicians (Ann. Int. Med. 2011;154:260-7).
A computerized order template would make such a goal – and the insulin treatment needed to achieve it – more automatic. “A lot of places are still struggling to get people to buy into controlling glucose levels in the hospital,” Dr. Korytkowski said.
Evidence documenting the advantages of a computerized insulin-order template appeared in an article published last October by physicians at the Massachusetts General Hospital, one of the few U.S. sites with a computerized system in place, Dr. Korytkowski said.
The study analyzed 128 patients with type 2 diabetes who received a basal-bolus insulin regimen at MGH during April 2007-May 2009, a period when the computerized system was not available to all MGH physicians.
Insulin treatment was guided by the computerized template in 63 patients, and 65 received treatment prescribed by physicians who had received a brief teaching session and a dosing pamphlet, she said.
The results showed significantly better glucose control in the group whose treatment had computerized guidance, with an average blood glucose level of 194 mg/dL, compared with an average level of 224 mg/dL in the patients who were treated without using the computer-based dosage template (Diabetes Care 2010;33:2181-3).
Dr. Korytkowski said that she has been a consultant to Eli Lilly.
'A lot of places are still struggling to get people to buy into controlling glucose levels in the hospital.'
Source DR. KORYTKOWSKI
Expert Analysis from the ADA Annual Advanced Postgraduate Course
Quick Statin Use After Stroke Cuts Mortality
Major Finding: Stroke patients who started on a statin during their acute-phase hospitalization had a 15% absolute reduced rate of death at 1 year, compared with patients never treated with a statin.
Data Source: Review of 12,689 patients enrolled in Kaiser Permanente of Northern California who had an acute ischemic stroke during 2000–2007.
Disclosures: Dr. Flint reported having no relevant disclosures.
LOS ANGELES – Starting or maintaining acute stroke patients on a statin during their initial hospitalization was linked with a dramatic improvement in 1-year survival in a retrospective review of medical records for more than 12,000 U.S. patients.
On the basis of the finding, Kaiser Permanente of Northern California will issue a revised order set that will recommend to physicians that they start acute stroke patients on 80 mg simvastatin as soon as possible on the first day of their hospitalization, Dr. Alexander C. Flint reported at the conference.
“Based on results from the SPARCL [Stroke Prevention by Aggressive Reduction in Cholesterol Levels] trial, pretty much everyone in the stroke community believes that patients who have had an ischemic stroke should be treated with high-dose statin to prevent a second stroke (N. Engl. J. Med. 2006; 355:549–59).
In our study, the question wasn't whether to treat, but the timing. What our results say is that you should not wait until the patient is discharged or is an outpatient, but that you should start the statin on day 1,” Dr. Flint said in an interview.
The data he reported showed that stroke patients who started on a statin during their acute-phase hospitalization had a 15% absolute reduced rate of death during the first year following their stroke, compared with patients who did not start on a statin and did not receive a statin prior to their stroke (Stroke 2011;42:e-42–110).
After adjustment for several possible confounding factors, including age, sex, race and ethnicity, year of stroke, and comorbidities such as hypertension and diabetes, stroke patients who started on a statin while hospitalized had a statistically significant, 45% lower relative risk of death during the subsequent year, compared with patients who did not receive a statin.
The study involved 12,689 patients who received care from Kaiser Permanente of Northern California and had an ischemic stroke during 2000–2007. The total included 3,749 patients who were on steady statin treatment for at least 3 months before their stroke, and 8,940 patients who were not receiving a statin at all before their stroke.
Of the 3,749 patients who were on a statin before their stroke, most (3,280, or 87%) continued to receive a statin during their hospitalization. And among the 8,940 who did not receive regular statin treatment before their stroke, 3,013 (34%) began statin treatment while hospitalized.
Patients who received a statin prior to their stroke but did not continue while hospitalized had a statistically significant 15% relative reduction in their mortality during the following year, compared with patients who never received a statin.
The key element for mortality protection appeared to be treatment while hospitalized. Relative mortality reduction compared with non–statin users was 41% among patients who were on a statin both before their stroke and while hospitalized, and 45% among those who started on a statin while hospitalized, said Dr. Flint, a neurointensivist and stroke specialist at Kaiser Redwood City (Calif.). Patients who received a statin before their stroke but discontinued the drug once hospitalized had the worst outcomes, with a mortality rate that was 2.5 times as high as that of patients who never received a statin.
Further analysis highlighted the importance of an early start to statin treatment in hospitalized patients, and also showed a dose-response relationship. Patients who received at least 60 mg of their statin daily either before hospitalization or both before and during hospitalization had a significantly lower mortality rate, compared with patients who took less than 60 mg/day. Dr. Flint noted that about 70% of patients received lovastatin, and about 20% received simvastatin.
Regarding timing, patients who either began on a statin for the first time or restarted their treatment on their first hospitalized day had a significantly lower 1-year mortality, compared with patients who did not start or restart their statin until their third day in hospital.
Dr. Flint also reported an additional analysis that had been run to determine whether patients' survival prognosis drove their statin treatment instead of their statin treatment's driving their survival.
To do this, he looked at patterns of care at each of the 17 Kaiser Permanente of Northern California hospitals that were involved in the study. This “grouped treatment analysis” demonstrated that although the survival prognosis of patients who were withdrawn from prior statin treatment while hospitalized played some role in the relationship, it was unable to explain all of the survival effect, indicating that statin treatment itself during hospitalization played a significant role in subsequent survival.
The strong impact that early statin treatment during stroke hospitalization has on long-term survival probably depends on the pleiotropic effects of statins. The timing makes it less likely that the effect of statins on lipid levels can explain the observed survival benefits, Dr. Flint said.
'In our study, the question wasn't whether to treat, but the timing. … You should start the statin on day 1.'
Source DR. FLINT
Major Finding: Stroke patients who started on a statin during their acute-phase hospitalization had a 15% absolute reduced rate of death at 1 year, compared with patients never treated with a statin.
Data Source: Review of 12,689 patients enrolled in Kaiser Permanente of Northern California who had an acute ischemic stroke during 2000–2007.
Disclosures: Dr. Flint reported having no relevant disclosures.
LOS ANGELES – Starting or maintaining acute stroke patients on a statin during their initial hospitalization was linked with a dramatic improvement in 1-year survival in a retrospective review of medical records for more than 12,000 U.S. patients.
On the basis of the finding, Kaiser Permanente of Northern California will issue a revised order set that will recommend to physicians that they start acute stroke patients on 80 mg simvastatin as soon as possible on the first day of their hospitalization, Dr. Alexander C. Flint reported at the conference.
“Based on results from the SPARCL [Stroke Prevention by Aggressive Reduction in Cholesterol Levels] trial, pretty much everyone in the stroke community believes that patients who have had an ischemic stroke should be treated with high-dose statin to prevent a second stroke (N. Engl. J. Med. 2006; 355:549–59).
In our study, the question wasn't whether to treat, but the timing. What our results say is that you should not wait until the patient is discharged or is an outpatient, but that you should start the statin on day 1,” Dr. Flint said in an interview.
The data he reported showed that stroke patients who started on a statin during their acute-phase hospitalization had a 15% absolute reduced rate of death during the first year following their stroke, compared with patients who did not start on a statin and did not receive a statin prior to their stroke (Stroke 2011;42:e-42–110).
After adjustment for several possible confounding factors, including age, sex, race and ethnicity, year of stroke, and comorbidities such as hypertension and diabetes, stroke patients who started on a statin while hospitalized had a statistically significant, 45% lower relative risk of death during the subsequent year, compared with patients who did not receive a statin.
The study involved 12,689 patients who received care from Kaiser Permanente of Northern California and had an ischemic stroke during 2000–2007. The total included 3,749 patients who were on steady statin treatment for at least 3 months before their stroke, and 8,940 patients who were not receiving a statin at all before their stroke.
Of the 3,749 patients who were on a statin before their stroke, most (3,280, or 87%) continued to receive a statin during their hospitalization. And among the 8,940 who did not receive regular statin treatment before their stroke, 3,013 (34%) began statin treatment while hospitalized.
Patients who received a statin prior to their stroke but did not continue while hospitalized had a statistically significant 15% relative reduction in their mortality during the following year, compared with patients who never received a statin.
The key element for mortality protection appeared to be treatment while hospitalized. Relative mortality reduction compared with non–statin users was 41% among patients who were on a statin both before their stroke and while hospitalized, and 45% among those who started on a statin while hospitalized, said Dr. Flint, a neurointensivist and stroke specialist at Kaiser Redwood City (Calif.). Patients who received a statin before their stroke but discontinued the drug once hospitalized had the worst outcomes, with a mortality rate that was 2.5 times as high as that of patients who never received a statin.
Further analysis highlighted the importance of an early start to statin treatment in hospitalized patients, and also showed a dose-response relationship. Patients who received at least 60 mg of their statin daily either before hospitalization or both before and during hospitalization had a significantly lower mortality rate, compared with patients who took less than 60 mg/day. Dr. Flint noted that about 70% of patients received lovastatin, and about 20% received simvastatin.
Regarding timing, patients who either began on a statin for the first time or restarted their treatment on their first hospitalized day had a significantly lower 1-year mortality, compared with patients who did not start or restart their statin until their third day in hospital.
Dr. Flint also reported an additional analysis that had been run to determine whether patients' survival prognosis drove their statin treatment instead of their statin treatment's driving their survival.
To do this, he looked at patterns of care at each of the 17 Kaiser Permanente of Northern California hospitals that were involved in the study. This “grouped treatment analysis” demonstrated that although the survival prognosis of patients who were withdrawn from prior statin treatment while hospitalized played some role in the relationship, it was unable to explain all of the survival effect, indicating that statin treatment itself during hospitalization played a significant role in subsequent survival.
The strong impact that early statin treatment during stroke hospitalization has on long-term survival probably depends on the pleiotropic effects of statins. The timing makes it less likely that the effect of statins on lipid levels can explain the observed survival benefits, Dr. Flint said.
'In our study, the question wasn't whether to treat, but the timing. … You should start the statin on day 1.'
Source DR. FLINT
Major Finding: Stroke patients who started on a statin during their acute-phase hospitalization had a 15% absolute reduced rate of death at 1 year, compared with patients never treated with a statin.
Data Source: Review of 12,689 patients enrolled in Kaiser Permanente of Northern California who had an acute ischemic stroke during 2000–2007.
Disclosures: Dr. Flint reported having no relevant disclosures.
LOS ANGELES – Starting or maintaining acute stroke patients on a statin during their initial hospitalization was linked with a dramatic improvement in 1-year survival in a retrospective review of medical records for more than 12,000 U.S. patients.
On the basis of the finding, Kaiser Permanente of Northern California will issue a revised order set that will recommend to physicians that they start acute stroke patients on 80 mg simvastatin as soon as possible on the first day of their hospitalization, Dr. Alexander C. Flint reported at the conference.
“Based on results from the SPARCL [Stroke Prevention by Aggressive Reduction in Cholesterol Levels] trial, pretty much everyone in the stroke community believes that patients who have had an ischemic stroke should be treated with high-dose statin to prevent a second stroke (N. Engl. J. Med. 2006; 355:549–59).
In our study, the question wasn't whether to treat, but the timing. What our results say is that you should not wait until the patient is discharged or is an outpatient, but that you should start the statin on day 1,” Dr. Flint said in an interview.
The data he reported showed that stroke patients who started on a statin during their acute-phase hospitalization had a 15% absolute reduced rate of death during the first year following their stroke, compared with patients who did not start on a statin and did not receive a statin prior to their stroke (Stroke 2011;42:e-42–110).
After adjustment for several possible confounding factors, including age, sex, race and ethnicity, year of stroke, and comorbidities such as hypertension and diabetes, stroke patients who started on a statin while hospitalized had a statistically significant, 45% lower relative risk of death during the subsequent year, compared with patients who did not receive a statin.
The study involved 12,689 patients who received care from Kaiser Permanente of Northern California and had an ischemic stroke during 2000–2007. The total included 3,749 patients who were on steady statin treatment for at least 3 months before their stroke, and 8,940 patients who were not receiving a statin at all before their stroke.
Of the 3,749 patients who were on a statin before their stroke, most (3,280, or 87%) continued to receive a statin during their hospitalization. And among the 8,940 who did not receive regular statin treatment before their stroke, 3,013 (34%) began statin treatment while hospitalized.
Patients who received a statin prior to their stroke but did not continue while hospitalized had a statistically significant 15% relative reduction in their mortality during the following year, compared with patients who never received a statin.
The key element for mortality protection appeared to be treatment while hospitalized. Relative mortality reduction compared with non–statin users was 41% among patients who were on a statin both before their stroke and while hospitalized, and 45% among those who started on a statin while hospitalized, said Dr. Flint, a neurointensivist and stroke specialist at Kaiser Redwood City (Calif.). Patients who received a statin before their stroke but discontinued the drug once hospitalized had the worst outcomes, with a mortality rate that was 2.5 times as high as that of patients who never received a statin.
Further analysis highlighted the importance of an early start to statin treatment in hospitalized patients, and also showed a dose-response relationship. Patients who received at least 60 mg of their statin daily either before hospitalization or both before and during hospitalization had a significantly lower mortality rate, compared with patients who took less than 60 mg/day. Dr. Flint noted that about 70% of patients received lovastatin, and about 20% received simvastatin.
Regarding timing, patients who either began on a statin for the first time or restarted their treatment on their first hospitalized day had a significantly lower 1-year mortality, compared with patients who did not start or restart their statin until their third day in hospital.
Dr. Flint also reported an additional analysis that had been run to determine whether patients' survival prognosis drove their statin treatment instead of their statin treatment's driving their survival.
To do this, he looked at patterns of care at each of the 17 Kaiser Permanente of Northern California hospitals that were involved in the study. This “grouped treatment analysis” demonstrated that although the survival prognosis of patients who were withdrawn from prior statin treatment while hospitalized played some role in the relationship, it was unable to explain all of the survival effect, indicating that statin treatment itself during hospitalization played a significant role in subsequent survival.
The strong impact that early statin treatment during stroke hospitalization has on long-term survival probably depends on the pleiotropic effects of statins. The timing makes it less likely that the effect of statins on lipid levels can explain the observed survival benefits, Dr. Flint said.
'In our study, the question wasn't whether to treat, but the timing. … You should start the statin on day 1.'
Source DR. FLINT