Advertisement
Optimizing Migraine Care

Optimizing Migraine Care

The American Headache Society (AHS) recently joined the Choosing Wisely initiative of the American Board of Internal Medicine in an effort to draw attention to tests and procedures that are associated with low-value care in headache medicine. An AHS committee of headache specialists produced a list of five such tests and treatments, and their methods and rationale were published in Headache. “We wanted the list to address common but often unnecessary or potentially risky tests and treatments for headache that in many cases do not represent evidence-based strategies,” explains Elizabeth W. Loder, MD, MPH, FAHS, who was lead author of the study. Imaging According to the AHS, neuroimaging studies should not be performed in patients with stable headaches who meet criteria for migraine. In addition, CT scans should not be used in non-emergency situations as a diagnostic tool for headache patients when MRI is available. “MRIs can diagnose more underlying conditions that may cause headache that can otherwise be missed with CT,” says Dr. Loder. In addition, MRIs do not expose patients to radiation like CT scans. The recommendations note that MRI is of better value and safer than CT for migraineurs in all but a few emergency situations. Treatments The AHS also recommends against prescribing opioid or butalbital-containing medications as first-line treatment for recurrent headache disorders. “The effectiveness of opioids is not in question,” Dr. Loder explains, “but these agents pose serious long-term risks and should be reserved for select patients. Effective long-term treatments will, in most cases, be necessary to manage this chronic disorder.” In addition, the risk of dependency and abuse associated with opioid or butalbital-containing...
Tackling Heart Failure Readmissions

Tackling Heart Failure Readmissions

According to recent estimates, heart failure (HF) currently affects about 6 million adults in the United States, and the prevalence is projected to increase 25% by 2030. When HF patients are hospitalized, it represents a turning point in the natural history of their disease. “About 25% of HF patients who are discharged from the hospital are readmitted within 30 days,” says Clyde W. Yancy, MD, MSc, FACC. HF patients often need to be readmitted because the underlying cause of HF worsens. Hospitalizations are responsible for the majority of the nearly $40 billion that is spent annually for HF care in the U.S. As a result, these hospitalizations have become a focal point for quality improvement efforts and initiatives aimed at reducing costs. In an effort to improve outcomes, CMS has mandated that hospitals report their 30-day readmission rates for HF and acute myocardial infarction (AMI). The problem with this approach, according to Dr. Yancy, is that public reporting of outcomes is not effective as a hospital performance indicator. “Readmission rates, particularly for HF, are not a good marker of quality of care,” he says. “The emphasis on 30-day readmissions is misguided because the primary driver of these events is often patient population and the community that is served by hospitals.” Clinical investigations have also suggested that public reporting does not provide effective incentives for improvement and has had only minor effects on outcomes. Widespread Concern The changing paradigm to deny payment for HF readmissions within 30 days of discharge has led to widespread concern across hospitals. “Implementing HF programs and readmission reduction strategies are undertakings that require significant analysis,...
Refusal of Curative Care in the ED

Refusal of Curative Care in the ED

Resuscitating and stabilizing acutely ill or injured patients is a top priority for ED personnel, but traditional aggressive approaches to care may sometimes not suit the needs of those with advanced chronic illnesses who present to the ED with critical or terminal events. When seriously ill ED patients decline care targeted to cure disease, it may be challenging to rapidly shift treatment plans, especially if physicians feel unprepared and untrained for such scenarios. Framing the Conversation “When managing seriously ill patients who refuse curative care, it’s important to consider patient decision-making capacity,” says Sangeeta Lamba, MD. Pertinent information and options, including the risks of refusing care, should be provided. Ideally, patients will be able to communicate that they understand this information and verbalize their rationale for refusal based on personal goals. “It’s also important to involve the patient’s family, surrogates, or healthcare proxy,” adds Dr. Lamba. With clinical deterioration, patients may lose their ability to communicate. Others can then assist with decision making, especially if they know what patients value. “ED clinicians should first discuss overall patient goals and values before addressing specific procedures or issues,” Dr. Lamba says. “This information can help physicians frame future conversations and treatment plans to achieve patients’ objectives. It’s vital to understand the ‘why’ behind patient refusal and to use appropriate language and tone when having such conversations.” The ED team should also present viable alternatives if optimal treatment is not desired by patients or their family. Handling Transitions Once goals are clarified, patients may need to be shifted from curative care to a comfort-care approach. This transition must occur seamlessly and be...
Reducing  Poor Surgical  Oncology Practices

Reducing Poor Surgical Oncology Practices

As part of the American Board of Internal Medicine Foundation’s “Choosing Wisely” campaign, the American College of Surgeons (ACS) and the Commission on Cancer (CoC) have developed lists of five measures focusing on tests or procedures that are commonly ordered but not always necessary in surgery and surgical oncology. Although the ACS and CoC developed their own sets of measures, each organization strongly supports the other, according to Stephen B. Edge, MD, FACS, an executive committee member of the CoC. “These measures address the care of different patients,” he says. “The CoC addresses cancer patients in many parts of their care, whereas the ACS addresses all surgical patients.” The Commission on Cancer Measures After vetting a long list of potential measures, the CoC arrived at the measures listed in Table 1. Strong evidence supports using needle biopsy to determine if an abnormal finding may be indicative of breast cancer. Needle biopsy for a worrisome finding on breast imaging or examination improves treatment outcomes when compared with a diagnostic surgical lumpectomy, says Dr. Edge. In 2006, the Institute of Medicine recommended that all patients completing cancer treatment be given a summary of the therapies they received as well as a survivorship care plan. “This recommendation, however, is not being followed for most cancer patients,” Dr. Edge says. “The reasons are multi-faceted and include the time and effort it takes to create these plans and the difficulty in defining exactly how they should be constructed.” He adds that a survivorship plan explaining what tests patients should expect—and informing them that having more tests performed will not help—may reduce anxiety, uncertainty, and...
ADA 2014

ADA 2014

New research is being presented at ADA 2014, the 74th Scientific Sessions of the American Diabetes Association, from June 13-17 in San Francisco.   Meeting Highlights The Effects of Diet on Diabetes Risk Diabetes Missed in Many Asian Americans Can Hepatitis B Vaccination Prevent Diabetes? Long-Term Effects of Diabetes Prevention Is It Depression or Diabetes Distress?   News From ADA 2014 Weekly GLP-1 Agonist Matches Daily Victoza in T2D Targets Tightened for Kids’ Type 1 Diabetes Canola Oil Cuts Heart Risk in Diabetes Victoza Lowers Glucose in Genetic Form of Diabetes Baby Formula Doesn’t Prevent Type 1 Diabetes New Rivals to Top Diabetes Drug Lantus Show Promise in Studies Combination Diabetes Drug Effective After 1 yr-Study Depression Predicts Type 1 Diabetes Death, but Hope Prevails First-Ever ADA Guidance Specifically for Type 1 Diabetes “Bionic Pancreas” Works for 5 Days in Outpatient Settings Statins Not Cost-Effective for Many Newly Eligible Patients Sulfonylureas May Up Fracture Risk in Diabetes, Along With TZDs Girl Power: Islet Transplants from Women Donors Work Better Is Celiac Screening for Kids With Type 1 Diabetes Adequate? ACC/AHA Lipid Guidelines: A Step up in Diabetes Care, or Not? Lipid, Blood Pressure Guidelines in the Spotlight Insulin Analogs: Is Benefit Worth Cost in Type 2 Diabetes? Cutting-Edge Science Tops ADA Agenda in San Francisco   More From ADA 2014 Registration Housing Travel & Transportation General Information 74th Scientific Sessions App Online Itinerary Planner Day-At-a-Glance Schedule Focus on Fellows Abstracts City Information Continuing Education    ...
Page 1 of 212
[ HIDE/SHOW ]