Two European prospective case series published in JAMA Dermatology found no direct association between skin lesions on the hands and feet and SARS-CoV-2 in young people, which raises questions about other contributing factors, such as lockdown conditions, which may be clarified with additional research.

Lindy P. Fox, MD, professor of dermatology at the University of California, San Francisco, who was not an author of either study, urged caution in interpreting these results. Data from the American Academy of Dermatology and a recent paper from the British Journal of Dermatology suggest a real association exists, at in least some patients. “It’s going to be true that most patients with toe lesions are PCR [polymerase chain reaction]-negative because it tends to be a late phenomenon when patients are no longer shedding virus,” Dr. Fox said in an interview.

Reports about chickenpox-like vesicles, urticaria, and other skin lesions in SARS-CoV-2 patients have circulated in the clinical literature and the media. Acute acro-ischemia has been cited as a potential sign of infection in adolescents and children.

One of the European studies, which was published in JAMA Dermatology, explored this association in 20 patients aged 1-18 years (mean age, 12.3 years), who presented with new-onset acral inflammatory lesions in their hands and feet at La Fe University Hospital, in Valencia, during the country’s peak quarantine period in April. Investigators conducted blood tests and reverse transcriptase–PCR (RT-PCR) for SARS-CoV-2, and six patients had skin biopsies.

Juncal Roca-Ginés, MD, of the department of dermatology, at the Hospital Universitario y Politécnico in La Fe, and coauthors, identified acral erythema in 6 (30%) of the cases, dactylitis in 4 (20%), purpuric maculopapules in 7 (35%), and a mixed pattern in 3 (15%). Serologic and viral testing yielded no positive results for SARS-CoV-2 or other viruses, and none of the patients exhibited COVID-19 symptoms such as fever, dry cough, sore throat, myalgia, or taste or smell disorders. In other findings, 45% of the patients had a history of vascular reactive disease of the hands, and 75% reported walking barefoot in their homes while staying at home. Only two patients reported taking medications.

In the six patients who had a biopsy, the findings were characteristic of chillblains, “confirming the clinical impression,” the authors wrote. Concluding that they could not show a relationship between acute acral skin changes and COVID-19, they noted that “other studies with improved microbiologic tests or molecular techniques aimed at demonstrating the presence of SARS-CoV-2 in the skin may help to clarify this problem.”

The other case series, which was also published in JAMA Dermatology and included 31 adults at a hospital in Brussels, who had recently developed chillblains, also looked for a connection between SARS-CoV-2 and chilblains, in April. Most of the participants were in their teens or 20s. Lesions had appeared on hands, feet, or on both extremities within 1-30 days of consultation, presenting as erythematous or purplish erythematous macules, occasionally with central vesicular or bullous lesions or necrotic areas. Patients reported pain, burning, and itching.

Skin biopsies were obtained in 22 patients and confirmed the diagnosis of chilblains; of the 15 with immunofluorescence analyses, 7 patients were found to have vasculitis of small-diameter vessels.

Of the 31 patients, 20 (64%) reported mild symptoms consistent with SARS-CoV-2, yet none of the RT-PCR or serologic test results showed signs of the virus in all 31 patients. “Because some patients had experienced chilblains for more than 15 days [under 30 days or less] at the time of inclusion, we can reasonably exclude the possibility that serologic testing was done too soon,” observed the authors. They also didn’t find eosinopenia, lymphopenia, and hyperferritinemia, which have been associated with COVID-19, they added.

Changes in lifestyle conditions during the pandemic may explain the appearance of these lesions, according to the authors of both studies, who mentioned that walking around in socks or bare feet and reduced physical activity could have indirectly led to the development of skin lesions.

It’s also possible that young people have less severe disease and a delayed reaction to the virus, Ignacio Torres-Navarro, MD, a dermatologist with La Fe University and the Spanish study’s corresponding author, said in an interview. Their feet may lack maturity in neurovascular regulation and/or the eccrine glands, which can happen in other diseases such as neutrophilic idiopathic eccrine hidradenitis. “In this context, perhaps there was an observational bias of the parents to the children when this manifestation was reported in the media. However, nothing has been demonstrated,” he said.

In an accompanying editor’s note, Claudia Hernandez, MD, of the departments of dermatology and pediatrics, Rush University Medical Center, Chicago, and Anna L. Bruckner, MD, of the departments of dermatology and pediatrics at the University of Colorado, Aurora, wrote that “it is still unclear whether a viral cytopathic process vs a viral reaction pattern or other mechanism is responsible for ‘COVID toes.’ ” Lack of confirmatory testing and reliance on indirect evidence of infection complicates this further, they noted, adding that “dermatologists must be aware of the protean cutaneous findings that are possibly associated with COVID-19, even if our understanding of their origins remains incomplete.”

In an interview, Dr. Fox, a member of the AAD’s’s COVID-19 Registry task force, offered other possible reasons for the negative antibody tests in the studies. The assay might not have been testing the correct antigen, or the timing of the test might not have been optimal. “More studies will help this become less controversial,” she said.

The authors of the two case series acknowledged potential limitations of their studies. Neither was large in scope: Both took place over a week’s time and included small cohorts. The Belgian study had no control group or long-term follow-up. Little is still known about the clinical manifestations and detection methods for SARS-CoV-2, noted the authors of the Spanish study.

The Spanish study received funding La Fe University Hospital’s department of dermatology, and the authors had no disclosures. The Belgian study received support from the Fondation Saint-Luc, which provided academic funding for its lead author, Marie Baeck, MD, PhD. Another author of this study received personal fees from the Fondation Saint-Luc and personal fees and nonfinancial support from Bioderma. The authors of the editor’s note had no disclosures.

SOURCES: Roca-Ginés J et al. JAMA Dermatol. 2020 Jun 25. doi: 10.1001/jamadermatol.2020.2340; Herman A et al. JAMA Dermatol. 2020 Jun 25. doi: 10.1001/jamadermatol.2020.2368.

Two European prospective case series published in JAMA Dermatology found no direct association between skin lesions on the hands and feet and SARS-CoV-2 in young people, which raises questions about other contributing factors, such as lockdown conditions, which may be clarified with additional research.

Lindy P. Fox, MD, professor of dermatology at the University of California, San Francisco, who was not an author of either study, urged caution in interpreting these results. Data from the American Academy of Dermatology and a recent paper from the British Journal of Dermatology suggest a real association exists, at in least some patients. “It’s going to be true that most patients with toe lesions are PCR [polymerase chain reaction]-negative because it tends to be a late phenomenon when patients are no longer shedding virus,” Dr. Fox said in an interview.

Reports about chickenpox-like vesicles, urticaria, and other skin lesions in SARS-CoV-2 patients have circulated in the clinical literature and the media. Acute acro-ischemia has been cited as a potential sign of infection in adolescents and children.

One of the European studies, which was published in JAMA Dermatology, explored this association in 20 patients aged 1-18 years (mean age, 12.3 years), who presented with new-onset acral inflammatory lesions in their hands and feet at La Fe University Hospital, in Valencia, during the country’s peak quarantine period in April. Investigators conducted blood tests and reverse transcriptase–PCR (RT-PCR) for SARS-CoV-2, and six patients had skin biopsies.

Juncal Roca-Ginés, MD, of the department of dermatology, at the Hospital Universitario y Politécnico in La Fe, and coauthors, identified acral erythema in 6 (30%) of the cases, dactylitis in 4 (20%), purpuric maculopapules in 7 (35%), and a mixed pattern in 3 (15%). Serologic and viral testing yielded no positive results for SARS-CoV-2 or other viruses, and none of the patients exhibited COVID-19 symptoms such as fever, dry cough, sore throat, myalgia, or taste or smell disorders. In other findings, 45% of the patients had a history of vascular reactive disease of the hands, and 75% reported walking barefoot in their homes while staying at home. Only two patients reported taking medications.

In the six patients who had a biopsy, the findings were characteristic of chillblains, “confirming the clinical impression,” the authors wrote. Concluding that they could not show a relationship between acute acral skin changes and COVID-19, they noted that “other studies with improved microbiologic tests or molecular techniques aimed at demonstrating the presence of SARS-CoV-2 in the skin may help to clarify this problem.”

The other case series, which was also published in JAMA Dermatology and included 31 adults at a hospital in Brussels, who had recently developed chillblains, also looked for a connection between SARS-CoV-2 and chilblains, in April. Most of the participants were in their teens or 20s. Lesions had appeared on hands, feet, or on both extremities within 1-30 days of consultation, presenting as erythematous or purplish erythematous macules, occasionally with central vesicular or bullous lesions or necrotic areas. Patients reported pain, burning, and itching.

Skin biopsies were obtained in 22 patients and confirmed the diagnosis of chilblains; of the 15 with immunofluorescence analyses, 7 patients were found to have vasculitis of small-diameter vessels.

Of the 31 patients, 20 (64%) reported mild symptoms consistent with SARS-CoV-2, yet none of the RT-PCR or serologic test results showed signs of the virus in all 31 patients. “Because some patients had experienced chilblains for more than 15 days [under 30 days or less] at the time of inclusion, we can reasonably exclude the possibility that serologic testing was done too soon,” observed the authors. They also didn’t find eosinopenia, lymphopenia, and hyperferritinemia, which have been associated with COVID-19, they added.

Changes in lifestyle conditions during the pandemic may explain the appearance of these lesions, according to the authors of both studies, who mentioned that walking around in socks or bare feet and reduced physical activity could have indirectly led to the development of skin lesions.

It’s also possible that young people have less severe disease and a delayed reaction to the virus, Ignacio Torres-Navarro, MD, a dermatologist with La Fe University and the Spanish study’s corresponding author, said in an interview. Their feet may lack maturity in neurovascular regulation and/or the eccrine glands, which can happen in other diseases such as neutrophilic idiopathic eccrine hidradenitis. “In this context, perhaps there was an observational bias of the parents to the children when this manifestation was reported in the media. However, nothing has been demonstrated,” he said.

In an accompanying editor’s note, Claudia Hernandez, MD, of the departments of dermatology and pediatrics, Rush University Medical Center, Chicago, and Anna L. Bruckner, MD, of the departments of dermatology and pediatrics at the University of Colorado, Aurora, wrote that “it is still unclear whether a viral cytopathic process vs a viral reaction pattern or other mechanism is responsible for ‘COVID toes.’ ” Lack of confirmatory testing and reliance on indirect evidence of infection complicates this further, they noted, adding that “dermatologists must be aware of the protean cutaneous findings that are possibly associated with COVID-19, even if our understanding of their origins remains incomplete.”

In an interview, Dr. Fox, a member of the AAD’s’s COVID-19 Registry task force, offered other possible reasons for the negative antibody tests in the studies. The assay might not have been testing the correct antigen, or the timing of the test might not have been optimal. “More studies will help this become less controversial,” she said.

The authors of the two case series acknowledged potential limitations of their studies. Neither was large in scope: Both took place over a week’s time and included small cohorts. The Belgian study had no control group or long-term follow-up. Little is still known about the clinical manifestations and detection methods for SARS-CoV-2, noted the authors of the Spanish study.

The Spanish study received funding La Fe University Hospital’s department of dermatology, and the authors had no disclosures. The Belgian study received support from the Fondation Saint-Luc, which provided academic funding for its lead author, Marie Baeck, MD, PhD. Another author of this study received personal fees from the Fondation Saint-Luc and personal fees and nonfinancial support from Bioderma. The authors of the editor’s note had no disclosures.

SOURCES: Roca-Ginés J et al. JAMA Dermatol. 2020 Jun 25. doi: 10.1001/jamadermatol.2020.2340; Herman A et al. JAMA Dermatol. 2020 Jun 25. doi: 10.1001/jamadermatol.2020.2368.

Two European prospective case series published in JAMA Dermatology found no direct association between skin lesions on the hands and feet and SARS-CoV-2 in young people, which raises questions about other contributing factors, such as lockdown conditions, which may be clarified with additional research.

Lindy P. Fox, MD, professor of dermatology at the University of California, San Francisco, who was not an author of either study, urged caution in interpreting these results. Data from the American Academy of Dermatology and a recent paper from the British Journal of Dermatology suggest a real association exists, at in least some patients. “It’s going to be true that most patients with toe lesions are PCR [polymerase chain reaction]-negative because it tends to be a late phenomenon when patients are no longer shedding virus,” Dr. Fox said in an interview.

Reports about chickenpox-like vesicles, urticaria, and other skin lesions in SARS-CoV-2 patients have circulated in the clinical literature and the media. Acute acro-ischemia has been cited as a potential sign of infection in adolescents and children.

One of the European studies, which was published in JAMA Dermatology, explored this association in 20 patients aged 1-18 years (mean age, 12.3 years), who presented with new-onset acral inflammatory lesions in their hands and feet at La Fe University Hospital, in Valencia, during the country’s peak quarantine period in April. Investigators conducted blood tests and reverse transcriptase–PCR (RT-PCR) for SARS-CoV-2, and six patients had skin biopsies.

Juncal Roca-Ginés, MD, of the department of dermatology, at the Hospital Universitario y Politécnico in La Fe, and coauthors, identified acral erythema in 6 (30%) of the cases, dactylitis in 4 (20%), purpuric maculopapules in 7 (35%), and a mixed pattern in 3 (15%). Serologic and viral testing yielded no positive results for SARS-CoV-2 or other viruses, and none of the patients exhibited COVID-19 symptoms such as fever, dry cough, sore throat, myalgia, or taste or smell disorders. In other findings, 45% of the patients had a history of vascular reactive disease of the hands, and 75% reported walking barefoot in their homes while staying at home. Only two patients reported taking medications.

In the six patients who had a biopsy, the findings were characteristic of chillblains, “confirming the clinical impression,” the authors wrote. Concluding that they could not show a relationship between acute acral skin changes and COVID-19, they noted that “other studies with improved microbiologic tests or molecular techniques aimed at demonstrating the presence of SARS-CoV-2 in the skin may help to clarify this problem.”

The other case series, which was also published in JAMA Dermatology and included 31 adults at a hospital in Brussels, who had recently developed chillblains, also looked for a connection between SARS-CoV-2 and chilblains, in April. Most of the participants were in their teens or 20s. Lesions had appeared on hands, feet, or on both extremities within 1-30 days of consultation, presenting as erythematous or purplish erythematous macules, occasionally with central vesicular or bullous lesions or necrotic areas. Patients reported pain, burning, and itching.

Skin biopsies were obtained in 22 patients and confirmed the diagnosis of chilblains; of the 15 with immunofluorescence analyses, 7 patients were found to have vasculitis of small-diameter vessels.

Of the 31 patients, 20 (64%) reported mild symptoms consistent with SARS-CoV-2, yet none of the RT-PCR or serologic test results showed signs of the virus in all 31 patients. “Because some patients had experienced chilblains for more than 15 days [under 30 days or less] at the time of inclusion, we can reasonably exclude the possibility that serologic testing was done too soon,” observed the authors. They also didn’t find eosinopenia, lymphopenia, and hyperferritinemia, which have been associated with COVID-19, they added.

Changes in lifestyle conditions during the pandemic may explain the appearance of these lesions, according to the authors of both studies, who mentioned that walking around in socks or bare feet and reduced physical activity could have indirectly led to the development of skin lesions.

It’s also possible that young people have less severe disease and a delayed reaction to the virus, Ignacio Torres-Navarro, MD, a dermatologist with La Fe University and the Spanish study’s corresponding author, said in an interview. Their feet may lack maturity in neurovascular regulation and/or the eccrine glands, which can happen in other diseases such as neutrophilic idiopathic eccrine hidradenitis. “In this context, perhaps there was an observational bias of the parents to the children when this manifestation was reported in the media. However, nothing has been demonstrated,” he said.

In an accompanying editor’s note, Claudia Hernandez, MD, of the departments of dermatology and pediatrics, Rush University Medical Center, Chicago, and Anna L. Bruckner, MD, of the departments of dermatology and pediatrics at the University of Colorado, Aurora, wrote that “it is still unclear whether a viral cytopathic process vs a viral reaction pattern or other mechanism is responsible for ‘COVID toes.’ ” Lack of confirmatory testing and reliance on indirect evidence of infection complicates this further, they noted, adding that “dermatologists must be aware of the protean cutaneous findings that are possibly associated with COVID-19, even if our understanding of their origins remains incomplete.”

In an interview, Dr. Fox, a member of the AAD’s’s COVID-19 Registry task force, offered other possible reasons for the negative antibody tests in the studies. The assay might not have been testing the correct antigen, or the timing of the test might not have been optimal. “More studies will help this become less controversial,” she said.

The authors of the two case series acknowledged potential limitations of their studies. Neither was large in scope: Both took place over a week’s time and included small cohorts. The Belgian study had no control group or long-term follow-up. Little is still known about the clinical manifestations and detection methods for SARS-CoV-2, noted the authors of the Spanish study.

The Spanish study received funding La Fe University Hospital’s department of dermatology, and the authors had no disclosures. The Belgian study received support from the Fondation Saint-Luc, which provided academic funding for its lead author, Marie Baeck, MD, PhD. Another author of this study received personal fees from the Fondation Saint-Luc and personal fees and nonfinancial support from Bioderma. The authors of the editor’s note had no disclosures.

SOURCES: Roca-Ginés J et al. JAMA Dermatol. 2020 Jun 25. doi: 10.1001/jamadermatol.2020.2340; Herman A et al. JAMA Dermatol. 2020 Jun 25. doi: 10.1001/jamadermatol.2020.2368.

Coronary revascularization does not confer a survival advantage over initial medical therapy in patients with stable ischemic heart disease (SIHD) but reduces unstable angina, according to a new study-level meta-analysis.

Routine upfront revascularization is also associated with less spontaneous myocardial infarction but this is at the cost of increased procedural infarctions, reported lead investigator Sripal Bangalore, MD, of New York University.

“These relationships should be taken into consideration for shared decision-making for the management of patients with stable ischemic heart disease,” he said in a late-breaking trial session at PCR e-Course 2020, the virtual meeting of the Congress of European Association of Percutaneous Cardiovascular Interventions (EuroPCR).

The results, simultaneously published in Circulation, are consistent with last year’s ISCHEMIA trial and other contemporary trials, such as COURAGE, FAME 2, and BARI 2D, that have failed to show a reduction in mortality with revascularization alone in SIHD. Guidelines continue, however, to recommend revascularization to improve survival in SIHD based on trials performed in the 1980s when medical therapy was limited, Dr. Bangalore observed.

The updated meta-analysis included 14 randomized controlled trials, including the aforementioned, and 14,877 patients followed for a weighted mean of 4.5 years. Most trials enrolled patients who had preserved left ventricular function and low symptom burden (Canadian Cardiovascular Society Class I/II).

In the revascularization group, 87.5% of patients underwent any revascularization. Percutaneous coronary intervention (PCI) was the first procedure in 71.3% and bypass surgery the first choice in 16.2%. In eight trials, stents were used in at least 50% of PCI patients; drug-eluting stents were mainly used in FAME 2, ISCHEMIA, and ISCHEMIA-CKD.

In eight trials, statins were used in at least 50% of patients. Nearly 1 in 3 patients (31.9%) treated initially with medical therapy underwent revascularization during follow-up.

Results show no reduction in mortality risk with routine revascularization in the overall analysis (relative risk, 0.99; 95% confidence interval, 0.90-1.09) or when analyzed by whether studies did or did not use stents (P for interaction = .85).

Trial sequential analysis also showed that the cumulative z-curve crossed the futility boundary, “suggesting we have great data to show that there is lack of even a 10% reduction in death with revascularization,” Dr. Bangalore said.

Results were very similar for cardiovascular death (RR, 0.92; 95% CI, 0.80-1.06), including when analyzed by study stent status (P for interaction = .60).

There was no significant reduction in overall MI risk with revascularization, although a borderline significant 11% decrease in MIs was found in the contemporary stent era trials (RR, 0.89; 95% CI, 0.80-0.998).

Revascularization was associated with a 148% increase in the risk of procedural MI (RR, 2.48; 95% CI, 1.86-3.31) but reduced risk of spontaneous MI (RR, 0.76; 95% CI, 0.67-0.85).

Unstable angina was reduced in patients undergoing revascularization (RR, 0.64; 95% CI, 0.45-0.92), driven by a 55% reduction in the contemporary stent era trials. Freedom from angina was also greater with routine revascularization but the difference was modest, Dr. Bangalore said. There was no difference between the two strategies in heart failure or stroke.

“This meta-analysis is well done but really doesn’t change what we already know,” Rasha Al-Lamee, MBBS, of Imperial College, London, said in an interview. “The most important message is that intervention in stable CAD does not change survival. We don’t need to rush to intervene: We have time to plan the best strategy for each patient and to modify our plans based on their response.”

The analysis addresses some of the issues with previous meta-analyses that have included trials that were not strictly stable CAD trials such as SWISSI-2, COMPARE-ACUTE, and DANAMI-3-PRIMULTI, she noted. “However a study like this is only as good as the trials that are included. We must remember that unblinded trials really cannot be used to accurately assess endpoints that are prone to bias such as unstable angina and freedom from angina.”

Following the presentation, dedicated discussant Davide Capodanno, MD, PhD, of the University of Catania (Italy) said, “We have seen beyond any doubt that there is no difference in mortality. For cardiovascular death, it’s pretty much the same. It’s a little bit more mixed and nuanced, the story of myocardial infarction.”

“Additional science is needed to understand the prognostic implications,” he said. “Of course we know that spontaneous myocardial infarction is bad, but I’m not so sure about periprocedural MI. Is this something that is as important as spontaneous myocardial infarction?”

The meta-analysis is the largest ever performed, but there was clinical heterogeneity in the individual studies, especially in the definition of MI, Dr. Capodanno observed. Because of the use of trial-level data rather than patient-level data, the analysis also could not account for adherence to treatment or the effect of stent type or medication dosage.

The MI issue really depends on the trial definition of MI, Dr. Al-Lamee said. “We need long-term follow-up from ISCHEMIA to understand what it means for our patients. While revascularization clearly increases procedural MI rates, it also results in lower spontaneous MI rates with no impact on overall MI or death,” she said. “We will only know if these MIs are important if we see what impact they have in the long term.”

Although the meta-analysis combined data from several decades, it’s likely that the outdated revascularization techniques in the older trials are balanced out by the outdated medical therapy in the same trials, Dr. Al-Lamee observed.

The new findings can certainly be used in patient-physician discussions, with more follow-up from ISCHEMIA to provide additional insights, she said.

“We will of course hear more about the placebo-controlled efficacy of PCI in the blinded ORBITA-2 trial. And I would really like to see some of the older studies of patients and perceptions of the effect of PCI repeated,” Dr. Al-Lamee said. “Now we have more data, are we informing our patients and referrers correctly of the impact of our procedures, and do they truly choose revascularization with a true awareness of what it does and does not do?”

Dr. Bangalore reported grants from the National Heart, Lung, and Blood Institute and Abbott Vascular; and serving on the advisory boards of Abbott Vascular, Biotronik, Meril, SMT, Pfizer, Amgen, and Reata. Dr. Al-Lamee reported speaker’s honorarium from Philips Volcano and Menarini Pharmaceuticals. Dr. Capodanno has disclosed no relevant financial relationships.

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

Coronary revascularization does not confer a survival advantage over initial medical therapy in patients with stable ischemic heart disease (SIHD) but reduces unstable angina, according to a new study-level meta-analysis.

Routine upfront revascularization is also associated with less spontaneous myocardial infarction but this is at the cost of increased procedural infarctions, reported lead investigator Sripal Bangalore, MD, of New York University.

“These relationships should be taken into consideration for shared decision-making for the management of patients with stable ischemic heart disease,” he said in a late-breaking trial session at PCR e-Course 2020, the virtual meeting of the Congress of European Association of Percutaneous Cardiovascular Interventions (EuroPCR).

The results, simultaneously published in Circulation, are consistent with last year’s ISCHEMIA trial and other contemporary trials, such as COURAGE, FAME 2, and BARI 2D, that have failed to show a reduction in mortality with revascularization alone in SIHD. Guidelines continue, however, to recommend revascularization to improve survival in SIHD based on trials performed in the 1980s when medical therapy was limited, Dr. Bangalore observed.

The updated meta-analysis included 14 randomized controlled trials, including the aforementioned, and 14,877 patients followed for a weighted mean of 4.5 years. Most trials enrolled patients who had preserved left ventricular function and low symptom burden (Canadian Cardiovascular Society Class I/II).

In the revascularization group, 87.5% of patients underwent any revascularization. Percutaneous coronary intervention (PCI) was the first procedure in 71.3% and bypass surgery the first choice in 16.2%. In eight trials, stents were used in at least 50% of PCI patients; drug-eluting stents were mainly used in FAME 2, ISCHEMIA, and ISCHEMIA-CKD.

In eight trials, statins were used in at least 50% of patients. Nearly 1 in 3 patients (31.9%) treated initially with medical therapy underwent revascularization during follow-up.

Results show no reduction in mortality risk with routine revascularization in the overall analysis (relative risk, 0.99; 95% confidence interval, 0.90-1.09) or when analyzed by whether studies did or did not use stents (P for interaction = .85).

Trial sequential analysis also showed that the cumulative z-curve crossed the futility boundary, “suggesting we have great data to show that there is lack of even a 10% reduction in death with revascularization,” Dr. Bangalore said.

Results were very similar for cardiovascular death (RR, 0.92; 95% CI, 0.80-1.06), including when analyzed by study stent status (P for interaction = .60).

There was no significant reduction in overall MI risk with revascularization, although a borderline significant 11% decrease in MIs was found in the contemporary stent era trials (RR, 0.89; 95% CI, 0.80-0.998).

Revascularization was associated with a 148% increase in the risk of procedural MI (RR, 2.48; 95% CI, 1.86-3.31) but reduced risk of spontaneous MI (RR, 0.76; 95% CI, 0.67-0.85).

Unstable angina was reduced in patients undergoing revascularization (RR, 0.64; 95% CI, 0.45-0.92), driven by a 55% reduction in the contemporary stent era trials. Freedom from angina was also greater with routine revascularization but the difference was modest, Dr. Bangalore said. There was no difference between the two strategies in heart failure or stroke.

“This meta-analysis is well done but really doesn’t change what we already know,” Rasha Al-Lamee, MBBS, of Imperial College, London, said in an interview. “The most important message is that intervention in stable CAD does not change survival. We don’t need to rush to intervene: We have time to plan the best strategy for each patient and to modify our plans based on their response.”

The analysis addresses some of the issues with previous meta-analyses that have included trials that were not strictly stable CAD trials such as SWISSI-2, COMPARE-ACUTE, and DANAMI-3-PRIMULTI, she noted. “However a study like this is only as good as the trials that are included. We must remember that unblinded trials really cannot be used to accurately assess endpoints that are prone to bias such as unstable angina and freedom from angina.”

Following the presentation, dedicated discussant Davide Capodanno, MD, PhD, of the University of Catania (Italy) said, “We have seen beyond any doubt that there is no difference in mortality. For cardiovascular death, it’s pretty much the same. It’s a little bit more mixed and nuanced, the story of myocardial infarction.”

“Additional science is needed to understand the prognostic implications,” he said. “Of course we know that spontaneous myocardial infarction is bad, but I’m not so sure about periprocedural MI. Is this something that is as important as spontaneous myocardial infarction?”

The meta-analysis is the largest ever performed, but there was clinical heterogeneity in the individual studies, especially in the definition of MI, Dr. Capodanno observed. Because of the use of trial-level data rather than patient-level data, the analysis also could not account for adherence to treatment or the effect of stent type or medication dosage.

The MI issue really depends on the trial definition of MI, Dr. Al-Lamee said. “We need long-term follow-up from ISCHEMIA to understand what it means for our patients. While revascularization clearly increases procedural MI rates, it also results in lower spontaneous MI rates with no impact on overall MI or death,” she said. “We will only know if these MIs are important if we see what impact they have in the long term.”

Although the meta-analysis combined data from several decades, it’s likely that the outdated revascularization techniques in the older trials are balanced out by the outdated medical therapy in the same trials, Dr. Al-Lamee observed.

The new findings can certainly be used in patient-physician discussions, with more follow-up from ISCHEMIA to provide additional insights, she said.

“We will of course hear more about the placebo-controlled efficacy of PCI in the blinded ORBITA-2 trial. And I would really like to see some of the older studies of patients and perceptions of the effect of PCI repeated,” Dr. Al-Lamee said. “Now we have more data, are we informing our patients and referrers correctly of the impact of our procedures, and do they truly choose revascularization with a true awareness of what it does and does not do?”

Dr. Bangalore reported grants from the National Heart, Lung, and Blood Institute and Abbott Vascular; and serving on the advisory boards of Abbott Vascular, Biotronik, Meril, SMT, Pfizer, Amgen, and Reata. Dr. Al-Lamee reported speaker’s honorarium from Philips Volcano and Menarini Pharmaceuticals. Dr. Capodanno has disclosed no relevant financial relationships.

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

Coronary revascularization does not confer a survival advantage over initial medical therapy in patients with stable ischemic heart disease (SIHD) but reduces unstable angina, according to a new study-level meta-analysis.

Routine upfront revascularization is also associated with less spontaneous myocardial infarction but this is at the cost of increased procedural infarctions, reported lead investigator Sripal Bangalore, MD, of New York University.

“These relationships should be taken into consideration for shared decision-making for the management of patients with stable ischemic heart disease,” he said in a late-breaking trial session at PCR e-Course 2020, the virtual meeting of the Congress of European Association of Percutaneous Cardiovascular Interventions (EuroPCR).

The results, simultaneously published in Circulation, are consistent with last year’s ISCHEMIA trial and other contemporary trials, such as COURAGE, FAME 2, and BARI 2D, that have failed to show a reduction in mortality with revascularization alone in SIHD. Guidelines continue, however, to recommend revascularization to improve survival in SIHD based on trials performed in the 1980s when medical therapy was limited, Dr. Bangalore observed.

The updated meta-analysis included 14 randomized controlled trials, including the aforementioned, and 14,877 patients followed for a weighted mean of 4.5 years. Most trials enrolled patients who had preserved left ventricular function and low symptom burden (Canadian Cardiovascular Society Class I/II).

In the revascularization group, 87.5% of patients underwent any revascularization. Percutaneous coronary intervention (PCI) was the first procedure in 71.3% and bypass surgery the first choice in 16.2%. In eight trials, stents were used in at least 50% of PCI patients; drug-eluting stents were mainly used in FAME 2, ISCHEMIA, and ISCHEMIA-CKD.

In eight trials, statins were used in at least 50% of patients. Nearly 1 in 3 patients (31.9%) treated initially with medical therapy underwent revascularization during follow-up.

Results show no reduction in mortality risk with routine revascularization in the overall analysis (relative risk, 0.99; 95% confidence interval, 0.90-1.09) or when analyzed by whether studies did or did not use stents (P for interaction = .85).

Trial sequential analysis also showed that the cumulative z-curve crossed the futility boundary, “suggesting we have great data to show that there is lack of even a 10% reduction in death with revascularization,” Dr. Bangalore said.

Results were very similar for cardiovascular death (RR, 0.92; 95% CI, 0.80-1.06), including when analyzed by study stent status (P for interaction = .60).

There was no significant reduction in overall MI risk with revascularization, although a borderline significant 11% decrease in MIs was found in the contemporary stent era trials (RR, 0.89; 95% CI, 0.80-0.998).

Revascularization was associated with a 148% increase in the risk of procedural MI (RR, 2.48; 95% CI, 1.86-3.31) but reduced risk of spontaneous MI (RR, 0.76; 95% CI, 0.67-0.85).

Unstable angina was reduced in patients undergoing revascularization (RR, 0.64; 95% CI, 0.45-0.92), driven by a 55% reduction in the contemporary stent era trials. Freedom from angina was also greater with routine revascularization but the difference was modest, Dr. Bangalore said. There was no difference between the two strategies in heart failure or stroke.

“This meta-analysis is well done but really doesn’t change what we already know,” Rasha Al-Lamee, MBBS, of Imperial College, London, said in an interview. “The most important message is that intervention in stable CAD does not change survival. We don’t need to rush to intervene: We have time to plan the best strategy for each patient and to modify our plans based on their response.”

The analysis addresses some of the issues with previous meta-analyses that have included trials that were not strictly stable CAD trials such as SWISSI-2, COMPARE-ACUTE, and DANAMI-3-PRIMULTI, she noted. “However a study like this is only as good as the trials that are included. We must remember that unblinded trials really cannot be used to accurately assess endpoints that are prone to bias such as unstable angina and freedom from angina.”

Following the presentation, dedicated discussant Davide Capodanno, MD, PhD, of the University of Catania (Italy) said, “We have seen beyond any doubt that there is no difference in mortality. For cardiovascular death, it’s pretty much the same. It’s a little bit more mixed and nuanced, the story of myocardial infarction.”

“Additional science is needed to understand the prognostic implications,” he said. “Of course we know that spontaneous myocardial infarction is bad, but I’m not so sure about periprocedural MI. Is this something that is as important as spontaneous myocardial infarction?”

The meta-analysis is the largest ever performed, but there was clinical heterogeneity in the individual studies, especially in the definition of MI, Dr. Capodanno observed. Because of the use of trial-level data rather than patient-level data, the analysis also could not account for adherence to treatment or the effect of stent type or medication dosage.

The MI issue really depends on the trial definition of MI, Dr. Al-Lamee said. “We need long-term follow-up from ISCHEMIA to understand what it means for our patients. While revascularization clearly increases procedural MI rates, it also results in lower spontaneous MI rates with no impact on overall MI or death,” she said. “We will only know if these MIs are important if we see what impact they have in the long term.”

Although the meta-analysis combined data from several decades, it’s likely that the outdated revascularization techniques in the older trials are balanced out by the outdated medical therapy in the same trials, Dr. Al-Lamee observed.

The new findings can certainly be used in patient-physician discussions, with more follow-up from ISCHEMIA to provide additional insights, she said.

“We will of course hear more about the placebo-controlled efficacy of PCI in the blinded ORBITA-2 trial. And I would really like to see some of the older studies of patients and perceptions of the effect of PCI repeated,” Dr. Al-Lamee said. “Now we have more data, are we informing our patients and referrers correctly of the impact of our procedures, and do they truly choose revascularization with a true awareness of what it does and does not do?”

Dr. Bangalore reported grants from the National Heart, Lung, and Blood Institute and Abbott Vascular; and serving on the advisory boards of Abbott Vascular, Biotronik, Meril, SMT, Pfizer, Amgen, and Reata. Dr. Al-Lamee reported speaker’s honorarium from Philips Volcano and Menarini Pharmaceuticals. Dr. Capodanno has disclosed no relevant financial relationships.

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

Background: The transgender population historically has not been identified in population research. Little is known about their health care needs.

Dr. Hoegh is a hospitalist at the University of Colorado at Denver, Aurora.

Background: The transgender population historically has not been identified in population research. Little is known about their health care needs.

Dr. Hoegh is a hospitalist at the University of Colorado at Denver, Aurora.

Background: The transgender population historically has not been identified in population research. Little is known about their health care needs.

Dr. Hoegh is a hospitalist at the University of Colorado at Denver, Aurora.

Fibroepithelial polyp of the hypopharynx

Our patient underwent an upper endoscopy to evaluate symptoms of refractory gastroesophageal reflux disease and was found to have a large hiatal hernia. Upon careful endoscopic withdrawal, the polyp was briefly visualized as it was pulled back into the oropharynx. The patient was referred for flexible laryngoscopy that confirmed a polypoid mass involving the right lateral piriform wall. She subsequently underwent direct laryngoscopy with harmonic scalpel-assisted excision of the lesion leading to resolution of her symptom of oropharyngeal dysphagia. The surgical specimen measured 3 × 1.4 × 0.4 cm. Pathology demonstrated benign overlying squamous mucosa with submucosa composed of bland spindle cells and fat, consistent with a benign fibroepithelial polyp (Figure C, original magnification × 100; stain: hematoxylin and eosin).

Fibroepithelial polyps are rare benign lesions of the hypopharynx and proximal esophagus that can lead to oropharyngeal dysphagia.¹ Larger hypopharyngeal polyps have been associated with aspiration and airway compromise.¹ Owing to their proximal location, these lesions are more readily identified under flexible laryngoscopy, but can also be observed with esophagogastroduodenoscopy. Cross-sectional imaging of the neck can be considered for patients with oropharyngeal dysphagia and a normal video-swallow study. Although the underlying pathogenesis remains unclear, inflammation or infection may play a role, especially in smokers.² The rate of recurrence after resection is low.¹

Further evaluation for her symptomatic hiatal hernia was performed and the patient ultimately underwent a laparoscopic Nissen fundoplication with wedge gastroplasty, leading to improvement in her symptoms of gastroesophageal reflux disease. This case illustrates that, although esophagogastroduodenoscopy is not considered the first step in the evaluation of patients with oropharyngeal dysphagia, a careful examination can sometimes reveal the diagnosis.
 

References

1. Caceres M, et al. Large pedunculated polyps originating in the esophagus and hypopharynx. Ann Thorac Surg. 2006;81:393-6.

2. Maskey AP, et al. Endobronchial fibroepithelial polyp. J Bronchology Interv Pulmonol. 2012;19:313-4.

ginews@gastro.org

Fibroepithelial polyp of the hypopharynx

Our patient underwent an upper endoscopy to evaluate symptoms of refractory gastroesophageal reflux disease and was found to have a large hiatal hernia. Upon careful endoscopic withdrawal, the polyp was briefly visualized as it was pulled back into the oropharynx. The patient was referred for flexible laryngoscopy that confirmed a polypoid mass involving the right lateral piriform wall. She subsequently underwent direct laryngoscopy with harmonic scalpel-assisted excision of the lesion leading to resolution of her symptom of oropharyngeal dysphagia. The surgical specimen measured 3 × 1.4 × 0.4 cm. Pathology demonstrated benign overlying squamous mucosa with submucosa composed of bland spindle cells and fat, consistent with a benign fibroepithelial polyp (Figure C, original magnification × 100; stain: hematoxylin and eosin).

Fibroepithelial polyps are rare benign lesions of the hypopharynx and proximal esophagus that can lead to oropharyngeal dysphagia.¹ Larger hypopharyngeal polyps have been associated with aspiration and airway compromise.¹ Owing to their proximal location, these lesions are more readily identified under flexible laryngoscopy, but can also be observed with esophagogastroduodenoscopy. Cross-sectional imaging of the neck can be considered for patients with oropharyngeal dysphagia and a normal video-swallow study. Although the underlying pathogenesis remains unclear, inflammation or infection may play a role, especially in smokers.² The rate of recurrence after resection is low.¹

Further evaluation for her symptomatic hiatal hernia was performed and the patient ultimately underwent a laparoscopic Nissen fundoplication with wedge gastroplasty, leading to improvement in her symptoms of gastroesophageal reflux disease. This case illustrates that, although esophagogastroduodenoscopy is not considered the first step in the evaluation of patients with oropharyngeal dysphagia, a careful examination can sometimes reveal the diagnosis.
 

References

1. Caceres M, et al. Large pedunculated polyps originating in the esophagus and hypopharynx. Ann Thorac Surg. 2006;81:393-6.

2. Maskey AP, et al. Endobronchial fibroepithelial polyp. J Bronchology Interv Pulmonol. 2012;19:313-4.

ginews@gastro.org

Fibroepithelial polyp of the hypopharynx

Our patient underwent an upper endoscopy to evaluate symptoms of refractory gastroesophageal reflux disease and was found to have a large hiatal hernia. Upon careful endoscopic withdrawal, the polyp was briefly visualized as it was pulled back into the oropharynx. The patient was referred for flexible laryngoscopy that confirmed a polypoid mass involving the right lateral piriform wall. She subsequently underwent direct laryngoscopy with harmonic scalpel-assisted excision of the lesion leading to resolution of her symptom of oropharyngeal dysphagia. The surgical specimen measured 3 × 1.4 × 0.4 cm. Pathology demonstrated benign overlying squamous mucosa with submucosa composed of bland spindle cells and fat, consistent with a benign fibroepithelial polyp (Figure C, original magnification × 100; stain: hematoxylin and eosin).

Fibroepithelial polyps are rare benign lesions of the hypopharynx and proximal esophagus that can lead to oropharyngeal dysphagia.¹ Larger hypopharyngeal polyps have been associated with aspiration and airway compromise.¹ Owing to their proximal location, these lesions are more readily identified under flexible laryngoscopy, but can also be observed with esophagogastroduodenoscopy. Cross-sectional imaging of the neck can be considered for patients with oropharyngeal dysphagia and a normal video-swallow study. Although the underlying pathogenesis remains unclear, inflammation or infection may play a role, especially in smokers.² The rate of recurrence after resection is low.¹

Further evaluation for her symptomatic hiatal hernia was performed and the patient ultimately underwent a laparoscopic Nissen fundoplication with wedge gastroplasty, leading to improvement in her symptoms of gastroesophageal reflux disease. This case illustrates that, although esophagogastroduodenoscopy is not considered the first step in the evaluation of patients with oropharyngeal dysphagia, a careful examination can sometimes reveal the diagnosis.
 

References

1. Caceres M, et al. Large pedunculated polyps originating in the esophagus and hypopharynx. Ann Thorac Surg. 2006;81:393-6.

2. Maskey AP, et al. Endobronchial fibroepithelial polyp. J Bronchology Interv Pulmonol. 2012;19:313-4.

ginews@gastro.org

An annular morphology was appreciated on close inspection and small pustules were seen at the edges—features consistent with tinea faciei, a fungal infection of facial skin. A skin exam did not reveal any scaling or erythema on the scalp, hands, feet, trunk, or nails. The diagnosis was confirmed during the visit with a skin scraping and examination in potassium hydroxide with parker pen blue ink (Swartz-Lamkins stain) which revealed hyphae. The diagnosis was made with the knowledge that a history of eczema increases the risk of fungal, viral, and bacterial infections due to an impaired skin barrier.

Tinea faciei is an uncommon diagnosis that often is misdiagnosed as facial dermatitis, rosacea, or acne. The differential diagnosis also includes discoid lupus and psoriasis. Rarely is the annular presentation as obvious as it was here. Diagnosing tinea faciei in a patient can be made more challenging if the patient is already being treated with steroids. That’s because the steroids may decrease the clinical signs of tinea and allow subtle, slow progression of disease.

The location of fungal disease has implications for treatment. While some cases of tinea faciei may respond to topical antifungals, involvement of the eyebrows and glandular structures of the mid-face are beyond the depth of penetration of topical formulations. In these cases, systemic antifungals such as terbinafine, griseofulvin, or itraconazole are more effective.

Because of eyebrow and glandular involvement, this patient was given oral terbinafine 250 mg/d for 3 weeks and the lesion cleared completely in that time.

‌

Photos and text for Photo Rounds Friday courtesy of Jonathan Karnes, MD (copyright retained). Dr. Karnes is the medical director of MDFMR Dermatology Services, Augusta, ME.

An annular morphology was appreciated on close inspection and small pustules were seen at the edges—features consistent with tinea faciei, a fungal infection of facial skin. A skin exam did not reveal any scaling or erythema on the scalp, hands, feet, trunk, or nails. The diagnosis was confirmed during the visit with a skin scraping and examination in potassium hydroxide with parker pen blue ink (Swartz-Lamkins stain) which revealed hyphae. The diagnosis was made with the knowledge that a history of eczema increases the risk of fungal, viral, and bacterial infections due to an impaired skin barrier.

Tinea faciei is an uncommon diagnosis that often is misdiagnosed as facial dermatitis, rosacea, or acne. The differential diagnosis also includes discoid lupus and psoriasis. Rarely is the annular presentation as obvious as it was here. Diagnosing tinea faciei in a patient can be made more challenging if the patient is already being treated with steroids. That’s because the steroids may decrease the clinical signs of tinea and allow subtle, slow progression of disease.

The location of fungal disease has implications for treatment. While some cases of tinea faciei may respond to topical antifungals, involvement of the eyebrows and glandular structures of the mid-face are beyond the depth of penetration of topical formulations. In these cases, systemic antifungals such as terbinafine, griseofulvin, or itraconazole are more effective.

Because of eyebrow and glandular involvement, this patient was given oral terbinafine 250 mg/d for 3 weeks and the lesion cleared completely in that time.

‌

Photos and text for Photo Rounds Friday courtesy of Jonathan Karnes, MD (copyright retained). Dr. Karnes is the medical director of MDFMR Dermatology Services, Augusta, ME.

An annular morphology was appreciated on close inspection and small pustules were seen at the edges—features consistent with tinea faciei, a fungal infection of facial skin. A skin exam did not reveal any scaling or erythema on the scalp, hands, feet, trunk, or nails. The diagnosis was confirmed during the visit with a skin scraping and examination in potassium hydroxide with parker pen blue ink (Swartz-Lamkins stain) which revealed hyphae. The diagnosis was made with the knowledge that a history of eczema increases the risk of fungal, viral, and bacterial infections due to an impaired skin barrier.

Tinea faciei is an uncommon diagnosis that often is misdiagnosed as facial dermatitis, rosacea, or acne. The differential diagnosis also includes discoid lupus and psoriasis. Rarely is the annular presentation as obvious as it was here. Diagnosing tinea faciei in a patient can be made more challenging if the patient is already being treated with steroids. That’s because the steroids may decrease the clinical signs of tinea and allow subtle, slow progression of disease.

The location of fungal disease has implications for treatment. While some cases of tinea faciei may respond to topical antifungals, involvement of the eyebrows and glandular structures of the mid-face are beyond the depth of penetration of topical formulations. In these cases, systemic antifungals such as terbinafine, griseofulvin, or itraconazole are more effective.

Because of eyebrow and glandular involvement, this patient was given oral terbinafine 250 mg/d for 3 weeks and the lesion cleared completely in that time.

‌

Photos and text for Photo Rounds Friday courtesy of Jonathan Karnes, MD (copyright retained). Dr. Karnes is the medical director of MDFMR Dermatology Services, Augusta, ME.

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

CASE CONTINUED

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

Reducing the Risk for Cardiovascular Conditions

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

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

Setting and Meeting BP Goals

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

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

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

Continue to: Monitor the patient's BP

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

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

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

CASE CONTINUED

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

Reducing the Risk for Cardiovascular Conditions

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

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

Setting and Meeting BP Goals

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

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

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

Continue to: Monitor the patient's BP

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

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

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

CASE CONTINUED

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

Reducing the Risk for Cardiovascular Conditions

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

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

Setting and Meeting BP Goals

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

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

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

Continue to: Monitor the patient's BP

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

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

Dear colleagues,

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

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

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

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

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

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

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

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

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

Dear colleagues,

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

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

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

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

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

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

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

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

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

Dear colleagues,

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Kimberly Orleck, PA-C

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Kimberly Orleck, PA-C

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Kimberly Orleck, PA-C

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

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

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

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

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

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

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

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

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

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

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

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

Stay informed about state and federal policies

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

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

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

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

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

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

Make plans, be flexible

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

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

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

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

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

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

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

Old financial models may no longer work

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

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

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

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

Focused on the future

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

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

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

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

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

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

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

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

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

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

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

Stay informed about state and federal policies

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

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

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

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

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

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

Make plans, be flexible

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

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

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

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

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

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

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

Old financial models may no longer work

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

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

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

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

Focused on the future

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

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

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

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

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

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

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

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

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

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

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

Stay informed about state and federal policies

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

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

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

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

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

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

Make plans, be flexible

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

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

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

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

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

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

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

Old financial models may no longer work

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

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

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

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

Focused on the future

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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