Adult HPV Vaccine Age, Guidelines

The HPV vaccine is having a significant effect of decreasing cervical cancer.  More recently HPV is associated with oral cancer and anal cancer.

HPV goes through latex And many of  other sexually transmitted diseases do not.  Many adults don’t know that the “safe sex” procedures they use may not work with HPV.

This recent review of this CDC information says that the vaccine has a low side effect rate in adults.  The CDC data is established up to age 26.  The CDC cannot recommend the vaccines for older adults.  Adults older than 26 years who are sexually active should examine this data and balance that with their HPV risks.

 Gardasil 9 has the broadest range of efficacy.  The Prevents infection by 9 different types of HPV virus.  These 9 types account for 90% of cervical cancers.”                                                                  Bill Chesnut M.D.

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  • ·         Why Adults Should Get the HPV Vaccine
  • ·         When Should Adults Get the HPV Vaccine?
  • ·         Are There Any Adults Who Should Not Receive the HPV Vaccine?
  • ·         What Are the HPV Vaccine Ingredients?
  • ·         What Are the Risks and Side Effects of the HPV Vaccine?
    Human papillomavirus (HPV) is the virus that causes cervical cancer in women and genital warts in men and women. The HPV vaccine effectively prevents infection with the HPV types responsible for most cervical cancers and can also prevent genital warts. HPV vaccination is most effective during childhood or adolescence, but adults can also benefit from the HPV vaccine.

Why Adults Should Get the HPV Vaccine

HPV infection is extremely common; most sexually active people will be infected with HPV at some point in life. HPV infection usually causes no symptoms, but can cause genital warts and anal cancer in both women and men. HPV can also cause throat cancer.

In women, HPV infection can cause cells in the cervix to grow abnormally. In a small fraction of women, these HPV-induced changes will develop into cervical cancer. About 12,000 women are diagnosed with cervical cancer each year and about 4,000 women die from the condition.

The HPV vaccine prevents infection by the HPV types responsible for most cervical cancers. There are three available forms of the HPV vaccine:

Cervarix: Prevents infection by HPV-16 and HPV-18. These two HPV types cause 70% of all cervical cancers. It is used for the prevention of cervical cancer and precancers.
Gardasil: Prevents infection by HPV-16, HPV-18, and also HPV-6 and HPV-11, the two HPV types that cause 90% of genital warts. It is used to prevent cancers and precancers of the cervix, vulva, vagina, anus, penis, and throat.
Gardasil 9: Prevents infection by the same HPV types as Gardasil, plus HPV-31, HPV-33, HPV-45, HPV-52, and HPV-58. Collectively, these types are implicated in 90% of cervical cancers.
All HPV vaccines are extremely effective at preventing infection by the HPV types they cover. Getting the HPV vaccine reduces a woman’s risk of cervical cancer and precancerous growths substantially. Men cannot develop cervical cancer, but the HPV vaccine may prevent genital warts, anal cancer, and the spread of HPV to sexual partners. Gardasiland, Gardasil 9 are approved for males ages 9 through 26.

The HPV vaccine does not treat or cure an HPV infection in women or men who are already infected by one of these HPV types.

When Should Adults Get the HPV Vaccine?

The CDC recommends that all women ages 26 years and younger receive three doses of the HPV vaccine. The CDC recommends that all men ages 21 years and younger receive three doses of the HPV vaccine. It is an option for all men, but is recommended for men who have sex with men or who have a compromised immune system (including HIV) who are ages 26 and younger.

CDC guidelines recommend the three doses of the HPV vaccine should be given as follows:

First dose: ideally at ages 11 or 12
Second dose: one to two months after the first dose
Third dose: six months after the first dose
Some adults may have received doses of the HPV vaccine in childhood or adolescence. All three doses should be given to get the most protection from HPV infection. Re-vaccination in adulthood is recommended if the vaccination schedule was not completed.

Are There Any Adults Who Should Not Receive the HPV Vaccine?

Certain people should not get the HPV vaccine or should wait before getting it:

Anyone who has had a life-threatening allergic reaction to a previous dose of the HPV vaccine
Anyone who has had a previous life-threatening allergic reaction to an ingredient in the HPV vaccine
Pregnant women
Anyone with a moderate or severe illness; people who feel mildly ill may still receive the HPV vaccine.
The HPV vaccine is not known to be harmful to pregnant women or their babies. However, until more information is known, pregnant women are advised not to receive the HPV vaccine. Women who are breastfeeding can safely receive the HPV vaccine.

The HPV vaccine’s safety and effectiveness have not yet been studied in adults older than age 26. Until that information is available, the HPV vaccine is not recommended for adults older than age 26.

What Are the HPV Vaccine Ingredients?

The HPV vaccine contains no viruses and is not made from human papillomavirus. The active ingredients in the HPV vaccine are proteins that are similar to those found in the human papillomavirus. Genetically modified bacteria produce the proteins, which are then purified and mixed into a sterile, water-based solution.

What Are the Risks and Side Effects of the HPV Vaccine?

In clinical trials and in real-world use, the HPV vaccine appears to be very safe. More than 40 million doses of the vaccine — mostly Gardasil, which was approved in 2006 — have been given in the U.S. Cervarix was approved in 2009 and Gardasil 9 was approved in 2014.

From 2006 to 2014, there were about 25,000 reports to the government of HPV vaccine side effects. Over 90% of these were classified as nonserious. The most common side effects of the HPV vaccine are minor:

About one in 10 people will have a mild fever after the injection.
About one person in 30 will get itching at the injection site.
About one in 60 people will experience a moderate fever.
These symptoms go away quickly without treatment. Other mild-to-moderate side effects resulting from the HPV vaccine include:

Arm pain

Severe side effects, or adverse events, are uncommonly reported and have included:

Blood clots
Guillain-Barre syndrome
Chronic inflammatory demyelinating polyneuropathy
Systemic exertion intolerance disease (formerly called chronic fatigue syndrome)
Government, academic, and other public health investigators could not identify the HPV vaccine as the cause of any severe adverse event. There were 117 deaths as of September 2015, none of which could be directly tied to the HPV vaccine. The conclusion of public health investigators was that the HPV vaccine was unlikely to be the cause of these events. Such events occur at a certain rate in any group of tens of millions of people. The vaccination before each adverse event seemed to be a simple coincidence.


Administration working to reshape healthcare with 34 new regulations before next January

“This type of change in American healthcare delivery allows unintended consequences. I find it interesting to look up the professional biography of the physicians involved in making these changes. My experience is the vast majority of these doctors do not have qualifying experience delivering care to understand the complexity of this issue. Put me to the test and look up the practice experience of the top expert in this matter, Dr. Patrick Conway, chief medical officer at the Centers for Medicare and Medicaid Services, who oversees CMMI.” Bill Chesnut, MD

(Return to New Health News,

Obama Administration working to reshape healthcare before next January.                                                       AMA News May 10, 2016.

STAT (5/10, Scott) reports that as January 20, 2017 approaches, “the Obama administration is racing to burnish its health care legacy, introducing major new initiatives that will take full effect just weeks before the president leaves office.” The article says the number of uninsured has dropped significantly because of the Affordable Care Act, yet, Administration officials are moving “to use other parts of the law to reshape how health care itself is delivered across the United States.” According to the Administration, “34 initiatives have been announced or are currently being tested at” the Center for Medicare and Medicaid Innovation.
WASHINGTON — As the clock ticks toward Jan. 20, 2017, the Obama administration is racing to burnish its health care legacy, introducing major new initiatives that will take full effect just weeks before the president leaves office.

The ranks of the uninsured have dropped dramatically since the passage of the Affordable Care Act six years ago. But administration officials are now hustling to use other parts of the law to reshape how health care itself is delivered across the United States.

They’re trying to tackle the biggest health care issue of the day — drug prices— and setting ambitious goals for revamping how primary care is provided. They have also undertaken significant new efforts when it comes to paying for surgeries and preventing disease.

What will happen over the next eight months is as much as these projects can be accelerated, they will be,” said Kathleen Sebelius, the former US Health and Human Services secretary. “The time clock is very much in everybody’s mind.”

Every administration tries to get as much done as it can before time runs out, but this White House has a tool that none of its predecessors did: an agency created by the Affordable Care Act and given $10 billion over 10 years to test new models for paying for and delivering health care.

The administration seems intent on stretching the authority given to this new agency, called the Center for Medicare and Medicaid Innovation, as far as it can in its final days. The agency, for instance, recently proposed a new plan for overhauling Medicare Part B drug payments — and it’s mandatory for many providers.

“They are definitely taking a broad interpretation of the authority and using it as a vehicle,” said Caroline Pearson, senior vice president at Avalere Health, an independent consulting firm. “They’re trying to push through as much regulatory reform as they can.”

The administration said that 34 initiatives have been announced or are currently being tested at CMMI.

Broadly speaking, the agency has stuck to widely supported ideas for improving health care. That means paying doctors as a group to treat a patient instead of for each individual service, which should foster cooperation. And it means encouraging preventive care to forestall more costly problems down the road.

“We believe delivery system reform, and the work of the innovation center, is truly bipartisan,” said Dr. Patrick Conway, chief medical officer at the Centers for Medicare and Medicaid Services, who oversees CMMI. “We think it will continue beyond this administration.”

But some of its work is highly controversial — and will still be in its infancy when the next administration takes over, putting it at risk of being undone.

The second part of the Medicare drug overhaul, which aims to encourage doctors to prescribe less expensive drugs without sacrificing the quality of care, is currently expected to take effect after Jan. 1, 2017.

The pharmaceutical industry is lobbying hard against it, and some physician and patient groups have also said they are deeply concerned. Republicans in Congress have already urged the White House to withdraw the proposal altogether. The opponents describe the plan as an overreach of what CMMI was intended to do and warn it could compromise the care that cancer patients receive.

“The part that maybe was unforeseen was the size of the demo, the fact that it was mandatory, the length of time that it was in existence, and the lack of detail about pretty significant changes” to drug payments from the insurance program, Lori Reilly, executive vice president of policy and research at PhRMA, told reporters at a recent briefing.

There is some disagreement about what would need to be done to undo what the Obama White House is trying to accomplish — Could a President Trump just sign a piece of paper? Or would he need to go through the regulatory process? What about any contracts that have been signed? — but everybody acknowledges that a GOP president and a Republican Congress could find a way to stop the plans that this administration has put into motion.

“If the Republicans win and get their acts together, I think Phase 2 never gets implemented,” Pearson said. “It probably doesn’t go anywhere.”


Where the Health Care Dollars Go

“US Healthcare is in flux and looking for a better way to take care of our sick. This graph shows the exact percentages of spending. Physician’s services are 15.9 % of the healthcare dollar. A pie chart showing the size of the slices is a part of this particle. It can’t be produced here.  Please use the link to the AMA below for the graphics and complete information. 

Please notice in the sixth paragraph that physician service cost rose 4.1% annually in total between 2004 and 2014. The AMA did not calculate this figure to account for the increase in physicians, PA, Nurse practitioners between 2004 and 2014. I don’t have that figure. Common sense implies the amount of the tax care dollar spent for services by individual providers has decreased a lot.” Bill Chesnut, MD.

 To go back to New Health News:

Where the health care dollars go                                         AMA News_3/4/2016   Visit the AMA’s spending in health care Web page for further insight.

With all the talk about rising health care costs, you may be wondering how those vital dollars are being spent. A new analysis answers this question.

A close look at national health expenditures can offer physicians a clearer vision of the total costs and funding that are required each year to keep the health care system functioning. A new analysis (log in) from the AMA sheds light on health care spending.

In 2014, the last year for which data are available, U.S. health expenditures were more than $3.0 trillion—which breaks down to $9,523 per person. This reflects a growth rate of 5.3 percent over 2013. “In comparison,” the analysis said, “spending grew by 2.9 percent in 2013 and by an average of 4.0 percent per year” from 2007 to 2012.

“Despite the uptick,” the analysis said, “the 5.3 percent growth rate is still low by historical standards.”

“Important factors behind the acceleration in growth include the coverage expansions of the Affordable Care Act (ACA) as well as the introduction of new drug treatments for hepatitis C, cancer and multiple sclerosis,” the analysis said.

Out of that $3.0 trillion, only 15.9 percent went to physician services. Furthermore, physician spending grew by an average of only 4.1 percent per year between 2004 and 2014, which is 1.5 percentage points lower than the average annual growth rate for hospital spending and a full 2 percentage points lower than that for clinical spending, showing physician spending is not the main driver behind rising health care costs.

On the other hand, prescription drug spending rose 12.2 percent in 2014 (9.8%), marking an abrupt departure from growth rates of recent years. “There hadn’t been double-digit growth in this category since 2003,” the analysis said, “and post-2006 growth rates had remained well below 6 percent.” More than one-third of the new drug spending was from new treatments for hepatitis C.

Investigating a longer window of spending

The analysis also investigates the changes in health care spending over both 25 year and 50-year windows to present the patterns that allow analysts to look at short-term changes in a broader context.

The ACA Medicaid expansion’s effect on spending is evident in 2014. Medicaid spending increased by 11 percent—the largest single-year increase since 2001—and its share of spending increased from 15.5 percent to 16.4 percent.

The most dramatic change over the past ten years was in the share of spending paid for by Medicare, which increased from 16.4 percent of spending to 20.4 percent of spending between 2004 and 2014. Changes in the share of spending paid for by Medicare and Medicaid are tied to changes in program expansion and payment policy as well as cyclical economic factors for Medicaid.

Private health insurance has historically been the largest source of funds for health care spending since the 1970s. It continued this trend in 2014 with a 32.7 percent share of the pie, followed by Medicare and Medicaid—these three sources account for the majority of payments in the health care system. The smallest source of funds was out of pocket spending, whose share has continued to trickle downward over the past 50 years from a high of over 40 percent to only 10.9 percent in 2014.

Visit the AMA’s spending in health care Web page for further insight.


My Bronze plan’s monthly premium jumped $194 this year.

“This gentleman is experienced in administrative duties in healthcare and keeps good records of his expenses. He was president of an Ohio hospital.” Bill Chesnut, MD

To return to New Health News,

 $lammed by ObamaCare

My Bronze plan’s monthly premium jumped $194 this year. I never thought I’d look forward to Medicare, but I do now.      By CHRISTOPHER E. PRESS__   Wall Street Journal Opinion   March 7, 2016

This year my family joined millions of others whose health-insurance premium has become their biggest annual expense. More than our mortgage. More than our property taxes. More than our state income tax. More than our annual food or energy costs. With this year’s $194-a-month premium increase, I could roughly buy a Chevy Sonic or Ford Fiesta. Since 1999 our premiums are up 350%. Bad as this is, the story gets worse.

Each year our family is subject to paying health-insurance premiums and, if we see a doctor, deductibles and copays. Think of this total exposure as “health-care cost risk”—the sum of certain payments (premiums) plus the potential payments you could incur (copays and deductibles). Since early 1999 my family’s health-care cost risk has increased 1,190%. Over the same period, the Dow Jones Industrial Average is up about 80%, the consumer-price index is up 42%, gold is up 200%, median new home prices are up 74%, and the average cost per gigabyte of hard drive is down 99% to under three cents from $22.

Here’s the math behind my whopping increase. In 1999, having gone into business for myself, I needed health insurance for my then-young family. To enroll, I met a Blue Cross Blue Shield agent at Starbucks. (Quaint, huh?) We insured our family of four for $274 a month with a $250-per-person deductible.


Our annual health-care cost risk was $274 x 12, plus $1,000 in deductibles for a total of $4,288. My individual risk (that is, my personal share, excluding my dependents) was $1,072. By 2009, those figures had jumped to $10,716 in annual premiums for our family of four, plus $2,000 in deductibles—a threefold increase in health-care cost risk.

Since ObamaCare became law, the increase has been more than fourfold. The kids are “OTP”—off the payroll; just my wife and me now. In December 2014, I shopped on the Internet (not so quaint) for new health insurance. I bought a Bronze plan for two people that cost $1,037 a month and had a $12,600 family deductible ($6,300 each). We were blessed last year; we didn’t have perfect health but never filed a claim.

So I was shocked when my 2016 renewal notice showed a 19% monthly premium increase to $1,231—with a higher deductible. All comparable Bronze plans were within dollars of each other, so I grudgingly renewed. My individual health-care cost risk for 2016? It is $1,231 x 12, plus $12,900 in deductibles, for a grand total of $27,672. My individual share is half—$13,836. Nearly 13 times more than the $1,072 of 1999.

I accept that inflation accounts for some of this increase. And, being older, I present a higher actuarial risk. But 13 times more? The increase reflects an enormous shift of economic risk from the insurer to . . . me. One might think that this would lower my premium, not raise it. Alas, no. Risk assessment has gone kablooey.

I never thought I’d look forward to Medicare. If I were eligible today, my premium would be $122 a month, about one-tenth of my current premium. I have 21 months to go.

Many in the workforce have been shielded by their employers from the full effects of these changes. Small businesses, the self-employed, pre-Medicare retirees, part-timers and the unemployed have no shield. Who can be surprised if they go uninsured? If you can’t afford $14,000 in premiums, why pay them when all it buys is the exposure to another $14,000 (in deductibles) you don’t have?

I know the idea is that, over time, higher premiums and deductibles will lead to lower health-care prices, more competitors and better value. But “over time” reeks of the economists’ adage “in the long run”—when we’re all dead and, notably, have no health-care costs.

Meanwhile, how can we claim to have the world’s best health-care system when a healthy family’s insurance premiums are its largest household expense?

Mr. Press, a former president of Blanchard Valley Hospital in Ohio, is a health-care consultant and adjunct professor at Emory University’s Rollins School of Public Health.

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Quality reporting costs physicians thousands of dollars per year.

“The well-intended  but complicating reporting requirement for a provider when giving health care  has a negative effect on availability. Providers see fewer patients. Providers now often see the computer screen while providing healthcare. “Talking to the screen” instead of “talking to  the patient” damages the experience for both. It removes much of the pleasure of giving your best healthcare to the person in front of you.” Bill Chesnut, MD

To return to New Health News:

Quality reporting costs physicians thousands of dollars per year.

A study published in the March 2016 issue of the journal Health Affairs examines physician payment systems in the United States. Researchers surveyed 394 physician practices and found that physicians and staff averaged 15.1 hours per physician per week processing quality metrics—an equivalent of 785.2 hours per physician per year—at an average cost of $40,069 per physician per year. However, they noted that time and money spent reporting was lower for specialists compared to primary care physicians; primary care physicians averaged 3.9 hours per week dealing with quality measures, compared with 1.1 hours for orthopaedists. The researchers agree that much is to be gained from quality measurement, but write that “the current system is unnecessarily costly, and greater effort is needed to standardize measures and make them easier to report.”
Read more…

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Most physicians see income loss in new methods of calculating costs.

“The pressure on physicians when seeing medicare and Medicaid patients is increased by this government change  calculating payments. This particularly injures physicians in private practice  not employed by a hospital.” Bill Chesnut, MD

To return to New Health News:

 Few physician groups see increases under VBM program.

According to Modern Healthcare, for the second year in a row, relatively few provider practices benefited from the U.S. Centers for Medicare & Medicaid Services (CMS) value-based payment modifier (VBM) program. According to CMS data, 13,813 physician groups participated in the program, but only 128 group practices will see reimbursement increases, while 8,208 will remain unchanged and 5,477 (39.65105%) will be penalized. CMS is gradually phasing in the VBM program; it only applied to group practices of 100 or more eligible professionals during 2015, and to groups of 10 or more in 2016. In 2017, it will apply to all physicians and physician groups.

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MRI for the evaluation of knee pain: comparison of ordering practices of primary care physicians and orthopaedic surgeons.

“If you have knee pain and are considering a knee MRI, see an orthopedic surgeon first. This study shows the differences in treatment if the orthopedic surgeon orders the MRI compared to another specialty. Emphasis added is mine.” Bill Chesnut, MD

To return to New Health News:

 MRI for the evaluation of knee pain: comparison of ordering practices of primary care physicians and orthopaedic surgeons.

BACKGROUND: Knee pain is one of the most common reasons for outpatient visits in the U.S. The great majority of such cases can be effectively evaluated through physical examination and judicious use of radiography. Despite this, an increasing number of magnetic resonance images (MRIs) of the knee are being ordered for patients with incomplete work-ups or for inappropriate indications. We hypothesized that MRIs ordered by orthopaedic providers were more likely to result in changes in diagnoses and/or plans for care than those ordered by non-orthopaedic providers.

METHODS: We reviewed the charts of all consecutive new patients seen at our orthopaedic outpatient office between January 1, 2010, and December 31, 2011, with International Classification of Diseases, Ninth Revision (ICD-9) codes for meniscal or unspecific sprains and strains of the knee. A total of 1592 patients met our inclusion criteria and were divided into two groups: those initially evaluated and referred by their primary care physician (PCP) (n = 747) and those initially evaluated by one of our staff orthopaedic surgeons (n = 845).

RESULTS: MRI-ordering rates were nearly identical between orthopaedic surgeons and PCPs (25.0% versus 24.8%; p = 0.945). MRIs ordered by orthopaedic surgeons, however, resulted in significantly more arthroscopic interventions than those ordered by PCPs (41.2% versus 31.4%; p = 0.042). Orthopaedic surgeons ordered MRIs for patients who were more likely to benefit from arthroscopic intervention, including patients who were younger (mean age, 45.1 years versus 56.5 years for those with PCP-ordered MRIs; p < 0.001), patients with acute symptoms (39.3% versus 22.2%; p < 0.001), and patients with a history of trauma (49.3% versus 36.2%; p = 0.019). Finally, orthopaedic surgeons were less likely than PCPs to order MRIs for patients with substantial osteoarthritis who subsequently underwent total knee arthroplasty (4.3% versus 9.2%; p = 0.048).

CONCLUSIONS: MRI utilization by orthopaedic surgeons results in more appropriate interventions for patients with symptoms and findings most amenable to surgical intervention.  Author: Timothy T Roberts;Natalie Singer;Shazaan Hushmendy;Ian J Dempsey;Jared T Roberts;Richard L Uhl;Paul E M Johnson

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Interns spend four hours every day on electronic health records for ten patients.

“Each resident spent an average of 112 hours per month on 206 electronic patient record encounters.  The internal medicine interns spent 18,322 hours to review 33,733” electronic patient record encounters in just four months, the authors wrote. “Our study objectively measured interns’ EHR use and found that interns spent at least five hours a day on the EHR caring for a maximum of 10 patients, confirming prior subjective reports,” according to the study. Authors of the study noted one conclusion that few would dispute: Programs need to find novel solutions that will reduce the time residents spend on documentation in EHRs.”   Time spent faceto-a-screen rather than eyes on a patient is detrimental to physician training. So much is learned during training at the bedside or operating table directly evaluating a patient.” Bill Chesnut, MD

Documentation woes: Study tracks residents’ time spent on EHRs_____AMA Wire_3/2/2016,

How much time do your peers really spend dealing with electronic health records (EHR)? One internal medicine program explored that question and tracked the average “mouse miles”–or active time—residents spent using EHRs, and the results were very telling. Find out how many hours residents spent on EHRs in just four months, and see how you compare.

Exploring EHR usage among first-year residents

A team of researchers tracked the active EHR usage of 41 first-year residents at a university-affiliated community teaching hospital for the months of May, July and October 2014, and January 2015. During this time, “active EHR usage time was tallied for each patient chart viewed each day and was termed an electronic patient record encounter,” researchers recently wrote in a study published in the Journal of Graduate Medical Education. “The EHR usage activities within the electronic patient record encounter included chart reviews, orders, chart documentation and other activities.”

They also tracked the time first-year residents spent using resources within the EHR system, such as “as communicating with providers via text-paging and crosschecking regulatory, medical or peer-reviewed resources,” according to the study.

The results: Time residents spent on EHR and key behaviors

Using a built-in time tracking program within the hospital’s EHR, authors of the study found that:

Each resident spent an average of 112 hours per month on 206 electronic patient record encounters.  “The internal medicine interns spent 18,322 hours to review 33,733” electronic patient record encounters in just four months, the authors wrote.
The time residents spent on EHR usage is an objective finding consistent with previous literature that has been more subjective. “Our study objectively measured interns’ EHR use and found that interns spent at least five hours a day on the EHR caring for a maximum of 10 patients, confirming prior subjective reports,” according to the study.

Authors of the study noted that the majority of studies on EHR usage are often self-reported, whereas their findings are based on a tracking system within the EHR system, which provided automated tracking logs of interns’ EHR times and minimized the “error of human reporting” in the study’s data.

·         As residents became more familiar with EHRs, their time spent using them significantly improved. From July to January, total hours of active EHR use per resident decreased by 18 percent—shaving off roughly 23 hours of EHR time, despite residents having more patient encounters in January. Residents spent five hours a day on EHRs in January, as opposed to the seven hours a day they spent on EHRS in July.

“This improvement was most likely gained from increased familiarity with using the EHR, comfort with managing different clinical scenarios and learning from colleagues,” authors of the study noted.

·         Times spent on EHR activities—particularly chart reviews—also improved as residents learned how to navigate the EHR system. A significant reduction in time was noted across EHR activities from July to January, during which time residents reduced the time they spent on chart reviews and patient orders by two minutes. Documentation time decreased by three minutes, and time spent on other EHR activities went down by two minutes.
·         Residents may learn how to successfully navigate their EHR system in seven months or less. “In January, interns spent shorter or comparable time to interns from a different cohort during the previous May,” the study authors wrote. In fact, in January, residents in the study only spent 30 minutes using EHRs—just one minute more than the time interns from the previous year had spent on their EHRs in May.

“This suggests that interns reached the maximal proficiency level on clinical documentation prior to or around January,” the study authors wrote. “This is a novel observation to the best of our knowledge, which begs the question: Did the intern class reach their optimal time spent per electronic patient record encounter in seven months or less?”

Why residents need more time with patients, less time in EHRs

While the time residents needed to become completely proficient in EHR use remains debatable, authors of the study noted one conclusion that few would dispute: Programs need to find novel solutions that will reduce the time residents spend on documentation in EHRs.

Authors of the study noted that the findings correlate with national studies showing that residents are dissatisfied with the time they spend on EHRs. In a nationwide survey “residents’ perceptions of the time devoted to documentation were generally negative; residents felt that clinical documentation took time away from education, patient care and more importantly, motivation to provide high-quality care,” the study authors wrote. “This has been linked to reduced resident satisfaction and increased burnout.”


Warnings about concurrent use of opioids, benzodiazepines.

“This is an important health fact that is not broadly known. This is not research. It is a petition asking for warning labels. A combination of benzodiazepines and opioid pain medications is common. Benzodiazepines are a class of psychoactive drugs used to treat anxiety, insomnia, and a range of other conditions. They are one of the most widely prescribed medications in the U.S., particularly among elderly patients. Benzodiazepines possess sedative, hypnotic, anti-anxiety, anticonvulsant, and muscle relaxant properties.” Bill Chesnut, MD.

Public health officials petition FDA to add boxed warnings about concurrent use of opioids, benzodiazepines.

The Washington Post (2/22, Dennis) reports in “To Your Health” that “dozens of public health officials and academics across the country are pushing the Food and Drug Administration to warn people about the potential dangers of taking” opioid pain medications along with benzodiazepines. In a petition, officials from 41 state and municipal health departments, as well as some universities, “urged the agency” to add boxed warnings to both medications, “given evidence that using them together increases the chance of deadly overdoses.”


ACA had little effect on ED visits

“Improving healthcare delivery is a continuing effort always in motion. The lack of urgent care availability and the education of the public about using them is a challenge we will address.” Bill Chesnut, MD

ACA had little effect on ED visits, CDC report finds

US News & World Report (2/18, Leonard) reports on its “Data Mine” blog that a government report released Thursday suggests the Affordable Care Act “is still far from achieving” its goal of reducing visits to emergency departments. The report from the CDC’s National Center for Health Statistics found that in 2014, the percentage of adults visiting the ED “didn’t differ much from the year before, despite the fact that 7.9 million gained coverage between the two years.” The report stated that ED “use overall has not changed significantly after the first full year of ACA implementation.”

AMA News 2.21, 2016.


Long-term hospice care driving up costs for Medicare

“Hospice care is another shining testament to our society caring for the dying. Hospice is a wonderful service of exceptional providers with one of the most difficult tasks in medicine. The hospice program must be protected from misuse that endangers its ability to continue its mission. This type of transparent accounting is necessary.” Bill Chesnut, MD

 Long-term hospice care driving up costs for Medicare_____AMA NEWS 2.19.16

The Wall Street Journal (2/19, A1, Weaver, Mathews, McGinty, Subscription Publication) reports on its front page that while Medicare’s hospice program is supposed to cover only patients who physicians certify are likely to die within six months, a Wall Street Journal analysis of billing records shows about 107,000 beneficiaries between 2005 and 2013 received hospice care for an average of nearly 1,000 days, driving up costs for the program.


US military fails to provide adequate therapy for soldiers with PTSD

“This post is of the largest independent examination of mental health treatment in the military. It shows that we fail attempting to provide even the minimum of treatment visits for these veterans in PTSD.” Bill Chesnut, MD

 US military fails to provide adequate therapy for soldiers with PTSD, depression, study finds

USA Today (2/18, Zoroya) reports that a study released Feb. 18 by the RAND Corp. suggests that the US military is “struggling to provide adequate therapy sessions for thousands of active-duty troops suffering from post-traumatic stress disorder and depression.”

According to the study, only a third of troops suffering from PTSD and fewer than a quarter of those suffering from clinical depression receive the minimum number of therapy sessions once they have been diagnosed. RAND “described the study as the largest independent examination of mental health treatment in the military.”

AMA News Febrary 21, 2016.

Difficulties in accessing hospital price information

“This post is a problem. Hospital charges are not only difficult to obtain but are often impossible for most people to access. I experienced this a month ago trying to determine future medical costs. I talked to the admissions office of the hospital explaining the need for an estimate to remove the fracture hardware. They said they did not make that information available to anyone as a general policy. I can see it is complicated for a hospital. It might be a liability despite disclaimers. There is not an easy answer. My view is that a hospital should not be considered malevolent when refusing to release a price for future surgery. That may never be possible.

This post refers to information that cannot be confirmed quickly; a subscription is required. Typically I don’t consider using this type of material for medical research. This post is an exception” Bill Chesnut, MD

 Survey of 54 hospitals in six states reveals difficulties in accessing hospital price information

Modern Healthcare (2/21, Evans, Subscription Publication) reports that the Pioneer Institute in Boston, MA, “a health policy think tank,” conducted a survey using “mock consumers to test how accessible” hospital price information is. The survey found that “mock consumers found it ‘difficult and frustrating’ to get the price of a common and standard imaging procedure.” Even when prices were provided, they “were sometimes inaccurate,” the “survey of 54 hospitals in six states” revealed.


What Accounts For The Lower Growth In Health Care Spending?


“This post is from It is an easy to understand summary of the lowering of the growth of health care spending comparing 2000-2005 with 2005-2010.” Bill Chesnut, MD

What Accounts For The Lower Growth In Health Care Spending?  Kenneth Thorpe_February 18, 2016  

Several recent studies have examined the factors accounting for the recent slowdown in growth in real per capita health care spending. The most recent entrant to this literature is the newly published work ofDunn, Rittmueller, and Whitmire. Earlier work has identified two large categories of change as contributors to slower growth: the 2007-2009 recession, and other structural changes in the delivery and payment of health care. Understanding the relative role of these two factors is important in determining whether the slowdown is temporary or will be sustained.

The new paper by Dunn and colleagues builds on a framework that I developed with my colleagues at Emory in 2004-2005, that decomposes the growth in spending to changes in the prevalence of treated disease, spending per case treated, and population growth by medical condition. We have published several updates to this initial paper over the past ten years.

We found that the roles played by changes in treated prevalence and cost per case since the mid-1980s differ by time period and by payer. Rising treated prevalence has consistently been the major driver of rising Medicare spending over time, while prevalence plays a smaller role in growth in private health insurance spending. Understanding the factors that account for these variations over time may provide useful information in projecting trends in health care spending.

Dunn and colleagues examine data from 2000-2005 and 2005-2010 using the aforementioned decomposition. They conclude that the spending slowdown observed between 2005 and 2010 was traced largely to lower growth in cost per case. The reductions differed, however, by medical condition. One of their conclusions is that reduced growth in cost per case is linked, in part, to blockbuster drugs, such as Norvasc and Toprol XL to treat hypertension, which came off patent during the 2005 to 2010 time period.

Indeed, our tabulations show that nominal spending on hypertension during this period actually declined by $2 billion. Patent expirations have assumed an even more important role more recently, as $84 billion worth of branded drugs came off patent between 2010 and 2013 alone. Tracking trends in drugs scheduled to come off patent will provide important information regarding future spending trends.

Several other factors could also underlie the slowdown in the growth in treated prevalence and spending per case treated going forward. On the spending side, delivery system reforms and the migration away from fee-for-service payment are structural changes that will continue to put downward pressure on growth in spending per case. These reforms include bundled payments that provide incentives for more efficient placement of patients in post-acute care settings and reductions in readmissions and the costs of the initial hospitalization. Understanding the role of these shifts in the site of treatment will be helpful in projecting future spending trends.

Several other factors are likely to affect trends in treated prevalence. Most important may the recent slowdown in the growth in obesity rates, which will affect both the incidence and prevalence of several chronic conditions. There is already some evidence that the incidence and prevalence of diabetes has leveled off between 2008 and 2012. Tracking the role of changes in chronic disease incidence and prevalence overall and by payer will provide useful information in determining whether the slower growth in spending is short lived or may continue.

Adding these epidemiologic prevalence trends to the more traditional national health account projections methodology may enable more precise health care spending projections overall and by source of treatment.


Is BMI an Independent Risk Factor for Unfavorable Outcomes Following Total Hip Arthroplasty

“These two commentaries are editorial balance to an article ‘ Effect of Body Mass Index on Complications and Reoperations After Total Hip Arthroplasty’. I did not post the original article as the commentaries explain the research and the healthcare problem that is developing. This problem is that CMS has changed payment for surgery in total hip replacement to a bundle, a single payment to the hospital, who then pays the surgeon. This starts in April, 2016. The amount of payment is affected by the complication and readmission rate. Both hospitals and surgeons will be pressured, probably forced into selecting healthy patients who will have lower complications and faster recovery. Both of those factors change what the hospital is paid and the profile of the surgeon. There is not an answer I can see inside this new payment construct, which begins April 1 for most hospitals and the surgeons who operate there. This is my best understanding of the real conflict that will effect healthcare decisions. I am not a part of the discussions occurring as I retired July, 2015.” Bill Chesnut, MD


Is BMI an Independent Risk Factor for Unfavorable Outcomes Following Total Hip Arthroplasty?

Commentary on an article by Eric R. Wagner, MD, et al.: “Effect of Body Mass Index on Complications and Reoperations After Total Hip Arthroplasty”

Nader Toossi, MD; Norman A. Johanson, MD

J Bone Joint Surg Am, 2016 Feb 03; 98 (3): e11 .


High body mass index (BMI) has been shown to have a strong association with unfavorable outcomes following total hip arthroplasty1. An increasing proportion of patients undergoing total hip arthroplasty have a high BMI value2. The article by Wagner et al. is a single institution’s retrospective review of prospectively collected data regarding 21,361 primary total hip arthroplasties performed between 1985 and 2012. The relationship between BMI, as an independent variable, and outcomes were reported as hazard ratios, and survival estimates were made by the Kaplan-Meier method. The findings are largely consistent with those of the current literature; however, the treatment of BMI as a continuous variable is unique and represents an advance in understanding obesity in more of a “dose-response” relationship to surgical complications and points to a more refined risk-adjustment strategy. This is the greatest strength of the study.

A limitation of the study is its failure to address the combined effect of diabetes and high BMI on the surgical outcomes. Diabetes mellitus is strongly associated with both high BMI values and certain surgical complications, such as periprosthetic joint infection and wound dehiscence3. Although the authors offered a credible explanation for the increased risk of infection, they did not present statistical evidence of controlling for the confounding effect of diabetes in their analysis. There are different ways to control for the confounding effect of diabetes on the outcome, such as case-matching, stratification, or adjusting for diabetic status in a multivariable analysis. The investigators could have stratified the patients on the basis of their diabetic status, or they could have adjusted for diabetes in the Cox model in addition to the other variables, such as age, sex, and preoperative diagnosis.

Although the large number of cases in this study is an advantage, and the focus on long-term follow-up (an average of ten years for the total cohort) is usually considered to be a point of strength in studies of arthroplasty outcomes, the long follow-up duration in this specific study is fraught with a limitation. Independent variables, such as sex and race, are constant throughout the lifetime of a patient. Some independent variables, such as age, follow a predictable trend over time. However, BMI neither remains constant nor follows a predictable trend over time4,5. This variability may confound the interpretation of outcomes, especially those that have a significant dose-response relationship. Additionally, the normal-BMI cohort may change its weight and, accordingly, BMI over the long term. The BMI value at the time of a complication or revision years later might vary substantially from the value at the time of total hip arthroplasty. Thus, one of the weaknesses of the present study is due to the inability to follow trends of BMI for individual patients during a long duration of follow-up postoperatively. The longer the follow-up duration, the higher the chances that the BMI value would change over the period of study.

Despite these limitations, the article paves the way for future and more comprehensive studies. This study points toward the importance of examining larger and more contemporary databases to elucidate the impact of higher levels of BMI, such as morbid obesity (a BMI of ≥40 kg/m2) and super obesity (a BMI of ≥50 kg/m2), on the array of commonly encountered complications.


What Will We Do Now with the Super-Obese Patient Undergoing Total Hip Arthroplasty?

Commentary on an article by Kimona Issa, MD, et al.: “Bariatric Orthopaedics: Total Hip Arthroplasty in Super-Obese Patients (Those with a BMI of ≥50 kg/m2)”

Raymond Paul Robinson, MD

J Bone Joint Surg Am, 2016 Feb 03; 98 (3): e12 .


The increasing body weights of our patients and the growing responsibility to avoid postoperative adverse events have put a new urgency into expanding our knowledge of the impact of comorbidities such obesity on our patients and health-care system. Thirty years ago in my own practice, performing a total hip replacement on a patient with a body mass index (BMI) of >40 kg/m2 was unusual. Higher complication rates were expected and were addressed as necessary. Now even heavier patients are appearing in our clinics, putting more pressure on surgeons and hospitals. The implementation of bundled payment requiring that hospitals cover any postoperative complication or need for readmission within ninety days will further increase these pressures. Not surprisingly, there is concern that patients with comorbidities such as extreme obesity may not be able to obtain care.

Issa et al. present new data about outcomes and complications of super-obese patients undergoing total hip arthroplasty. These data will be helpful in understanding the cost of care and expectations of the patient and health-care professionals. The authors present an excellent retrospective review of forty-five patients (forty-eight hips) with a minimum BMI of 50 kg/m2 who underwent total hip arthroplasty at one of four high-volume joint centers. They compare implant survival, complication rates, Harris hip scores, Short Form-36 (SF-36) scores, and University of California Los Angeles (UCLA) activity scores with a matched control group of patients with a BMI of <30 kg/m2. Patients were followed for four to twelve years, which further contributes to the previous study by Issa et al. on super-obese patients undergoing total hip arthroplasty followed for three years1.

In the current study, Issa et al. report an 8.2% lower implant survival rate in the super-obese patient at a mean time of six years and a 4.5% rate of septic revision. Compared with the non-obese patients, super-obese patients had inferior clinical results, as demonstrated by significantly lower postoperative scores. It is important to note that these results were submitted from experienced surgeons practicing in high-volume joint centers.

Equally important is the documentation that, even from 2001 to 2010, super-obese patients had difficulty finding surgeons who would perform the surgical procedure on them. Although the authors do not tell us why other surgeons would not operate on these patients, bundled payment will likely make access to care even harder for these patients. This article provides needed data that will help us to understand the increased burden of the super-obese patient on our health-care system.

Issa et al. point out that the study was retrospective, although many of the data were accumulated prospectively. The authors also do not discuss the option of delaying the surgical procedure on these patients until and unless they lose weight or undergo a bariatric surgical procedure, which are relevant alternative approaches.


What to Read and How to Read It_about orthopedic education 2.3.2016

“This post is to draw attention to this exceptional article in February 2016 issue of  Journal of Bone and Joint Surgery. For those not in the orthopedic field, the figures here show the formidable  amount of new information that must be mastered to stay current.

There are great nuggets in this article. I encourage all orthopaedic surgeons ortho nurses, physicians and residents, to review it. “ Bill Chesnut, MD

Orthopedic training: “What to Read and How to Read It.”   A Guide for Orthopaedic Surgeons

Chad A. Krueger, MD; Joseph R. Hsu, MD; Philip J. Belmont Jr, MD      J Bone Joint Surg Am, 2016 Feb 03; 98 (3): 243 -249 .

With the increasing amount of information available to orthopaedic surgeons, the choice of what to read can seem difficult bordering on overwhelming. As orthopaedic surgery continues to evolve toward a more evidence-based education system, deciding what information resources to use is ever more important. Many orthopaedic surgeons have had little formal instruction on what educational resources to read or how to best understand the information and assimilate it into their practice. This lack of knowledge may contribute to difficulties when trying to learn a topic, develop a plan of care, build a knowledge base for patient care, or develop a method for maintenance reading. This article reviews the rationale for using evidence-based medicine, explores the different types of educational resources available to orthopaedic surgeons, and delivers insight into the science of reading. This information should aid orthopaedic surgeons in using peer-reviewed publications to aid in their decision-making processes.

An Overwhelming Amount of Information

Although the exponential rise in publications has added immense knowledge to the field of orthopaedic surgery, the influx of data has made staying current with the literature very difficult. A few recent articles have attempted to address this issue13. There are more than 100 orthopaedic journals indexed on MEDLINE4, and more than 12,000 articles were published in orthopaedic or sports medicine journals in 20135. In addition, more than 600 of the orthopaedic surgery books available on were published in 2014 alone6. For an orthopaedic surgeon, reading only the articles in The Journal of Bone & Joint Surgery (American Volume) (JBJS) and Clinical Orthopaedics and Related Research would equate to reading approximately 120 articles per month. For a specialist primarily focused on reading The American Journal of Sports Medicine andArthroscopy, there are nearly sixty articles to read per month. If this is what is considered “staying current,” the time requirement to read even most of these articles is substantial and likely exceeds the amount of time that most responsible surgeons budget toward maintenance reading. Furthermore, this reading does not account for the time an orthopaedic surgeon spends finding, downloading, and interpreting information concerning patient or procedure-specific questions or reading other resources such as textbooks. This volume of information necessitates that an orthopaedic surgeon understand what resources to use in what circumstance and how each resource can most efficiently be utilized.

We are unaware of any widespread, formal instruction on how to identify the resources that will most effectively provide residents and practicing orthopaedists with the information they seek. The difficulties in identifying high-yield materials combined with varying levels of comfort in properly interpreting the methods and results of many primary sources7,8 leaves surgeons frustrated with the perceived overload of educational material available. For many of these reasons, surgeons and trainees alike tend not to read full scientific articles, preferring the more manageable abstracts instead9,10.

Take-Home Point

There is too much information produced in orthopaedics for one person to read and assimilate without a self-directed educational plan.


Mortality, readmission rates at VA hospitals may be similar to those at other facilities.

“This article in JAMA is a high five salute to the VA hospital system for large improvements. The original article in Jama is titled “Association of Admission to Veterans Affairs Hospitals vs Non–Veterans Affairs Hospitals With Mortality and Readmission Rates Among Older Men Hospitalized With Acute Myocardial Infarction, Heart Failure, or Pneumonia.”  The research studied 104 VA and 1513 non-VA hospitals, with each condition-outcome analysis cohort for VA and non-VA hospitals containing at least 7900 patients (men; ≥65 years), in 92 MSAs.
The authors have this conclusion: “Conclusions and Relevance  Among older men with AMI, HF, or pneumonia, hospitalization at VA hospitals, compared with hospitalization at non-VA hospitals, was associated with lower 30-day risk-standardized all-cause mortality rates for AMI and HF, and higher 30-day risk-standardized all-cause readmission rates for all 3 conditions, both nationally and within similar geographic areas… “

The article discusses changes during this period, 2010-2013. One parameter not studied that interests me is the ratio of medical staff members to patients. VA hospitals are often a part of a medical school teaching program with more students and residents participating in the care. Bill Chesnut, MD.

“Mortality, readmission rates at VA hospitals may be similar to those at other facilities, study finds

A new study on death rates and readmissions indicates VA hospitals “compare pretty favorably with others when it comes to treating older men with three common conditions – heart attacks, heart failure and pneumonia,” the AP (2/9, Tanner) reports. The 2010-2013 study, published in the Journal of the American Medical Association, found the “chances for dying or being readmitted within 30 days of treatment for those conditions varied only slightly for patients hospitalized within the VA system versus at outside hospitals.” These findings “contrast with longstanding concerns about challenges facing veterans and the VA health system, including quality questions and long waits for care.”

Reuters (2/9, Doyle) also reports on the study, noting while that 30-day mortality rates for heart attack and heart failure were slightly lower at VA hospitals, pneumonia deaths were slightly higher. However, all of the differences were less than one percentage point. Likewise, hospital readmissions for all of the conditions were higher in VA hospitals, but the differences were small.

AMA News 2.10.2016.

Hospitals employing physicians drives up costs compared to physicians who are not hospital employed for the same service.

“This comprehensive study documents that Medicare and Medicaid pay more for physician services if a hospital employs the physician. The details are here: file:///C:/Users/william/Desktop/JAMA%20Network%20_%20JAMA/Hospital%20employing%20physicians%20drives%20up%20costs..pdf  “Bill Chesnut, MD

Solving America’s opioid crisis: Remember the patient

“Caring for patients with chronic pain is complicated. It requires close attention and frequent monitoring of the treatment response. “ Bill Chesnut, MD

 Solving America’s opioid crisis: Remember the patient  AMA News_1/25/2016, 3:43 PM

Physicians, medical organizations and public health experts around the nation all have shared reasons why the opioid overdose epidemic must be top of mind in the medical world, and it comes down to one focus—the patient. A panel of experts recently gave recommendations that lead the way to making patient-focused pain management possible.

Reducing the stigma of chronic pain

One important aspect of the efforts to combat the opioid epidemic is reducing stigma so that patients with chronic pain do not lose access to the care that they need.

“What is our role as physicians in this current problem?” asked John A. Renner, MD, president of the American Academy of Addiction Psychiatry and professor of psychiatry at Boston University School of Medicine, speaking to physician leaders at the AMA State Legislative Strategy Conference earlier this month during a session on the opioid crisis.

“This epidemic is not going to be contained until we change practice within medicine,” Dr. Renner said. “Medicine does not shrink from treating these chronic conditions.”

There are many things that physicians can do now to begin those changes, he added. “Before prescribing opiates for either acute or chronic pain, the clinician must screen every patient for a history of substance use disorders and for co-occurring psychiatric disorders. A review of the PDMP should be part of every routine assessment.”

“Recognize that patients with any history of alcoholism or substance use disorder are at higher risk for abuse, and they should be managed very carefully,” Dr. Renner said. “This means avoiding prescribing opiates if there are other medications that may be more effective, careful[ly] prescribing … opiates if that is necessary, [and] it means monitoring the patient carefully, to look at how the treatment is progressing.”

However, this does not mean withholding opiates from patients with acute pain, he said.

Dr. Renner cited a case where a patient with a history of addiction needed surgery. The surgeon gave the patient a four-day supply of opioids but also carefully monitored the patient during those four days and the time following to make sure the patient’s pain was managed sufficiently.

“Sometimes prescribing [opioid-based] medication is the best way to prevent relapse,” Dr. Renner said. In other cases, “we need to work with primary care physicians as well as pain management specialists to develop alternatives for handling chronic pain without relying on opiates.”

“There is a moral imperative to treat pain,” said Myra Christopher, the Kathleen M. Foley chair for pain and palliative care at the Center for Practical Bioethics. “Those who are in the healing professions have ethical and moral obligations to do so.”

“That does not mean that there is a moral imperative, an ethical duty or obligation to prescribe opioids,” she added. “It means there is a moral imperative to address this issue [of chronic pain].” One solution, Christopher suggested, is to increase training in pain management.

“If you ask any medical school applicant” why they want to go to medical school, “they will say ‘I want to alleviate, or I want to treat pain and suffering,’” Christopher said. “That notion is really the foundation of what it means to be a healing profession.” However, although comprehensive management for chronic pain is necessary for many patients, most physicians have inadequate training on this approach.

Actions physicians can take to end the overdose crisis

In conjunction with patient-focused chronic pain management, physicians also need to be vigilant in taking steps to prevent overdose and treat patients who are living with substance use disorder.

“Where do we start when there are 44 people dying from opioid-related overdoses every day?” said Patrice A. Harris, MD, chair-elect of the AMA Board of Trustees, who also chairs the AMA Task Force to Reduce Prescription Opioid Abuse, during her opening remarks.

“This public health crisis related to opioid misuse and heroin addiction results in nearly 30,000 deaths annually and challenges us as physicians to amplify our current efforts and actions,” Dr. Harris said. “We use the word ‘actions’ deliberately [because] we must take concrete actions that will help end this crisis.”

The task force focuses on five recommendations for all physicians from “inside the profession,” Dr. Harris said. “These recommendations come from physicians who treat acute pain, chronic pain and patients who have substance use disorder. We must also look inwardly …. As physicians, we run toward the health crisis, not away from it.”

Action No. 1: Physicians should “voluntarily register for and use [their] state prescription drug monitoring programs (PDMP),” Dr. Harris said.

One example of a successful PDMP comes from the Ohio State Medical Association (OSMA). Also speaking on the panel with Christopher and Dr. Harris, Michael Bourn, DO, medical director of pain and palliative services at Doctor’s Hospital in Columbus, Ohio, described the success of his state’s PDMP for physician leaders.

The Ohio Automated Rx Reporting System (OARRS) is a tool to track the dispensing and personal furnishing of controlled prescription drugs to patients. OARRS is designed to monitor this information for suspected abuse or diversion and can give a prescriber or pharmacist critical information regarding a patient’s controlled substance prescription history to identify high-risk patients who could benefit from early intervention.

In 2010 there were about 5,000 Ohio prescribers with a voluntary OARRS account, but that number has increased to over 36,000 presently and counting. Between 2007 and 2014 the number of OARRS reports requested increased 5,900 percent, signifying its expanded use throughout the state in just seven years. In that same seven year period, Ohio experienced an approximately 50 percent decrease in “doctor shoppers” throughout the state and saw a significant drop in the number of patients seeking multiple prescriptions.

Action No. 2: “Focus on education,” Dr. Harris said. “Encourage yourselves and encourage your colleagues to ask themselves: When was the last time you took CME that was focused on opioid prescribing, to learn how to effectively use your state’s PDMP and to learn how to recognize the signs of abuse?”

Actions Nos. 3 and 4: “The third and fourth recommendations have to do with the stigma of pain,” Dr. Harris said. It’s important to reduce the stigma that surrounds pain patients in order for those with chronic pain to receive the care and the prescriptions they need to live happier, healthier lives, Dr. Harris said. It is also important to reduce the stigma of substance use disorder and increase access to treatment so patients feel comfortable in seeking that treatment.

Action No. 5: “Consider co-prescribing naloxone and support broad Good Samaritan protections,” Dr. Harris said. Last year access to naloxone—the life-saving medication that can reverse the effects of an opioid overdose by restoring breathing and preventing death—was increased substantially through new products and availability. “At the end of the day, remember what is most important—our patients.”

From JAMA Newsletter 1.26.16.                                 By AMA staff writer Troy Parks


Study finds physicians may be hesitant to recommend HPV vaccine for young adults

“This is so important to protect our youth. Do everything you can.” Bill Chesnut, MD.

Study finds physicians may be hesitant to recommend HPV vaccine for young adults

NPR (10/23) reports in its “Shots” blog that vaccination rates for human papillomavirus (HPV) “have remained far lower than rates for other routine childhood and teen immunizations.” A study found the reason for the low rates may be that primary care physicians “treat the HPV vaccine differently from other routinely recommended immunizations, hesitating to recommend it fully and on time and approaching their discussions with parents differently. In the actual NPR newsletter the title is Doctors, Not Parents, Are The Biggest Obstacle To The HPV Vaccine.

“The single biggest barrier to increasing HPV vaccination is not receiving a health care provider’s recommendation,” said lead study author Melissa Gilkey, an assistant professor of population medicine at Harvard Medical School. That’s more of an issue, she says, than parents’ decisions to refuse or delay HPV vaccination.

“Discomfort talking about sex appears to be a more salient factor” than safety concerns about the vaccine.

Nearly all cervical cancers result from HPV infections, which can also cause vaginal, vulvar, anal, penile or head and neck cancers. Although most strains of HPV infections go away on their own, a three-dose series of the vaccine protects against the strains responsible for an estimated 90 percent of HPV-related cancers.

The Centers for Disease Control and Prevention recommends it for all girls and boys ages 11 and 12 because it’s most effective prior to first engaging in sexual activity.”

Read the entire report here:



As opioid use disorders increase, physicians offer solutions

“The use of opioid medications to control pain is increasing because more physicians are taught to address chronic pain and be effective. With increased prescribing, there is increased misuse, nonmedical use, and suicide by opioid overdose. How to manage chronic pain as safely as possible is a daily conundrum in medical practice. There are additional methods we could use that are not yet widely known, such as “multimodal therapy.” Here is more data to consider.

The natural tendency of governing agencies writing more rules to restrict access is not useful except in denying care.  All healthcare is local, in my view. We need to do much more in each of our medical communities to address the pain maladies we see locally.” Bill Chesnut, MD

 As opioid use disorders increase, physicians offer solutions    AMA News_10/13/2015, 5:12 PM

As the opioid epidemic remains a devastating issue for patients and their families, a study published Tuesday in JAMA highlights the need to enhance access to treatment to curb the rising toll opioid use disorders are taking on the country.

The study conducted by Beth Han, MD and colleagues at the Substance Abuse and Mental Health Services Administration (SAMHSA) examines the prevalence of nonmedical use, opioid use disorders and related risk factors.

The study found that among adults age 18 through 64, the prevalence of nonmedical use of prescription opioids decreased from 5.4 percent in 2003 to 4.9 percent in 2013. Unfortunately, during the same time, the prevalence of prescription opioid use disorders increased from 0.6 percent to 0.9 percent.

The national discussion needs to center around a comprehensive public health approach that puts emphasis on treatment and education.

“Receiving treatment for substance use disorders is particularly critical,” the study states. “Most adults with prescription opioid use disorders or other substance use disorders neither receive treatment nor perceive a need for treatment. Particularly, policy and societal barriers prevent broad dissemination, access and adoption of highly effective medication-assisted therapies for people with prescription opioid use disorders.”

Another important element for addressing the epidemic is reducing the stigma surrounding substance use disorders to further promote treatment.

A second JAMA study published this week, conducted by researchers at the Johns Hopkins Bloomberg School of Public Health, found adjusted rates for the percentage of individuals with opioid use disorders receiving treatment were low: 18.8 percent in 2004-2008, increasing only to 19.7 percent in 2009-2013.

“Individuals in treatment received care in more settings, with the greatest increases in inpatient treatment and at physicians’ offices,” the authors said, further pressing for enhanced access to treatment. But, they continued, “Medication-assisted treatments are often unavailable in inpatient settings, which could hinder patient recovery.”

How physicians are tackling the need for enhanced treatment

The AMA recently submitted testimony (log in) to Congress calling for increased coverage for and access to treatment programs. “These are complex problems with no single solution,” the testimony said.

It emphasized the need to balance the treatment needs of pain patients with efforts to curb misuse. These include promoting appropriate prescribing, reducing diversion and misuse, promoting an understanding that substance use disorders are chronic conditions that respond to treatment, and expanding access to treatment for individuals with substance use disorders.

In the battle against opioid abuse, how can physicians in direct contact with patients enhance access to treatment? The AMA Task Force to Reduce Opioid Abuse supports enhanced treatment access and is helping physicians learn how to identify patients at risk for developing a substance use disorder. The Task Force is offering resources for physicians on its Preventing Opioid Abuse Web page.

The task force has identified five important goals for physicians:

  1.  Register and use your state prescription drug monitoring program(PDMP) to check patients’ prescription histories.
  2.  Educate themselves on managing pain and promoting safe, responsible opioid prescribing.
  3.  Support overdose prevention measures, such as increased access to the overdose reversal drug naloxone.
  4.  Reduce the stigma of substance use disorder and enhance access to treatment.
  5.  Ensure patients in pain aren’t stigmatized and can receive comprehensive treatment.

US prescription opioid abuse declines, but disorders and overdose deaths rise

Reuters (10/13, Doyle) reports that a new study published in the Journal of the American Medical Association found that the number of Americans abusing prescription opioid medications declined from 5.4% to 4.9% between 2003 and 2013. However, the study also found that the rate of opioid use disorders increased from 12.7% to 16.9% and the number of prescription opioid overdose deaths increased from 4.5% to 7.8% per 100,000 people over the same timeframe. A corresponding research letter in JAMA also found that from 2004 to 2013, the use of opioid addiction treatment options did not change in proportion to the number of opioid users.


How to beat burnout: 7 signs physicians should know

“I include this article from the AMA News for its insights which apply to many types of work and workers. It may help patients to understand their communications with some providers.” Bill Chesnut, MD.

How to beat burnout: 7 signs physicians should know

AMA News_3/4/2015, 2:36 PM

If constant stress has you feeling exhausted, detached from patients, or cynical, take notice. You may be in danger of burnout, which studies show is more prevalent among physicians than other professionals. But how can you avoid it? Learn the signs of physician burnout and what you can do to stay motivated on the job.

Mark Linzer, MD, Director of the Division of General Internal Medicine at Hennepin County Medical Center in Minneapolis, has studied physician burnout since 1996. He said he understands why many physicians eventually feel exhausted practicing medicine, but this problem is avoidable.

“Burnout doesn’t have to be highly expensive to fix,” Dr. Linzer said. “The problem is that no one is listening. People always want to say that physician wellness and performance measures will cost a lot of money, but preventing burnout can actually save money in the long run on recruiting and training new practice staff.”

If physicians want to keep burnout at bay, Dr. Linzer said there are some serious signs they should never ignore. Here are seven ways to know if your practice is getting the best of you—and when to finally do something about it:

  1. You have a high tolerance to stress.  
    Stress consistently ranks as the number one predictor for burnout among physicians, Dr. Linzer said. “Please don’t ignore the stress, even if you can take it,” he said. Physicians who consistently operate under high stress are at least 15 times more likely to burn out, according to his research.
  2. Your practice is exceptionally chaotic.  
    A quick glance around your practice will let you know if you or your colleagues may cave to stress. “People tend to think it’s the patients that always stress doctors out, but actually, it’s the opposite,” Dr. Linzer said. “Caring for patients keeps doctors motivated. What burns them out is caring for patients in a high-stress environment. Change the environment and you’ll change the overall quality of care.”
  3. You don’t agree with your boss’ values or leadership.  
    This one is particularly tricky to identify but “necessary to prevent burnout,” Dr. Linzer said. Whether at a large hospital or private practice, physicians need to feel as if the people leading them also share their values for medicine and patient care. Otherwise, their motivation can slowly wane.
  4. You’re the emotional buffer.  
    Working with patients requires more than medical expertise. “Often, the doctor acts as an emotional buffer,” Dr. Linzer said. “We will buffer the patient from our own stressful environment until we can’t take it anymore.”
  5. Your job constantly interferes with family events.  
    Spending quality time with loved ones helps physicians perform better. “When they can’t do those things, it’s all they think about during the day and the patient suffers,” Dr. Linzer said, citing work-life interference as one of the most common predictors for burnout among physicians in his studies.
  6. You lack control over your work schedule and free time.  
    When work demands increase, but control over your schedule doesn’t, stress can kick in and spark burnout. That’s why Dr. Linzer often tells practices, “If you standardize, customize”— a medical mantra to suggest that if physicians must work a long standardized set of hours each week, practices should at least customize their schedules to flexibly fit changes or needs in their daily lives.
  7. You don’t take care of yourself. 
    When was the last time you enjoyed a nice bubble bath or morning run? If you continually neglect yourself, you may neglect your patients, too. “As physicians, we want to be altruistic but one of the keys to altruism is self-care,” Dr. Linzer said.


How physician burnout compares to general working population.

“This trend is concerning. The physician burnout rate is escalating yearly recently. The causes are multifactorial and primarily from the environment in which physicians increasing work. Burnout turns the provider’s communications toward less kindness and empathy. Those qualities are essential to enjoy being a health care provider.” Bill Chesnut, MD

 How physician burnout compares to general working population.

AMA News_1/27/2016, 4:23 PM

Over just three years, physicians reported a nearly 9 percent increase in burnout rates. But how does physician burnout compare to that of the general working population? A recent national study provides insights, including key findings on work-life balance.

Physicians compared to the general working population
Physician burnout experts at the AMA and the Mayo Clinic conducted a survey of 6,880 physicians to “evaluate the prevalence of burnout and physicians’ satisfaction with work-life balance compared to the general U.S. population relative to 2011 and 2014,” according to a study recently published in Mayo Clinic Proceedings.

Compared with the general U.S. population, physicians in 2014:

  • Were more likely to be married (82.9 percent for physicians versus 67.5 for the general U.S. working population).
  • Worked a median of 10 hours more per week (50 hours versus 40 hours).
  • Displayed higher rates of emotional exhaustion (43.2 percent versus 24.8 percent), depersonalization (23.0 percent versus 14.0 percent) and overall burnout (48.8 percent versus 28.4 percent).
  • Reported lower satisfaction with work-life balance (36.0 percent of physicians reported being satisfied with their work-life balance, compared to 61.3 percent of the general U.S. working population).

Heart disease undertreated, underdiagnosed in women

“This is an important subject. Please help spread the word.” Bill Chesnut, MD


Group says heart disease undertreated, underdiagnosed in women!

 NBC Nightly News (1/25, story 8, 2:00, Holt) reported that an American Heart Association report “says heart disease remains undertreated and underdiagnosed in women.”

The Washington Post (1/25, Dennis) reports in “To Your Health” that “because the causes and symptoms of heart attacks can be strikingly different between the sexes, women are more vulnerable to slower diagnosis and inadequate treatment, according to” the “scientific statement published” in Circulation.

TIME (1/25, Sifferlin) reports that “women are also underrepresented in clinical trials for heart disease, the authors note.” Only about one-fifth of participants enrolled are women, “and even when women are included in trials, researchers often do not parse out the gender-specific data that could deepen scientists’ understanding of how the disease affects women.”

The CBS News (1/25, Marcus) website reports that the statement “also says black and Hispanic women are even more at risk for heart attacks and have poorer outcomes when they do have one.”


Four in ten Americans know someone addicted to opioids, survey finds

“Four in ten Americans know someone addicted to opioids, this survey finds. It is more prevalent than it is apparent. If someone’s behavior is off, and it wasn’t, suspect, they have a health problem that is being treated with opioids.” Bill Chesnut, MD

Four in ten Americans know someone addicted to opioids, survey finds

The Washington Post (11/24, Bernstein) reports that nearly four in 10 Americans “know someone who has been addicted to prescription” pain medications, “including 25 percent who say it was a close friend or family member and 2 percent who acknowledge their own addiction, according to a new poll” released today by the Kaiser Family Foundation. The survey also found that 16 percent of people say they know someone who has died from an opioid overdose. The Post adds that by “a margin of 77 percent to 58 percent, those polled say it is easy to get non-prescribed” pain medications “than say it is easy for people who medically need the drugs to get them.”

Bloomberg News (11/24, Tozzi) reports that the demographics of those “touched by the crisis skew white, higher-income, college-educated, younger, and male.” According to the article, drug overdoses “are eclipsing car crashes as a leading cause of accidental death for American adults.”

Drew Altman, president and CEO of the Kaiser Family Foundation, writes on the Wall Street Journal (11/24) “Washington Wire” blog that the broad impact of opioid addiction means the issue will likely gain more political traction.

Sen. Shaheen proposes $600 million in additional funding to fight opioid abuse TheAP (11/24, Ramer) reports that Sen. Jeanne Shaheen (D-NH) “is proposing $600 million in emergency funding to address” an opioid abuse “crisis that she says is spiraling out of control.” Shaheen, who announced her funding bill yesterday, said, “This should be an all-hands-on-deck moment, not just for New Hampshire but for our country.” According to the AP, most of the money in Shaheen’s proposal would go to HHS, including $250 million distributed to states as block grants for prevention and treatment programs. The CDC “would get $50 million to support work on prescription monitoring and other programs, and the National Institute on Drug Abuse would get $35 million for targeted research on drug addiction.”

AMA newsletter, November, 2015.