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ASCO 2013: Cancer Care Costs: A Look at Patient Expectations

The Particulars: Research indicates that patients who receive cancer treatment can experience significant financial distress. However, studies have not determined how well patients are informed about their costs of care. Data Breakdown: In a survey of insured adults with solid tumors who were receiving anticancer therapy for 1 month or longer, 19% reported high or overwhelming financial distress. When compared with expected levels of financial burden, 40% reported that they experienced a higher level of burden whereas about one-third experienced the same level of burden. High and overwhelming financial distress score and low quality of life (QOL) score were associated with higher than expected financial burden. Take Home Pearls: Many insured patients receiving cancer treatment appear to face out-of-pocket costs that are greater than expected. Those who are least prepared for this burden appear to report higher financial distress and lower...

FDA Approves Two Drugs, Companion Diagnostic Test for Advanced Skin Cancer

The U.S. Food and Drug Administration today approved two new drugs, Tafinlar (dabrafenib) and Mekinist (trametinib), for patients with advanced (metastatic) or unresectable (cannot be removed by surgery) melanoma, the most dangerous type of skin cancer. Melanoma is the leading cause of death from skin disease. The National Cancer Institute estimates 76,690 Americans will be diagnosed with melanoma and 9,480 will die from the disease in 2013. Tafinlar, a BRAF inhibitor, is approved to treat patients with melanoma whose tumors express the BRAF V600E gene mutation. Mekinist, a MEK inhibitor, is approved to treat patients whose tumors express the BRAF V600E or V600K gene mutations. Approximately half of melanomas arising in the skin have a BRAF gene mutation. Tafinlar and Mekinist are being approved as single agents, not as a combination treatment. The FDA approved Tafinlar and Mekinist with a genetic test called the THxID BRAF test, a companion diagnostic that will help determine if a patient’s melanoma cells have the V600E or V600K mutation in the BRAF gene. “Advancements in our understanding of the biological pathways of a disease have allowed for the development of Tafinlar and Mekinist, the third and fourth drugs the FDA has approved for treating metastatic melanoma in the past two years,” said Richard Pazdur, M.D., director of the Office of Hematology and Oncology Products in the FDA’s Center for Drug Evaluation and Research. Zelboraf (vemurafenib) and Yervoy (ipilimumab) were approved in 2011 for the treatment of metastatic or unresectable melanoma. “The co-approval of Tafinlar and Mekinist and the second companion diagnostic for BRAF mutation detection demonstrates the commitment of pharmaceutical and diagnostic partners...
The Impact of Chronic Lung Disease in MI

The Impact of Chronic Lung Disease in MI

Chronic lung disease (CLD)—including COPD, chronic bronchitis, and emphysema—is common, presenting in approximately one in seven patients presenting with myocardial infarction (MI). Patients with CLD are more likely to die or be hospitalized from cardiovascular disease than from any other disease. Despite this knowledge, few studies have explored the influence of CLD on patient management and outcomes following MI. Gaining a better understanding of this relationship could lead to opportunities for improving quality of care and outcomes for CLD patients. Treatments & Mortality for Chronic Lung Disease In a study published in the American Heart Journal, my colleagues and I utilized the National Cardiovascular Data Registry to determine the association of CLD with treatments and adverse events after MI. Our results showed that CLD patients presenting with non-STEMI had a 20% increased risk for in-hospital death when compared with those who did not have CLD. No such link, however, was found among CLD patients with STEMI. In addition, CLD patients with non-STEMI were markedly less likely to receive invasive procedures, such as cardiac catheterization, PCI, or CABG surgery. They were also slightly less likely to receive evidence-based medical therapies, including thienopyridines, β-blockers, and statins. Conversely, differences in treatment of STEMI patients with CLD were not clinically significant, according to findings in our investigation. Taking a Closer Look at Bleeding Risks This is also the first study to our knowledge indicating that, independent of other factors, CLD patients had a 20% to 25% higher risk of bleeding when compared with those without CLD. Major bleeding is one of the most common in-hospital complications following acute coronary syndromes and is associated...
Guidelines for Managing Stable Ischemic Heart Disease

Guidelines for Managing Stable Ischemic Heart Disease

Nearly 10 million Americans have stable ischemic heart disease (SIHD), which ranks among the leading causes of death among adults in the United States. According to study data, SIHD was the cause of nearly 380,000 deaths in the U.S. in 2010. The total costs associated with caring for heart disease has been estimated at $316.4 billion, while the total cost for coronary heart disease accounts for about $177.1 billion (Figure 1). More than 5 years have passed since guidelines were released on the management of patients with SIHD. In an effort to revisit those recommendations, the American College of Cardiology Foundation/ American Heart Association Task Force on Practice Guidelines and five other medical societies collaborated to release a 2012 guideline update for these patients that was published in Circulation. Influential Studies Shaping Revascularization The Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation (COURAGE) trial helped shape the revascularization section of the guidelines update, according to James C. Blankenship, MD, FSCAI, who was on the task force that revised the recommendations. “For the COURAGE trial, stable patients in whom catheterization demonstrated a need for revascularization were randomized to medical therapy or coronary intervention. The researchers concluded that neither showed a benefit with regard to death or heart attack. Stenting showed a benefit in angina control for 3 years. This finding, along with data from other studies, indicates that every lesion doesn’t necessarily need to be fixed and that the strongest indication for coronary stenting in stable patients is relief of symptoms.” Revisions in the revascularization section were also shaped by results of the Synergy Between Percutaneous Coronary Intervention With Taxus...
Improving ED Communication & Patient Throughput

Improving ED Communication & Patient Throughput

Among the many Affordable Care Act initiatives rumbling through the healthcare industry, the introduction of 30 to 40 million new patients is certain to create additional stress to an already overburdened healthcare system. As a result, hospitals must find ways to increase their patient throughput and operational efficiency. Unfortunately, inefficient inpatient discharge practices continue to create unnecessarily long hospital stays. Patient throughput in the ED impacts the rest of the hospital system. ED lengths of stay generally increase when hospital occupancy levels exceed 90%, so enhanced communication and patient throughput are vital throughout the acute care setting. Although many factors can hinder patient flow, nearly 70% of clinicians cite communication as the most challenging cause of patient throughput delays. EDs: The Communication Ground Zero Communication in the ED sets the course for patient flow throughout the hospital. Safe, efficient, quality care in the ED requires frequent and effective communication. Nearly half of EDs report operating at or above capacity, and wait times and patient visits have risen steadily for the last 20 years. Initial communication with ED patients must be a top priority. As soon as patients register at the ED, they must be clearly informed of their anticipated treatment. Early communication about details, such as estimated wait times, anticipated discharge times, and availability of immediate treatments for minor symptoms, can smooth transitions of care.  Intricacies are sometimes forgotten but have a tremendous impact on patient throughput. The physical design of individual patient rooms can greatly affect throughput. When rooms are well-designed and provide optimum flexibility, patients can receive faster, more efficient care. In order to save space for...
Death by Traffic

Death by Traffic

According to data from the CDC, motor vehicle traffic death rates declined by 49% for men aged 15 to 19 years from 1999 to...

Strategies for Managing Violence Against ED Personnel

[polldaddy poll=7143096] According to published data, about one in four emergency physicians (EPs) and nurses report that they were victims of physical assault in the past year. A recent study found that as many as 78% of EPs reported at least one act of physical or verbal aggression in the previous year, and 21% reported more than one episode. Another analysis revealed that before completion of training, more than 50% of emergency medicine residents had been physically hit or pushed by patients. Fear of assault or being shot was their second-leading concern, trailing only needlestick injuries from patients with HIV. EDs have been identified as high-risk settings for workplace violence (WPV), says Terry Kowalenko, MD. “In addition to the immediate concern of personal safety, WPV can decrease productivity and job satisfaction and contribute to the problem of early burnout. The toll of WPV may be even higher for non-physician staff. What’s clear is that data from recent reports on WPV are concerning, as the threat of violence in EDs is escalating throughout the United States.” A Call to Action: Preventing Violence in Healthcare Several organizations, most notably the Occupational Safety and Health Administration (OSHA), have recently issued a call to action to improve initiatives aimed at preventing violence in healthcare settings. In the Journal of Emergency Medicine, Dr. Kowalenko and colleagues had an analysis published that reviewed ED workplace violence in the context of risk factors for WPV. The study also reviewed current concepts for interventions designed to prevent WPV in the ED. “The reasons behind WPV in the ED are multifactorial,” explains Dr. Kowalenko. “Factors such as mental...

Do BSN Nurses Provide Better Care?

A paper entitled “An increase in the number of nurses with baccalaureate degrees is linked to lower rates of postsurgery mortality” appeared in Health Affairs in March and generated quite a lot of buzz on the Internet. Its major finding was that hospitals in Pennsylvania that had 10% more nurses with BSN degrees were found to have 2.12 fewer deaths per 1,000 postop patients than those that did not. The authors extrapolated this, saying that if all the hospitals they surveyed had the same percentage of BSN nurses as the best performers, 500 deaths may have been avoided. The reduction in mortality rates was not significantly affected by staffing levels, skill mix, or years of experience as a nurse. The mechanism for the decrease in death rates was not explained but assumed to be better rates of “rescue” after the development of complications, which also was significantly associated with the presence of more BSN nurses and not staffing levels, skill mix, or years of experience as a nurse. The abstract concludes, “The findings provide support for efforts to increase the production and employment of baccalaureate nurses.” The math in the paper is confusing. In 2006, 25,000 nurses responded and a third of them were staff nurses in general hospitals. The information from those nurses (presumably about 8,333 of them) was the basis of the study. They go on to say that there were 134 hospitals with an average of 48 respondents; that computes to 6,432 — a discrepancy of over 2,000. A cliché that is often used in comments about research papers is: “the study raises more questions than...
Extending Survival After Inoperable Pancreatic Cancer

Extending Survival After Inoperable Pancreatic Cancer

Surgical resection of adenocarcinoma can significantly improve survival, but only 20% of patients are candidates to undergo this treatment. Typically, patients with unresectable pancreatic adenocarcinoma receive palliative, non-curative therapy. Recent research, however, suggests that accurate radiographic restaging, multimodality treatment, and advanced surgical technique can offer patients who have been previously deemed unresectable the possibility for curative salvage pancreatectomy. A New Approach for Pancreatic Cancer In the Journal of the American College of Surgeons, my colleagues and I at MD Anderson reported results from a study cohort of 88 high-risk patients who had been informed that their tumors were inoperable after an initial surgical attempt at removal. Of these patients, 66 completed a multidisciplinary treatment protocol with successful tumor removal. Risk for metastatic disease was stratified based on tumor involvement with local blood vessels, biopsy results and the nature of the tumor, and overall health status aside from pancreatic cancer. Patients who met these criteria underwent the MD Anderson protocol, which involved the following: A collaborative interpretation of pancreas-specific CT scans by surgeons and radiologists. Carefully administered preoperative chemotherapy and radiation treatment with multidisciplinary restaging prior to surgery. Use of advanced surgical techniques with planned removal and vascular reconstruction of involved blood vessels near the tumor. Using this protocol, we achieved survival numbers that are comparable to those of patients receiving surgery for clearly operable tumors. On average, patients undergoing the MD Anderson protocol lived about 30 months after tumor removal, which is almost three times longer than the average survival of 11 months for patients who do not undergo tumor resection. Key Considerations: Patient Selection & Imaging Our findings...
Shoulder Arthroplasty for Proximal Humeral Nonunions

Shoulder Arthroplasty for Proximal Humeral Nonunions

Shoulder fractures are common injuries among the elderly, but the management of these fractures can be challenging for physicians. Treatment options include nonoperative modalities, osteosynthesis, and arthroplasty, but patients can still suffer from substantial pain and functional impairment even after receiving these interventions. Nonunions have been frequently linked to bone loss, poor bone quality, and soft-tissue contractures. “In previous studies, surgeons have had difficulty achieving fracture union with internal fixation and bone-grafting treatments in patients with proximal humeral fracture nonunions,” explains Thomas R. Duquin, MD. “As an alternative, unconstrained shoulder arthroplasty has been advocated for treating these nonunions. Unfortunately, research has documented high rates of unsatisfactory results with arthroplasty, especially with regard to functional outcomes.” Study Results on Proximal Humeral Nonunions In the Journal of Bone and Joint Surgery, Dr. Duquin and colleagues recently had a study published that reviewed the results and complications of conventional anatomic shoulder arthroplasty for proximal humeral nonunions. The study also identified factors associated with success or failure. From 1976 to 2007, 67 patients who underwent unconstrained shoulder arthroplasty for proximal humeral nonunions were followed for more than 2 years. The study included 49 women and 18 men with an average age of 64 and a mean duration of 9 years follow-up. Fracture type was assessed according to the Neer rating classification. There were two-part fractures in 36 patients, three-part fractures in 16 patients, and four-part fractures in 15 patients. Hemiarthroplasty was performed in 54 individuals, and total shoulder arthroplasty was done in 13. According to findings, there were 33 excellent or satisfactory results based on a modified Neer rating classification (Figure 1). “For...

ASCO 2013

New research is being presented at ASCO 2013, the annual meeting of the American Society of Clinical Oncology, from May 31-June 4 in Chicago. Find everything here that you need to know before and during the conference. Watch Scientific Program Committee Chair Dr. Douglas Yee discuss how the 2013 ASCO Annual Meeting reflects the priorities and issues that affect every oncology professional:   Meeting Highlights Cancer Care Costs: A Look at Patient Expectations Involving Family in Cancer Treatment Decisions Deciding on When to Operate in Lung Cancer Family Physicians’ Care of Cancer Patients Burnout Among Oncologists News from the Meeting Men’s Fitness in Middle Age Protects Against Cancer Surveillance Imaging Ineffective in Detecting Lymphoma Relapse Post-Surgery Surveillance Sufficient for Men with Stage I Seminoma Anti-PD-L1 Drug Shows Promising Anti-Cancer Effects Standard-Dose Radiation Best for Stage III NSCLC Funding Cuts Threaten Modernization of Cancer Research Is Nivolumab a ‘Breakthrough’ in Melanoma? Growth Factor Improves Ipilimumab Efficacy in Melanoma Pazopanib Improves PFS in Advanced Ovarian Cancer Breakthrough in Rare Eye Cancer: First Drug That Works Cetuximab Superior to Bevacizumab as First-Line Tx in CRC Tamoxifen for 10 Years Has Benefits, Says aTTom Bevacizumab Prolongs Survival in Advanced Cervical Cancer Sorafenib Potent New Tx for Advanced Thyroid Cancer Drug Combos Are the Future of Melanoma Treatment Cancer Drug Shortages Spawn Workarounds Cervical Cancer Screening With Vinegar Reduces Mortality No Benefit to Bevacizumab for Newly Diagnosed Glioblastoma? Novel Agent Shows Potential for Advanced Lung Cancer Strong Case for Weekly Paclitaxel in Breast Cancer Stop Using Calcium and Magnesium With Oxaliplatin Targeted Duo Boosts OS in Melanoma Herpes-Derived Tx for Melanoma? Dual Immune Tx...
The Economic Burden of Fecal Incontinence

The Economic Burden of Fecal Incontinence

As the elderly population in the United States continues to grow rapidly, it’s expected that the prevalence of fecal incontinence will also increase substantially. The condition is highly prevalent in both older men and women. Fecal incontinence can significantly decrease quality of life because patients often find it difficult to hide odor issues. In many cases, they develop depression and become socially isolated. Many sufferers live with the condition for 5 years or longer before seeking treatment. Despite its prevalence and harmful impact on patients and their caregivers, fecal incontinence remains understudied in clinical research. Furthermore, few studies have looked at its economic burden in the U.S. Quantifying Costs of Fecal Incontinence In Diseases of the Colon & Rectum, my colleagues and I had a study published that aimed to quantify per-patient annual costs associated with fecal incontinence. Patients with the condition were mailed a survey in 2010 to collect information on their sociodemographic characteristics, symptoms, and use of medical and non-medical resources for fecal incontinence. The analysis included 332 adult patients who had fecal incontinence for more than a year with at least monthly leakage of solid, liquid, or mucous stool. Three categories of cost were examined in the study: 1) direct medical costs, including dollars spent for diagnosis, treatment, and management of the condition; 2) direct non-medical costs, including dollars spent for non-medical resources, such as protective products or transportation to care; and 3) indirect costs, such as accountable dollars from loss of productivity. Unit costs were determined based on standard Medicare reimbursement rates, national average wholesale prices of medications, and estimates from other relevant sources. According...
Guidelines for Diagnosing & Treating Diabetic Foot Infections

Guidelines for Diagnosing & Treating Diabetic Foot Infections

As the incidence of diabetes has steadily increased over the last several decades throughout the United States, diabetic foot infections have also become increasingly common. As many as one in four people with diabetes will have a foot ulcer in their lifetime, and these wounds can easily become infected. If left unchecked, they can spread and may ultimately require amputation of the toe, foot, or part of the leg. Nearly 80% of all nontraumatic amputations occur in people with diabetes, 85% of which begin with a foot ulcer. “Lower extremity amputation severely affects quality of life in people with diabetes because it reduces independence and mobility,” says Warren S. Joseph, DPM, FIDSA. “Furthermore, about 50% of patients who have foot amputations die within 5 years, which ranks as a worse mortality rate than for most cancers.” However, about half of lower extremity amputations that are not caused by trauma can be prevented through proper care of foot infections. Preventing amputations is vital. In most cases, these infections can be prevented or cured when properly managed. Recommendations for Diabetic Foot Infections In a 2012 issue of Clinical Infectious Diseases, the Infectious Diseases Society of America (IDSA) published a clinical practice guideline for diagnosing and treating diabetic foot infections. The guideline addresses 10 common questions with evidencebased answers that experts have determined are most likely to help healthcare providers treating these infections. The guideline is a revision and update of IDSA’s 2004 recommendations for managing diabetic foot infections. With regard to diagnosis, the guideline recommends that infections in foot wounds be defined clinically by the presence of inflammation or purulence, and...

Cleveland Clinic: “If We Could See Inside Others’ Hearts”

A profound look at life in a 4-minute video. The camera shows the inner lives of people in a hospital as they go about their daily lives. Produced by the Cleveland Clinic, we get a peek as to what their story entails—worry, sadness, joy, bad news, good news, anxiety, and fear. It’s a reminder that we all go through struggles in life, and we should treat others with the benefit of the doubt, with courtesy, with compassion, and with...

APA 2013: Psychiatric ED Presentations Vary By Season

The Particulars: Anecdotal evidence suggests that seasonal patterns may affect how psychiatric patients utilize the ED. Few clinical studies have explored the prevalence of seasonal presentations involving psychiatric illness in the ED setting. Data Breakdown: In a study, investigators divided data on ED presentations involving mental diagnoses by season  and formed a baseline rate for diagnoses that was used to compare with individual seasons. When compared with those who presented in all other seasons, psychiatry patients who presented in the fall were significantly younger. Those who presented in the summer were significantly older. When compared with baseline data, presentations of substance-related disorder were significantly higher during the fall; adjustment and anxiety disorders were significantly lower during this season. No significant differences were seen among the number of presentations in all four seasons. Take Home Pearls: No significant differences appear to exist between seasons in the number of psychiatric presentations to the ED. However, psychiatric patients who present in the fall appear to be significantly younger than those who present in the summer when compared with patients presenting in other...
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