IUK Med Online | IUK Med Online
Wednesday, July 18, 2018
Home Blog

Rapid Diagnosis Correct in Over 90% of Helsinki Stroke Cases (CME/CE)

0


Medpage Today

Rapid Diagnosis Correct in Over 90% of Helsinki Stroke Cases

Finnish stroke service aces door-to-needle time of less than 20 minutes

MedpageToday

  • register today

    Earn Free CME Credits by reading the latest medical news in your specialty.

    sign up

  • by Contributing Writer, MedPage Today

Action Points

  • Note that this observational study in a single hospital found a nearly 15% rate of misdiagnosis among patients referred for acute recanalization therapy.
  • Despite this, unnecessary treatment or failure to provide necessary treatment occurred in less than 5% of cases.

Ischemic stroke patients who were evaluated and treated in under 20 minutes at Helsinki University Hospital received an accurate diagnosis more than 90% of the time, an analysis of the hospital’s stroke-code patients showed.

With door-to-thrombolysis times below 20 minutes, the neurologic emergency department (ED) correctly diagnosed 91% of acute cerebral ischemia cases, 99% of hemorrhagic strokes, and 62% of stroke mimics, reported Saana Pihlasviita, MD, of the University of Helsinki, and colleagues in Neurology.

“In 2011, we pushed the door-to-needle time [DTN] permanently below 20 minutes,” co-author Perttu Lindsberg, MD, PhD, of Helsinki University Hospital, told MedPage Today. “What we had not been monitoring was how well we had maintained the accuracy of our ED diagnostic process regarding the wide variety of stroke code patients, which include a plethora of mimics.”

“While EMS [emergency medical services] personnel in Helsinki are trained to suspect thrombolytic-eligible stroke patients and transport them quickly, diagnosis at admission is an independent clinical judgment,” Lindsberg said. “The CT findings are largely non-diagnostic for acute changes, which led us to wonder whether the time-pressure and therapy-geared expectations might have blurred the diagnostic accuracy.”

The analysis focused on acute stroke patients transported by EMS as candidates for acute recanalization therapy from May 2013 to November 2015, and assessed the accuracy of the initial evaluation only. Admission evaluations were performed by a stroke neurologist or a neurology resident with dedicated stroke training, primarily using CT imaging.

The investigators defined the initial diagnosis as the first working diagnosis the physician proposed after admission. The final diagnosis included all available patient records, including ancillary etiologic investigations after hospital discharge.

Among 1,015 stroke-code patients, the rate of correct admission diagnosis was 91.1% (604/663) for acute cerebral ischemia (517 ischemic stroke; 146 transient ischemic attack (TIA), 99.2% (117/118) for hemorrhagic stroke, and 61.5% (144/234) for stroke mimics.

About 15% of patients (150/1,015) were misdiagnosed, of which 90% had no acute findings on initial imaging and 67.6% presented with a NIH Stroke Scale score of 0 to 2. Of the 150 misdiagnosed patients, the final diagnosis was acute cerebral ischemia in 59 cases, intracerebral hemorrhage in one case, and stroke mimics in 90 cases.

In 70 cases, misdiagnosis changed medical management. In 13 cases, tissue plasminogen activator (tPA) was given unnecessarily; in five cases, it was omitted. Misdiagnosis led to a delay in antiplatelet medication of about 1 day in 14 patients and unnecessary stroke unit stays for 10 patients. A detailed review identified eight cases (0.8%) in which misdiagnosis possibly or likely worsened outcomes, but no deaths occurred as a result.

“The overall rate of misdiagnosis in admission evaluation was 14.8% for all arriving stroke code patients when mainly CT-based imaging was used,” Lindsberg said. “But it was rather surprising to find that for every 100 stroke-code patients, only two received unnecessary tPA, or was left without indicated tPA, due to inaccurate admission diagnosis.”

The swift door-to-needle process at Helsinki has been developed and refined over several decades, Lindsberg noted.

“We realized that rapid neurological evaluation must build on as much information and preparation from the pre-hospital phase as possible,” he said. “Pre-notification of essential clinical details enables us to activate the stroke team, review digital patient records for suitability and contraindications, review and pre-order necessary laboratory investigations, and ensure entry to an immediate CT to be interpreted by the treating neurologist.” The patient is examined on arrival and tPA is administered on the CT table.

In the last decade, “strategies to streamline pre-hospital stroke management have arisen, e.g., use of mobile stroke units, allowing diagnostic workup, treatment, and correct triage decisions, starting at the emergency site with a view toward the targeted hospital,” observed Klaus Fassbender, MD, of Saarland University Medical Center in Germany, and Kevin Sheth, MD, of Yale School of Medicine in New Haven, Connecticut, in an accompanying editorial.

In the U.S, for example, a modified Helsinki protocol using telestroke was associated with a median door-to-needle time of 34 minutes in northern California. And in Cleveland, stroke patients transported in a telemedicine-enabled mobile stroke unit were evaluated and treated in 31.5 minutes, nearly twice as fast as patients arriving by ambulance.

The Helsinki results show “that a protocol that sprints towards rapid treatment is feasible,” Sheth told MedPage Today.

“Every hospital has to start cutting into the triage process with a multidisciplinary team that does a root-cause analysis and cuts out everything that is not essential for tPA administration,” he said. “This is tough because people have a hard time changing protocols, but it can be done.”

The Helsinki study’s lack of a comparator — either a parallel or historical control group — was a limitation, Fassbender and Sheth noted. Future studies could include MRI or other imaging to ascertain the diagnosis and evaluate true positive and negative rates.

The study was funded by the Maire Taponen Foundation, Finnish Medical Foundation, Finnish Foundation for Cardiovascular Research, Helsinki University Hospital governmental research funds, Jane and Aatos Erkko Foundation, Signe and Ane Gyllenberg Foundation, and Sigrid Juse´lius Foundation.

Pihlasviita and Lindsberg disclosed no relevant relationships with industry. Co-authors disclosed relevant relationships with Boehringer Ingelheim, Pfizer, Bayer, Medfield Diagnostics, Lumosa Therapeutics, BrainsGate, Sanofi Aventis, PhotoThera, H.Lundbeck A/S, and Portola Pharmaceuticals.

Fassbender disclosed no relevant relationships with industry. Sheth disclosed holding a provisional patent for stroke detection technology and support from Remedy Pharmaceuticals, Bard, Stryker, and Novartis.

  • Reviewed by F. Perry Wilson, MD, MSCE Assistant Professor, Section of Nephrology, Yale School of Medicine and Dorothy Caputo, MA, BSN, RN, Nurse Planner
2018-07-17T16:45:00-0400
Take Posttest Comments

Accessibility Statement

At MedPage Today, we are committed to ensuring that individuals with disabilities can access all of the content offered by MedPage Today through our website and other properties. If you are having trouble accessing www.medpagetoday.com, MedPageToday's mobile apps, please email legal@ziffdavis.com for assistance. Please put "ADA Inquiry" in the subject line of your email.

Medpage Today

Rapid Diagnosis Correct in Over 90% of Helsinki Stroke Cases

Finnish stroke service aces door-to-needle time of less than 20 minutes

MedpageToday

  • register today

    Earn Free CME Credits by reading the latest medical news in your specialty.

    sign up

  • by Contributing Writer, MedPage Today

Action Points

  • Note that this observational study in a single hospital found a nearly 15% rate of misdiagnosis among patients referred for acute recanalization therapy.
  • Despite this, unnecessary treatment or failure to provide necessary treatment occurred in less than 5% of cases.

Ischemic stroke patients who were evaluated and treated in under 20 minutes at Helsinki University Hospital received an accurate diagnosis more than 90% of the time, an analysis of the hospital's stroke-code patients showed.

With door-to-thrombolysis times below 20 minutes, the neurologic emergency department (ED) correctly diagnosed 91% of acute cerebral ischemia cases, 99% of hemorrhagic strokes, and 62% of stroke mimics, reported Saana Pihlasviita, MD, of the University of Helsinki, and colleagues in Neurology.

"In 2011, we pushed the door-to-needle time [DTN] permanently below 20 minutes," co-author Perttu Lindsberg, MD, PhD, of Helsinki University Hospital, told MedPage Today. "What we had not been monitoring was how well we had maintained the accuracy of our ED diagnostic process regarding the wide variety of stroke code patients, which include a plethora of mimics."

"While EMS [emergency medical services] personnel in Helsinki are trained to suspect thrombolytic-eligible stroke patients and transport them quickly, diagnosis at admission is an independent clinical judgment," Lindsberg said. "The CT findings are largely non-diagnostic for acute changes, which led us to wonder whether the time-pressure and therapy-geared expectations might have blurred the diagnostic accuracy."

The analysis focused on acute stroke patients transported by EMS as candidates for acute recanalization therapy from May 2013 to November 2015, and assessed the accuracy of the initial evaluation only. Admission evaluations were performed by a stroke neurologist or a neurology resident with dedicated stroke training, primarily using CT imaging.

The investigators defined the initial diagnosis as the first working diagnosis the physician proposed after admission. The final diagnosis included all available patient records, including ancillary etiologic investigations after hospital discharge.

Among 1,015 stroke-code patients, the rate of correct admission diagnosis was 91.1% (604/663) for acute cerebral ischemia (517 ischemic stroke; 146 transient ischemic attack (TIA), 99.2% (117/118) for hemorrhagic stroke, and 61.5% (144/234) for stroke mimics.

About 15% of patients (150/1,015) were misdiagnosed, of which 90% had no acute findings on initial imaging and 67.6% presented with a NIH Stroke Scale score of 0 to 2. Of the 150 misdiagnosed patients, the final diagnosis was acute cerebral ischemia in 59 cases, intracerebral hemorrhage in one case, and stroke mimics in 90 cases.

In 70 cases, misdiagnosis changed medical management. In 13 cases, tissue plasminogen activator (tPA) was given unnecessarily; in five cases, it was omitted. Misdiagnosis led to a delay in antiplatelet medication of about 1 day in 14 patients and unnecessary stroke unit stays for 10 patients. A detailed review identified eight cases (0.8%) in which misdiagnosis possibly or likely worsened outcomes, but no deaths occurred as a result.

"The overall rate of misdiagnosis in admission evaluation was 14.8% for all arriving stroke code patients when mainly CT-based imaging was used," Lindsberg said. "But it was rather surprising to find that for every 100 stroke-code patients, only two received unnecessary tPA, or was left without indicated tPA, due to inaccurate admission diagnosis."

The swift door-to-needle process at Helsinki has been developed and refined over several decades, Lindsberg noted.

"We realized that rapid neurological evaluation must build on as much information and preparation from the pre-hospital phase as possible," he said. "Pre-notification of essential clinical details enables us to activate the stroke team, review digital patient records for suitability and contraindications, review and pre-order necessary laboratory investigations, and ensure entry to an immediate CT to be interpreted by the treating neurologist." The patient is examined on arrival and tPA is administered on the CT table.

In the last decade, "strategies to streamline pre-hospital stroke management have arisen, e.g., use of mobile stroke units, allowing diagnostic workup, treatment, and correct triage decisions, starting at the emergency site with a view toward the targeted hospital," observed Klaus Fassbender, MD, of Saarland University Medical Center in Germany, and Kevin Sheth, MD, of Yale School of Medicine in New Haven, Connecticut, in an accompanying editorial.

In the U.S, for example, a modified Helsinki protocol using telestroke was associated with a median door-to-needle time of 34 minutes in northern California. And in Cleveland, stroke patients transported in a telemedicine-enabled mobile stroke unit were evaluated and treated in 31.5 minutes, nearly twice as fast as patients arriving by ambulance.

The Helsinki results show "that a protocol that sprints towards rapid treatment is feasible," Sheth told MedPage Today.

"Every hospital has to start cutting into the triage process with a multidisciplinary team that does a root-cause analysis and cuts out everything that is not essential for tPA administration," he said. "This is tough because people have a hard time changing protocols, but it can be done."

The Helsinki study's lack of a comparator -- either a parallel or historical control group -- was a limitation, Fassbender and Sheth noted. Future studies could include MRI or other imaging to ascertain the diagnosis and evaluate true positive and negative rates.

The study was funded by the Maire Taponen Foundation, Finnish Medical Foundation, Finnish Foundation for Cardiovascular Research, Helsinki University Hospital governmental research funds, Jane and Aatos Erkko Foundation, Signe and Ane Gyllenberg Foundation, and Sigrid Juse´lius Foundation.

Pihlasviita and Lindsberg disclosed no relevant relationships with industry. Co-authors disclosed relevant relationships with Boehringer Ingelheim, Pfizer, Bayer, Medfield Diagnostics, Lumosa Therapeutics, BrainsGate, Sanofi Aventis, PhotoThera, H.Lundbeck A/S, and Portola Pharmaceuticals.

Fassbender disclosed no relevant relationships with industry. Sheth disclosed holding a provisional patent for stroke detection technology and support from Remedy Pharmaceuticals, Bard, Stryker, and Novartis.

  • Reviewed by F. Perry Wilson, MD, MSCE Assistant Professor, Section of Nephrology, Yale School of Medicine and Dorothy Caputo, MA, BSN, RN, Nurse Planner
2018-07-17T16:45:00-0400
Take Posttest Comments

Accessibility Statement

At MedPage Today, we are committed to ensuring that individuals with disabilities can access all of the content offered by MedPage Today through our website and other properties. If you are having trouble accessing www.medpagetoday.com, MedPageToday's mobile apps, please email legal@ziffdavis.com for assistance. Please put "ADA Inquiry" in the subject line of your email.



Source link

The Real Motives of Health Insurers

0


Medpage Today

The Real Motives of Health Insurers

Let’s tell the truth about what’s going on, says Michael Kirsch, MD

MedpageToday

  • by

A patient came to see me with lower abdominal pain. Was she interested in my medical opinion? Not really. She was told to see me by her gynecologist who had advised that the patient undergo a hysterectomy. Was this physician seeking my medical advice? Not really. Was this patient coming to see me as her day was boring and she needed an activity? Not really. After the visit with me, was the patient planning to return for further discussion of her medical status? Not really.

So, what was going on here. What had occurred that day was the result of an insurance company practice that I had thought had been properly interred years ago.

The woman had pelvic pain and consulted with her gynecologist. An ultrasound found a lesion within her uterus. A hysterectomy was advised. The insurance company directed that a second opinion be solicited. A second gynecologist concurred with the first specialist. The patient advised me that the insurance company wanted an opinion from a gastroenterologist that there was no gastrointestinal explanation for her pain. In other words, they did not want to pay for a hysterectomy that they deemed to be unnecessary.

How should we respond?

  • We should applaud the insurance company for its diligence to protect the patient from an unneeded surgery.
  • We should recognize that the insurance company is focused only on promoting medical quality with no concern for saving the company money.
  • We should cite the insurance company for industry excellence for facilitating smooth and efficient medical care.
  • We should tell the obvious truth about what is actually going on here.

This woman’s treatment plan, as recommended by two gynecologists, was halted by a bureaucrat who likely had less medical training than they did. I surmise that not enough boxes were checked on the submitted paperwork to permit the recommended surgery to proceed. The insurance companies, of course, claim fidelity to a medical quality mission. How would they like to be subjected to the same absurd level of scrutiny and oversight that they wield over us? When the reform hammer comes down on the insurance companies, my patient might be holding up a sign or a pitchfork, but it won’t be to stand up for them.

Michael Kirsch, MD, is a gastroenterologist who blogs at MD Whistleblower. This post appeared on KevinMD.

2018-07-17T17:00:00-0400
Comments

Accessibility Statement

At MedPage Today, we are committed to ensuring that individuals with disabilities can access all of the content offered by MedPage Today through our website and other properties. If you are having trouble accessing www.medpagetoday.com, MedPageToday's mobile apps, please email legal@ziffdavis.com for assistance. Please put "ADA Inquiry" in the subject line of your email.

Medpage Today

The Real Motives of Health Insurers

Let's tell the truth about what's going on, says Michael Kirsch, MD

MedpageToday

  • by

A patient came to see me with lower abdominal pain. Was she interested in my medical opinion? Not really. She was told to see me by her gynecologist who had advised that the patient undergo a hysterectomy. Was this physician seeking my medical advice? Not really. Was this patient coming to see me as her day was boring and she needed an activity? Not really. After the visit with me, was the patient planning to return for further discussion of her medical status? Not really.

So, what was going on here. What had occurred that day was the result of an insurance company practice that I had thought had been properly interred years ago.

The woman had pelvic pain and consulted with her gynecologist. An ultrasound found a lesion within her uterus. A hysterectomy was advised. The insurance company directed that a second opinion be solicited. A second gynecologist concurred with the first specialist. The patient advised me that the insurance company wanted an opinion from a gastroenterologist that there was no gastrointestinal explanation for her pain. In other words, they did not want to pay for a hysterectomy that they deemed to be unnecessary.

How should we respond?

  • We should applaud the insurance company for its diligence to protect the patient from an unneeded surgery.
  • We should recognize that the insurance company is focused only on promoting medical quality with no concern for saving the company money.
  • We should cite the insurance company for industry excellence for facilitating smooth and efficient medical care.
  • We should tell the obvious truth about what is actually going on here.

This woman's treatment plan, as recommended by two gynecologists, was halted by a bureaucrat who likely had less medical training than they did. I surmise that not enough boxes were checked on the submitted paperwork to permit the recommended surgery to proceed. The insurance companies, of course, claim fidelity to a medical quality mission. How would they like to be subjected to the same absurd level of scrutiny and oversight that they wield over us? When the reform hammer comes down on the insurance companies, my patient might be holding up a sign or a pitchfork, but it won't be to stand up for them.

Michael Kirsch, MD, is a gastroenterologist who blogs at MD Whistleblower. This post appeared on KevinMD.

2018-07-17T17:00:00-0400
Comments

Accessibility Statement

At MedPage Today, we are committed to ensuring that individuals with disabilities can access all of the content offered by MedPage Today through our website and other properties. If you are having trouble accessing www.medpagetoday.com, MedPageToday's mobile apps, please email legal@ziffdavis.com for assistance. Please put "ADA Inquiry" in the subject line of your email.



Source link

Intervention Leads to Better Use of Malaria Tx (CME/CE)

0


Medpage Today

Intervention Leads to Better Use of Malaria Tx

Increased uptake of testing for malaria also observed in Kenya health centers

MedpageToday

  • register today

    Earn Free CME Credits by reading the latest medical news in your specialty.

    sign up

  • by Staff Writer, MedPage Today

Action Points

  • A community-based intervention to tie distribution of subsidies for certain antimalarial therapies to a positive diagnostic test for malaria helped increase uptake of diagnostic testing and appropriate use of these drugs.
  • Note that the intervention led to a relative reduction of 30% in the proportion of artemisinin combination therapies (ACT) dispensed to those without a test, and to a relative increase of 40% in the proportion of ACT doses that were dispensed to individuals with a positive malaria diagnostic test.

A community-based intervention to tie distribution of subsidies for certain antimalarial therapies to a positive diagnostic test for malaria helped increase uptake of diagnostic testing and appropriate use of these drugs, researchers found.

In a cluster-randomized trial, participants in the intervention group were more likely to have malaria diagnostic testing for recent fever at 12 months compared with controls (adjusted RR 1.20, 95% CI 1.05 to 1.38, P=0.015), reported Wendy Prudhomme O’Meara, MD, of Duke University in Durham, North Carolina, and colleagues.

Moreover, the intervention resulted in an increase in the rational use of artemisinin combination therapies (ACTs), the authors wrote in PLoS Medicine.

They noted that while “public subsidies” have reduced the cost of artemisinin combination therapies, they are still not being targeted to those who actually have a malaria diagnosis. Studies estimate that individuals without malaria consume 66% to 80% of artemisinin combination therapies sold over the counter, largely because “malaria diagnostic testing is absent from the retail sector.” Additional research also found that 70% of individuals who have malaria, but no information about their diagnosis, do not seek out these therapies.

The authors also said that such overuse could potentially contribute to resistance, and there are no other “immediate successors” to replace artemisinin, which could potentially contribute to more deaths.

“The discordance between who needs an ACT and who purchases one highlights the importance of improving access to diagnostic testing amongst those who seek care outside the formal health sector,” they argued. “Targeting subsidized ACTs to individuals with parasitologically confirmed malaria could significantly contribute to sustainability and cost effectiveness of donor-funded subsidies as well as safeguard future efficacy of these key drugs.”

O’Meara’s group conducted a cluster-randomized trial in 32 community health centers in western Kenya that had retail outlets selling artemisinin combination therapies and existing community health worker programs.

In the intervention groups, community health workers were available in the villages to perform rapid diagnostic testing “on demand” for anyone with a malaria-like illness. Participants then received a voucher for a discount on artemisinin combination therapies at a participating retail medicine outlet.

Control groups received “a package of standard education, prevention, and referral services.” Surveys were conducted at baseline, 6 months, 12 months, and 18 months.

The primary outcome was malaria diagnostic testing after 12 months, and the main secondary outcome was “rational ACT use,” defined as “the proportion of ACTs used by test-positive individuals.”

Overall, there were 7,416 total households with fever in the last month who participated in the survey — either at baseline, 6 months, 12 months, or 20 months. Of those, about 63% of recent fevers were in children age <18 years. While the sample comprised an equal distribution of boys and girls, the adult sample was about 78% women.

There were 2,017 participants in the baseline sample, about two-thirds of which took artemisinin combination therapies for their illness and about 40% who took ACTs purchased from a retail outlet.

At the 12-month survey, 454 participants in the intervention group (50.5%) had a malaria diagnostic test for their recent fever compared with 389 participants in the control group (43.4%).

The authors noted that a “substantial improvement in rational ACT use was observed by the end of the study period.” The intervention lead to a relative 40% increase in the “proportion of ACT doses dispensed to individuals with a positive malaria test” (44.1% versus 51.9%, adjusted RR 1.40, 95% CI 1.19 to 1.64, P<0.001).

Moreover, they found a 30% relative reduction in the proportion of ACT dispensed to those without a test (37.3% versus 51.9%, adjusted RR 0.70, 95% CI 0.60 to 0.83).

Study limitations included the fact that authors were not able to “separate the effect of free testing from the voucher uptake of testing,” which could only be resolved by a similar study with free testing without a conditional voucher in the control arm, they stated. In addition, the study could not be continued to measure the long-term effects, and outcomes were based on self-report of the respondent or participant.

The study was supported by the NIH.

O’Meara and co-authors disclosed no relevant relationships with industry.

  • Reviewed by Robert Jasmer, MD Associate Clinical Professor of Medicine, University of California, San Francisco and Dorothy Caputo, MA, BSN, RN, Nurse Planner
2018-07-17T17:15:00-0400
Take Posttest Comments

Accessibility Statement

At MedPage Today, we are committed to ensuring that individuals with disabilities can access all of the content offered by MedPage Today through our website and other properties. If you are having trouble accessing www.medpagetoday.com, MedPageToday's mobile apps, please email legal@ziffdavis.com for assistance. Please put "ADA Inquiry" in the subject line of your email.

Medpage Today

Intervention Leads to Better Use of Malaria Tx

Increased uptake of testing for malaria also observed in Kenya health centers

MedpageToday

  • register today

    Earn Free CME Credits by reading the latest medical news in your specialty.

    sign up

  • by Staff Writer, MedPage Today

Action Points

  • A community-based intervention to tie distribution of subsidies for certain antimalarial therapies to a positive diagnostic test for malaria helped increase uptake of diagnostic testing and appropriate use of these drugs.
  • Note that the intervention led to a relative reduction of 30% in the proportion of artemisinin combination therapies (ACT) dispensed to those without a test, and to a relative increase of 40% in the proportion of ACT doses that were dispensed to individuals with a positive malaria diagnostic test.

A community-based intervention to tie distribution of subsidies for certain antimalarial therapies to a positive diagnostic test for malaria helped increase uptake of diagnostic testing and appropriate use of these drugs, researchers found.

In a cluster-randomized trial, participants in the intervention group were more likely to have malaria diagnostic testing for recent fever at 12 months compared with controls (adjusted RR 1.20, 95% CI 1.05 to 1.38, P=0.015), reported Wendy Prudhomme O'Meara, MD, of Duke University in Durham, North Carolina, and colleagues.

Moreover, the intervention resulted in an increase in the rational use of artemisinin combination therapies (ACTs), the authors wrote in PLoS Medicine.

They noted that while "public subsidies" have reduced the cost of artemisinin combination therapies, they are still not being targeted to those who actually have a malaria diagnosis. Studies estimate that individuals without malaria consume 66% to 80% of artemisinin combination therapies sold over the counter, largely because "malaria diagnostic testing is absent from the retail sector." Additional research also found that 70% of individuals who have malaria, but no information about their diagnosis, do not seek out these therapies.

The authors also said that such overuse could potentially contribute to resistance, and there are no other "immediate successors" to replace artemisinin, which could potentially contribute to more deaths.

"The discordance between who needs an ACT and who purchases one highlights the importance of improving access to diagnostic testing amongst those who seek care outside the formal health sector," they argued. "Targeting subsidized ACTs to individuals with parasitologically confirmed malaria could significantly contribute to sustainability and cost effectiveness of donor-funded subsidies as well as safeguard future efficacy of these key drugs."

O'Meara's group conducted a cluster-randomized trial in 32 community health centers in western Kenya that had retail outlets selling artemisinin combination therapies and existing community health worker programs.

In the intervention groups, community health workers were available in the villages to perform rapid diagnostic testing "on demand" for anyone with a malaria-like illness. Participants then received a voucher for a discount on artemisinin combination therapies at a participating retail medicine outlet.

Control groups received "a package of standard education, prevention, and referral services." Surveys were conducted at baseline, 6 months, 12 months, and 18 months.

The primary outcome was malaria diagnostic testing after 12 months, and the main secondary outcome was "rational ACT use," defined as "the proportion of ACTs used by test-positive individuals."

Overall, there were 7,416 total households with fever in the last month who participated in the survey -- either at baseline, 6 months, 12 months, or 20 months. Of those, about 63% of recent fevers were in children age <18 years. While the sample comprised an equal distribution of boys and girls, the adult sample was about 78% women.

There were 2,017 participants in the baseline sample, about two-thirds of which took artemisinin combination therapies for their illness and about 40% who took ACTs purchased from a retail outlet.

At the 12-month survey, 454 participants in the intervention group (50.5%) had a malaria diagnostic test for their recent fever compared with 389 participants in the control group (43.4%).

The authors noted that a "substantial improvement in rational ACT use was observed by the end of the study period." The intervention lead to a relative 40% increase in the "proportion of ACT doses dispensed to individuals with a positive malaria test" (44.1% versus 51.9%, adjusted RR 1.40, 95% CI 1.19 to 1.64, P<0.001).

Moreover, they found a 30% relative reduction in the proportion of ACT dispensed to those without a test (37.3% versus 51.9%, adjusted RR 0.70, 95% CI 0.60 to 0.83).

Study limitations included the fact that authors were not able to "separate the effect of free testing from the voucher uptake of testing," which could only be resolved by a similar study with free testing without a conditional voucher in the control arm, they stated. In addition, the study could not be continued to measure the long-term effects, and outcomes were based on self-report of the respondent or participant.

The study was supported by the NIH.

O'Meara and co-authors disclosed no relevant relationships with industry.

  • Reviewed by Robert Jasmer, MD Associate Clinical Professor of Medicine, University of California, San Francisco and Dorothy Caputo, MA, BSN, RN, Nurse Planner
2018-07-17T17:15:00-0400
Take Posttest Comments

Accessibility Statement

At MedPage Today, we are committed to ensuring that individuals with disabilities can access all of the content offered by MedPage Today through our website and other properties. If you are having trouble accessing www.medpagetoday.com, MedPageToday's mobile apps, please email legal@ziffdavis.com for assistance. Please put "ADA Inquiry" in the subject line of your email.



Source link

Geography Is Big Variable in Cancer Care

0


Medpage Today

Geography Is Big Variable in Cancer Care

End-of-life spending, breast cancer imaging varied widely

MedpageToday

  • by Senior Associate Editor, MedPage Today

The cost of care during the last month of a cancer patient’s life varied by as much as 90% depending on where the patient lived, an analysis of more than 1,000 cases showed.

Average expenditures during the last month of life ranged from about $10,000 in some areas to more than $19,000 in others. Investigators found that the wide variation in end-of-life expenditures was not associated with patient or family preferences but instead with treating physicians’ attitudes, beliefs, and knowledge about end-of-life care, as reported in Health Affairs.

“Numerous studies have shown that greater spending and more care at the end of life do not contribute to better outcomes,” said study author Nancy L. Keating, MD, of Harvard Medical School and Brigham and Women’s Hospital in Boston, said in a statement. “Given that more care and greater spending also do not stem from patient preferences, much of these additional services can be considered wasteful or even harmful.”

An unrelated study documented similar geography-related wide variation in the use of imaging studies during follow-up of patients with low-risk breast cancer. In almost a third of the 36,000 cases reviewed, physicians requested advanced imaging studies not recommended for monitoring low-risk breast cancer, such as PET, as reported in the Journal of the National Comprehensive Cancer Network.

End-of-Life Care

The study by Keating’s group added to a large volume of evidence that healthcare spending at end of life varies across geographic areas and is not associated with improved outcomes. The authors sought to extend the evidence by investigating potential explanations for the variation, including patient-related socioeconomic and demographic factors, clinical factors, availability of services, and patient and physician beliefs about end-of-life care.

Data for the analysis came from the Cancer Care Outcomes Research and Surveillance Consortium (CanCORS) and involved 1,132 patients, ages ≥65, with diagnoses of advanced-stage lung or colorectal cancer during 2003-2005. Follow-up continued to 2013. The data comprised medical facilities in 26 hospital referral regions (HRRs), which were stratified into quintiles on the basis of end-of-life spending.

The data included responses to a CanCORS survey conducted during 2005-2007 among physicians who patients identified as having key roles in their care.

Overall, healthcare expenditures during a patient’s last month of life averaged $13,663. Mean values ranged from $10,131 in the lowest-cost HRRs to $19,318 for HRRs in the highest of the five spending categories. In general, HRRs with higher levels of end-of-life spending had larger populations, more nonwhite residents, more physicians, fewer primary care doctors, and fewer hospital beds and hospice facilities.

The analysis showed no consistent associations with HRR-specific spending, including beliefs about cure, the toxicity associated with treatment, or general knowledge about cancer. The data showed a slight trend for an association between higher HRR-level spending and patient preference not to receive treatment that would extend their lives even if it caused more pain.

Analysis of the treating physicians’ views revealed several factors associated with HRR-level spending at end of life. Physicians in higher-spending areas reported feeling:

  • Less prepared to treat end-of-life symptoms
  • Less knowledgeable about discussing end-of-life options
  • Less comfortable discussing DNR status
  • Less comfortable discussing hospice care and less likely to enroll in hospice themselves if they had terminal cancer
  • More likely to recommend chemotherapy when patients were unlikely to benefit from it

Statistical modeling showed that physician beliefs explained 26% of the HRR-level variation in expenditures during the last 30 days of life, whereas patient beliefs did not influence the geographic variation. The availability of services, combined with patient demographics and clinical variables, explained 39% of the variation.

The findings emphasized the need for education and training “that help physicians feel more comfortable taking care of patients at the end of life, along with better training about the lack of efficacy and potential harms of some intensive treatments for patients with advanced cancer,” said Keating.

Breast Ca Imaging

The study of imaging during follow-up of patients with low-risk breast cancer compared clinical practices within the context of recommended imaging. The American College of Radiology, American Society of Clinical Oncology, and the NCCN have published recommendations about surveillance after treatment for breast cancer, and the guidance limits or discourages use of advanced imaging techniques in most cases.

Additionally, several large randomized trials and systematic reviews consistently showed that imaging studies beyond mammography, particularly nonbreast imaging, has no effect on survival or quality of life for patients with early breast cancer, according to Benjamin Franc, MD, of the University of California San Francisco, and colleagues. Inappropriate use of imaging can add thousands of dollars to the cost of care, which can be especially burdensome to patients with high-deductible insurance coverage.

The study included data for 36,045 women, ages 18-64, who had surgical treatment of one breast from 2010 through 2012. The data came from a large commercial health claims database. The principal objective was to examine geographic variation in rates of recommended postoperative breast imaging and high-cost whole-body imaging (including CT, MRI, PET, and bone scans). Geography was defined by standard metropolitan statistical areas (MSA).

The data showed that 70.8% of the women had at least one recommended dedicated breast imaging study. However, 31.7% had at least one advanced, whole-body imaging study, including 12.5% (one in eight) who had a PET scan. Across MSAs, the proportion of women who had at least one advanced-imaging study ranged from 18% to 46%.

Patient age and type of therapy (surgery alone versus surgery plus radiotherapy) topped the factors influencing the use of recommended imaging, but MSA came in third (OR 1.42, 95% CI 1.35 to 1.51). Use of PET/CT imaging was influenced most by the type of surgery a patient, followed by MSA (OR 1.82, 95% CI 1.70 to 1.97).

“Age and therapy make sense as predictors of breast imaging, but it doesn’t make sense that where you live makes a difference in whether you wee likely to get a follow-up mammogram or high-cost imaging,” Franc said in a statement. “What’s actionable here is that we have these guidelines, but doctors aren’t following them.”

The nature of the data used for the analysis did not provide insight into the reasons for the geographic variation. In an email response to MedPage Today, Franc cited several possibilities.

“In part, doctors in local areas may develop cultures of medical care that emphasize certain habits, essentially saying, ‘That’s how we do it around here.’ These habits can persist even as guidelines change.”

Another potential factor might be local awareness or access to information related to imaging tests, such as the national impact on prophylactic mastectomy and genetic testing that followed actress Angelina Jolie’s personal experience with breast cancer.

“This phenomenon can occur at much more local levels, where the ‘celebrity’ could be a local radio personality or even someone vocal in a support group,” said Franc. “These factors can influence patients to ask their physicians for tests that are recommended by guidelines, which is a positive outcome. Likewise, patients may insist on tests that are not necessarily indicated and have associated drawbacks, such as unnecessary exposure to medical radiation and financial toxicity.”

The study by Keating’s group was supported by the National Cancer Institute. Keating disclosed support from NCI.

Franc disclosed no relevant relationships with industry. One co-author disclosed a relevant relationship with Sutter Medical Group.

2018-07-17T17:30:00-0400
Comments

Accessibility Statement

At MedPage Today, we are committed to ensuring that individuals with disabilities can access all of the content offered by MedPage Today through our website and other properties. If you are having trouble accessing www.medpagetoday.com, MedPageToday's mobile apps, please email legal@ziffdavis.com for assistance. Please put "ADA Inquiry" in the subject line of your email.

Medpage Today

Geography Is Big Variable in Cancer Care

End-of-life spending, breast cancer imaging varied widely

MedpageToday

  • by Senior Associate Editor, MedPage Today

The cost of care during the last month of a cancer patient's life varied by as much as 90% depending on where the patient lived, an analysis of more than 1,000 cases showed.

Average expenditures during the last month of life ranged from about $10,000 in some areas to more than $19,000 in others. Investigators found that the wide variation in end-of-life expenditures was not associated with patient or family preferences but instead with treating physicians' attitudes, beliefs, and knowledge about end-of-life care, as reported in Health Affairs.

"Numerous studies have shown that greater spending and more care at the end of life do not contribute to better outcomes," said study author Nancy L. Keating, MD, of Harvard Medical School and Brigham and Women's Hospital in Boston, said in a statement. "Given that more care and greater spending also do not stem from patient preferences, much of these additional services can be considered wasteful or even harmful."

An unrelated study documented similar geography-related wide variation in the use of imaging studies during follow-up of patients with low-risk breast cancer. In almost a third of the 36,000 cases reviewed, physicians requested advanced imaging studies not recommended for monitoring low-risk breast cancer, such as PET, as reported in the Journal of the National Comprehensive Cancer Network.

End-of-Life Care

The study by Keating's group added to a large volume of evidence that healthcare spending at end of life varies across geographic areas and is not associated with improved outcomes. The authors sought to extend the evidence by investigating potential explanations for the variation, including patient-related socioeconomic and demographic factors, clinical factors, availability of services, and patient and physician beliefs about end-of-life care.

Data for the analysis came from the Cancer Care Outcomes Research and Surveillance Consortium (CanCORS) and involved 1,132 patients, ages ≥65, with diagnoses of advanced-stage lung or colorectal cancer during 2003-2005. Follow-up continued to 2013. The data comprised medical facilities in 26 hospital referral regions (HRRs), which were stratified into quintiles on the basis of end-of-life spending.

The data included responses to a CanCORS survey conducted during 2005-2007 among physicians who patients identified as having key roles in their care.

Overall, healthcare expenditures during a patient's last month of life averaged $13,663. Mean values ranged from $10,131 in the lowest-cost HRRs to $19,318 for HRRs in the highest of the five spending categories. In general, HRRs with higher levels of end-of-life spending had larger populations, more nonwhite residents, more physicians, fewer primary care doctors, and fewer hospital beds and hospice facilities.

The analysis showed no consistent associations with HRR-specific spending, including beliefs about cure, the toxicity associated with treatment, or general knowledge about cancer. The data showed a slight trend for an association between higher HRR-level spending and patient preference not to receive treatment that would extend their lives even if it caused more pain.

Analysis of the treating physicians' views revealed several factors associated with HRR-level spending at end of life. Physicians in higher-spending areas reported feeling:

  • Less prepared to treat end-of-life symptoms
  • Less knowledgeable about discussing end-of-life options
  • Less comfortable discussing DNR status
  • Less comfortable discussing hospice care and less likely to enroll in hospice themselves if they had terminal cancer
  • More likely to recommend chemotherapy when patients were unlikely to benefit from it

Statistical modeling showed that physician beliefs explained 26% of the HRR-level variation in expenditures during the last 30 days of life, whereas patient beliefs did not influence the geographic variation. The availability of services, combined with patient demographics and clinical variables, explained 39% of the variation.

The findings emphasized the need for education and training "that help physicians feel more comfortable taking care of patients at the end of life, along with better training about the lack of efficacy and potential harms of some intensive treatments for patients with advanced cancer," said Keating.

Breast Ca Imaging

The study of imaging during follow-up of patients with low-risk breast cancer compared clinical practices within the context of recommended imaging. The American College of Radiology, American Society of Clinical Oncology, and the NCCN have published recommendations about surveillance after treatment for breast cancer, and the guidance limits or discourages use of advanced imaging techniques in most cases.

Additionally, several large randomized trials and systematic reviews consistently showed that imaging studies beyond mammography, particularly nonbreast imaging, has no effect on survival or quality of life for patients with early breast cancer, according to Benjamin Franc, MD, of the University of California San Francisco, and colleagues. Inappropriate use of imaging can add thousands of dollars to the cost of care, which can be especially burdensome to patients with high-deductible insurance coverage.

The study included data for 36,045 women, ages 18-64, who had surgical treatment of one breast from 2010 through 2012. The data came from a large commercial health claims database. The principal objective was to examine geographic variation in rates of recommended postoperative breast imaging and high-cost whole-body imaging (including CT, MRI, PET, and bone scans). Geography was defined by standard metropolitan statistical areas (MSA).

The data showed that 70.8% of the women had at least one recommended dedicated breast imaging study. However, 31.7% had at least one advanced, whole-body imaging study, including 12.5% (one in eight) who had a PET scan. Across MSAs, the proportion of women who had at least one advanced-imaging study ranged from 18% to 46%.

Patient age and type of therapy (surgery alone versus surgery plus radiotherapy) topped the factors influencing the use of recommended imaging, but MSA came in third (OR 1.42, 95% CI 1.35 to 1.51). Use of PET/CT imaging was influenced most by the type of surgery a patient, followed by MSA (OR 1.82, 95% CI 1.70 to 1.97).

"Age and therapy make sense as predictors of breast imaging, but it doesn't make sense that where you live makes a difference in whether you wee likely to get a follow-up mammogram or high-cost imaging," Franc said in a statement. "What's actionable here is that we have these guidelines, but doctors aren't following them."

The nature of the data used for the analysis did not provide insight into the reasons for the geographic variation. In an email response to MedPage Today, Franc cited several possibilities.

"In part, doctors in local areas may develop cultures of medical care that emphasize certain habits, essentially saying, 'That's how we do it around here.' These habits can persist even as guidelines change."

Another potential factor might be local awareness or access to information related to imaging tests, such as the national impact on prophylactic mastectomy and genetic testing that followed actress Angelina Jolie's personal experience with breast cancer.

"This phenomenon can occur at much more local levels, where the 'celebrity' could be a local radio personality or even someone vocal in a support group," said Franc. "These factors can influence patients to ask their physicians for tests that are recommended by guidelines, which is a positive outcome. Likewise, patients may insist on tests that are not necessarily indicated and have associated drawbacks, such as unnecessary exposure to medical radiation and financial toxicity."

The study by Keating's group was supported by the National Cancer Institute. Keating disclosed support from NCI.

Franc disclosed no relevant relationships with industry. One co-author disclosed a relevant relationship with Sutter Medical Group.

2018-07-17T17:30:00-0400
Comments

Accessibility Statement

At MedPage Today, we are committed to ensuring that individuals with disabilities can access all of the content offered by MedPage Today through our website and other properties. If you are having trouble accessing www.medpagetoday.com, MedPageToday's mobile apps, please email legal@ziffdavis.com for assistance. Please put "ADA Inquiry" in the subject line of your email.



Source link

Teen suicide risk may be lower with intense team-based therapy

0



July 17, 2018 / 10:25 PM / Updated 10 minutes ago

Teen suicide risk may be lower with intense team-based therapy

(Reuters Health) – Adolescents who have harmed themselves or tried to commit suicide may be less likely to do it again when they participate in an intense therapy program focused on both individual and family treatment, a U.S. study suggests.

The research focused on what’s known as dialectical behavior therapy. This involves a combination of individual sessions for teens and their parents as well as family counseling. The goals include helping teens eliminate behavior that leads to self-harm, suicide, or reduced quality of life; teaching skills like mindfulness and emotion regulation; and helping teens and families change behaviors.

The study included 173 adolescents, ages 12 to 18, who had at least three previous episodes of self-harm, attempted suicide, or suicidal thoughts. Researchers randomly assigned teens to receive either six months of dialectal behavior therapy (DBT) or supportive therapy, which wasn’t as intense.

After six months of treatment, patients who received DBT were 70 percent less likely to attempt suicide and 67 percent less likely to harm themselves than teens who received supportive therapy, the study found.

“We already had strong evidence across multiple studies that DBT was effective at reducing suicidal and self-harm behaviors in adults, and there was a lot of hope in the field that DBT could be similarly effective for teens, given the high risk of suicide in this age group,” said study co-author Michele Berk, a psychiatry researcher at Stanford University in California.

“We finally have a treatment for adolescents that meets the gold standard for a `well-established’ evidence-based treatment for youth at high risk for suicide,” Berk said by email.

Teens were almost 15 years old on average at the start of the study and most were female.

Youth who received dialectical behavior therapy had weekly individual psychotherapy, group therapy sessions and skills training for families, youth and parent telephone coaching, and weekly consultations with teams of therapists involved in treatment of teens and their parents or other family members.

Overall, about 46 percent of teens in the DBT group completed at least 24 individual therapy sessions, compared with 16 percent of the youth in supportive therapy.

By the end of the six-month treatment period, 65 of 72 teens, or 90 percent, receiving DBT had no additional suicide attempts, compared with 51 of 65, or 78 percent, receiving supportive therapy, the study found.

In addition, 39 teens in the DBT group, or 54 percent, had no episodes of self-harm, compared with 24, or 37 percent of adolescents in supportive therapy.

After one year, however, there were no longer meaningful differences between treatment groups in suicide attempts or self-harm episodes.

One limitation of the study is the lack of male patients. Although teen girls are more likely to attempt suicide, adolescent boys are more likely to die, researchers note in JAMA Psychiatry. It’s not clear if results in female patients would apply to males.

Even so, the results build on some previous research suggesting that DBT might be effective for teens as well as for adults, said Dr. Paul Wilkinson, author of an accompanying editorial and a psychiatry researcher at the University of Cambridge in the UK.

“This is the second (and largest) randomized controlled trial that has shown DBT to be better than treatment as usual for adolescents with repeated self-harm,” Wilkinson said by email. “I think DBT worked because it was a more complex in-depth therapy, that was better at teaching adolescents and families strategies to reduce self-harm, and the feelings that lead to self-harm.”

SOURCE: bit.ly/2Nqpxjd JAMA Psychiatry, online June 20, 2018.




Source link

Screen time linked to ADHD symptoms in teens

0



July 17, 2018 / 8:45 PM / Updated 8 minutes ago

Screen time linked to ADHD symptoms in teens

(Reuters Health) – Teens who spend lots of time surfing the web, playing games and chatting with friends on smartphones and tablets may be more likely to develop ADHD symptoms than youth who don’t, a U.S. study suggests.

Researchers followed more than 2,500 Los Angeles high school students over two years, asking about symptoms of attention deficit hyperactivity disorder (ADHD) and their digital media habits.

None of the students had ADHD symptoms at the start of the study. Teens who reported frequent use of a wide variety of digital media platforms at the start of the study, however, were about 10 percent more likely to develop ADHD symptoms within the next two years, researchers report in JAMA.

“This study raises new concerns whether the proliferation of high-performance digital media technologies may be putting a new generation of youth at risk for ADHD,” said senior study author Adam Leventhal, director of the Health, Emotion, & Addiction Laboratory at the University of Southern California in Los Angeles.

“While digital media use in moderation might provide some benefits, like access to educational information or social support, excessive exposure to digital media entertainment could have adverse mental health consequences,” Leventhal said by email.

Older forms of screen time – like television watching and playing video games on consoles – have long been linked to an increased risk of ADHD and other emotional and behavioral problems, especially when teens are engaged in these activities for hours on end. But less is known about the long-term health effects of all the apps on smartphones and tablets.

A lot may depend on how often teens are being interrupted by beeps and buzzes from their phones, how they engage with their devices, and what types of social interactions they have in real life, Levanthal said.

Adolescents who are constantly getting notifications to check a message or do something with an app may lose their ability to focus and stay engaged in tasks like schoolwork for long periods of time, he said. Binge-watching videos, meanwhile, might interfere with the development of patience, impulse control, and the ability to delay gratification.

None of the students displayed symptoms of ADHD at the start of the study. Researchers assessed them with a standard questionnaire asking about symptoms like difficulty organizing and completing tasks, trouble remaining still or staying focused on activities.

Over the next two years, researchers surveyed teens every six months to see how often they did 14 different digital activities including texting, streaming videos or music, and sharing on social media.

High frequency users did these activities many times a day. Among 51 students in this category, about 11 percent developed ADHD symptoms by the end of the study.

Another 114 participants reported high frequency use of seven digital activities, and about 10 percent of these students also developed symptoms of ADHD during the study.

But among the 495 teens who didn’t do any of these activities frequently, slightly less than five percent developed ADHD symptoms.

The study wasn’t a controlled experiment designed to prove whether or how lots of screen time might directly cause symptoms of ADHD. It’s also possible some participants had undetected symptoms of ADHD when they joined the study or that teens who developed symptoms gravitated toward digital media as a result.

Even so, the results add to the evidence suggesting that parents should regulate how teens use smartphones and tablets, said Dr. Jenny Radesky, author of an accompanying editorial and a professor of pediatrics at the University of Michigan C.S. Mott Children’s Hospital in Ann Arbor.

“Rather than focusing on a time duration, I recommend that parents take stock of their family’s usual day, and identify where some downtime or single-tasking could occur,” Radesky said by email.

“Parents can take the lead and show their kids when and where they choose to create boundaries around media use (for example, putting their phone away during meals, or car rides, or setting an evening device curfew), and have their kids do the same,” Radesky advised.

SOURCE: bit.ly/2NX2Pju and bit.ly/2NXeZJl Journal of the American Medical Association, online July 17, 2018.




Source link

Pelzman's Picks: The Art of Giving Bad News

0


Medpage Today

Pelzman’s Picks: The Art of Giving Bad News

Also, a potential staffing "ghost town" at nursing homes

MedpageToday

  • by

Fred N. Pelzman, MD, of Weill Cornell Internal Medicine Associates and weekly blogger for MedPage Today, follows what’s going on in the world of primary care medicine. Pelzman’s Picks is a compilation of links to blogs, articles, tweets, journal studies, opinion pieces, and news briefs related to primary care that caught his eye.

2018-07-17T15:00:00-0400
Comments

Accessibility Statement

At MedPage Today, we are committed to ensuring that individuals with disabilities can access all of the content offered by MedPage Today through our website and other properties. If you are having trouble accessing www.medpagetoday.com, MedPageToday's mobile apps, please email legal@ziffdavis.com for assistance. Please put "ADA Inquiry" in the subject line of your email.

Medpage Today

Pelzman's Picks: The Art of Giving Bad News

Also, a potential staffing "ghost town" at nursing homes

MedpageToday

  • by

Fred N. Pelzman, MD, of Weill Cornell Internal Medicine Associates and weekly blogger for MedPage Today, follows what's going on in the world of primary care medicine. Pelzman's Picks is a compilation of links to blogs, articles, tweets, journal studies, opinion pieces, and news briefs related to primary care that caught his eye.

2018-07-17T15:00:00-0400
Comments

Accessibility Statement

At MedPage Today, we are committed to ensuring that individuals with disabilities can access all of the content offered by MedPage Today through our website and other properties. If you are having trouble accessing www.medpagetoday.com, MedPageToday's mobile apps, please email legal@ziffdavis.com for assistance. Please put "ADA Inquiry" in the subject line of your email.



Source link

Growing Array of Street Drugs Now Laced with Fentanyl

0


Medpage Today

Growing Array of Street Drugs Now Laced with Fentanyl

Physicians, officials spotlight grim trends and possible solutions

MedpageToday

  • by Washington Correspondent, MedPage Today

WASHINGTON — Fentanyl is increasingly appearing in commonly abused drugs including heroin, cocaine, and marijuana, creating new challenges for physicians, said healthcare officials and emergency room doctors at an event here Tuesday.

While doctors have known for some time that patients frequently overdosed on a combination of opioids and alcohol, or opioids and benzodiazepines, there has been a new trend emerging: “Fentanyl is being used to lace a wide variety of drugs, including marijuana,” said Nora Volkow, MD, director of the National Institute on Drug Abuse, speaking at a Politico Pro 2018 Summit panel.

Physicians and policy experts are seeing overdoses due to multiple drugs taken by one person, and in some instances that individual may not even be aware of their own polypharmacy.

Opioids and fentanyl in particular are highly addictive, creating a business opportunity for drug pushers, she suggested.

“Even though you don’t know that it’s the opioid, you’ll crave the drug that you had that sensation with and therefore seek the same dealer,” Volkow continued.

As a result, her agency is seeing “a significant increase” in overdoses from cocaine and methamphetamine, “presumably also combined with other drugs.”

This creates new challenges for clinicians, she said.

Two weekends ago, Philadelphia emergency physician Jeanmarie Perrone, MD, said her department witnessed “a surge,” with six or seven overdoses every night.

“When the patients woke up after they received Narcan, they said that they had only been doing cocaine and that they had no idea that there were opioids in their cocaine,” said Perrone, a summit speaker and director of Medical Toxicology for the University of Pennsylvania Perelman School of Medicine.

This is not the same as patients who admit to using multiple drugs, Perrone noted.

“I wonder if this is an even intentional adulteration to expand the population of opioid users … That panics me even more,” she said.

Said Volkow, “We are seeing that even though the mortality rate is very high, it continues to climb, which means more individuals are getting exposed to these drugs.”

Seeking Solutions

Even though her emergency room has services to quickly connect those with addiction issues to services — presumably following an overdose — Perrone said she is amazed by how often people aren’t ready for treatment.

“Despite the fact that we’re presenting a solution, they don’t see it as a solution,” she said, perhaps because it is being offered by physicians.

Recently, Perrone’s hospital expanded the care teams to include individuals in recovery. Certified recovery specialists, as they are known, serve as the patients’ advocates and are on call 24/7, she said.

In one program in New York, these specialists arrive at the scene of an overdose or treatment center and continue to follow up with patients for 90 days.

Even if patients reject the offer of treatment at first, “when the treatment issue comes up again, they’re more ready and they have a person to turn to,” Perrone said. “Having an advocate really makes the treatment pathway much better.”

In West Virginia, one of the hardest-hit states by the opioid epidemic, the state’s public health commissioner has made addiction treatment and overdose prevention a priority.

Rahul Gupta, MD, MPH, MBA, had his staff conduct an in-depth analysis of every one of West Virginia’s 887 overdose deaths in 2016.

After scouring public databases, Medicaid roster, medical examiner reports, birth and death records, as well as criminal records, he was able to piece together a portrait of the epidemic’s most likely victims. These happened to be men who worked in blue collar jobs, who were between the ages of 35 and 64, and who had less than a high school education.

Through the research, Gupta’s staff found that only 71% of people who overdosed had been given naloxone.

So Gupta began requiring all first responders to carry the opioid overdose-reversal drug, as well as having it available in elementary schools and public libraries. He also made naloxone available under a standing order beginning in January.

While overdose deaths in 2017 still grew by about 2% to 909 from 2016, “deaths slowed by about 25% in the second half of the year,” the Politico website reported in May.

At the summit, Gupta said he is now focused on predictive modeling.

In a resource-limited environment, it’s important to find the people who are highly likely to overdose, so that states like West Virginia can better allocate their resources with the goal of preventing those deaths.

The challenge is getting people connected to treatment, when they are ready for it, Gupta noted.

2018-07-17T15:30:00-0400
Comments