Tuesday, December 13, 2022

UC San Diego health recognized for health equity in care of sickle cell crisis

Telemedicine program designed to reduce health disparities

Grant and Award Announcement

UNIVERSITY OF CALIFORNIA - SAN DIEGO

Vandenberg and Gopal, UC San Diego Health 

IMAGE: THE CAPH AWARD WAS ACHIEVED WITH THE LEADERSHIP OF CHAD VANDENBERG, MPH, CHIEF QUALITY AND PATIENT SAFETY OFFICER, SRILA GOPAL, MBBS, MEDICAL DIRECTOR OF THE ADULT SICKLE CELL PROGRAM, AND THE ENTIRE TEAM AT UC SAN DIEGO HEALTH. view more 

CREDIT: UC SAN DIEGO HEALTH

UC San Diego Health has been awarded the prestigious 2022 California Association of Public Hospitals and Health Systems (CAPH) Quality Leaders Award (QLA) in the category of health equity. Every year, CAPH showcases the most impressive initiatives that improve and advance high-quality, equitable health care among member systems. 

Health equity is the state in which everyone has a fair and just opportunity to attain their highest level of health. This year’s award recognizes UC San Diego Health for forward thinking in establishing same-day infusion treatment protocols for individualized pain control for patients with sickle cell disease, a population of patients that often face racial discrimination. 

“On behalf of the medical team at UC San Diego Health, I am thrilled to accept this award from CAPH. The award recognizes our universal commitment to caring for patients in a safe, timely and equitable manner, regardless of race or ethnicity,” said Srila Gopal, MBBS, hematologist and medical director of the adult sickle cell program at UC San Diego Health. “In this case, we developed a novel approach to caring for patients with sickle cell disease in medical crisis.”

“Sickle cell disease is a disease of significant health care disparities,” said Patty Maysent, CEO, UC San Diego Health. “Our team took the initiative to investigate the issue and to develop an effective telemedicine strategy and program to help patients receive patient-centered care in a timely fashion.”

During the pandemic, UC San Diego Health launched a same-day infusion program for patients with sickle cell disease in extreme pain. The outpatient program is an alternative to the emergency department. 

“Patients are typically seen on the same day of reporting symptoms and as soon as an infusion slot becomes available,” said Gopal.

Sickle cell disease is a devastating inherited blood disorder that disproportionally affects individuals of African and Hispanic descent. Patients with the condition periodically experience excruciating pain when unhealthy red blood cells block blood flow through tiny blood vessels to the chest, abdomen and joints. Over time, the lack of oxygen to organs and tissues causes permanent damage.

The condition affects approximately 100,000 Americans and occurs in approximately 1 out of every 365 Black or African-American births. The estimated life expectancy for adult patients in California is 42 to 47 years old, a decade less than the rest of the country. 

“For patients in sickle cell crisis, intense pain can be accompanied by anemia and infections leading to tissue damage and strokes,” said Gopal. “Unfortunately, these patients often face bias and discrimination from providers who incorrectly assume that requests for pain management are a ‘drug seeking’ behavior for opioids rather than a legitimate health emergency.”

Episodes of pain for these patients represent a “vaso-occlusive crisis” that must be addressed without delay to protect vital organs. Treatment may include supportive care including fluids, pain medication and occasionally antibiotics and blood transfusions.

“What we have seen as a result of implementation is that our emergency room unitization has significantly decreased,” said Gopal. “The program is an effective way to see patients in an outpatient setting while facilitating compassionate care.”

The telehealth program enables easy communication between medical providers and patients, allowing the medical team to attend to patient needs in a timely fashion, despite pressures of the pandemic. Care is coordinated among infusion and outpatient sickle cell teams, including nurse case managers, physicians, advanced care providers and schedulers.

Gopal and team hope to expand the program to further increase the number of patients treated, offer treatment after-hours and also collaborate with the emergency department in redirecting patients to the infusion center for treatment.

Adults with sickle cell disease have limited access to care in California. Recognizing this need, UC San Diego Health established a comprehensive adult sickle cell program and is part of the Networking California for Sickle Cell Care program.

VIDEO

Patients and doctors agree on treatment goals only half the time, according to JNCCN study on people with neuroendocrine tumors

Researchers from City of Hope find only 30% of people with neuroendocrine tumors consider living longer to be their single top priority; 70% said addressing and overcoming pain, fatigue, or lack-of-function was more important than just prolonging life.

Peer-Reviewed Publication

NATIONAL COMPREHENSIVE CANCER NETWORK

JNCCN Cover, December 2022 

IMAGE: JNCCN COVER, DECEMBER 2022 view more 

CREDIT: NCCN

PLYMOUTH MEETING, PA [December 12, 2022] — New research from cancer research and treatment organization City of Hope in the December 2022 issue of JNCCN—Journal of the National Comprehensive Cancer Network finds that only 30% of patients with advanced neuroendocrine tumors (NETs) say their top goal for treatment is living longer. The remaining patients selected other single specific treatment goals as most important, such as maintaining the ability to do daily activities, reducing or eliminating pain, or reducing or eliminating symptoms like fatigue. 66.7% of those surveyed agreed with the statement: “I would rather live a shorter life than lose my ability to take care of myself.”

However, respondents felt their doctors were more singularly focused on extending overall survival, even if it impacted other outcomes. Only 51.7% of patients perceived that they had the same treatment goals as their physician.

“As a result of this research, I think cancer care providers need to have more honest dialogue with all of their neuroendocrine tumor patients about treatment goals and priorities of various health outcomes from treatment,” said lead researcher Daneng Li, MD, Associate Professor in the Department of Medical Oncology & Therapeutics Research at City of Hope. “This finding really challenges the traditional dogma that patients just want to live longer. Discussions regarding treatment goals are essential to ensure that health care teams are truly respecting patients’ desires for what they would like to get out of their treatment and are incorporating those preferences into the selection of overall treatment choices and planning.”

The study was conducted with 60 patients with advanced NETs of gastrointestinal, pancreatic, thoracic, or unknown primary origin, who were starting a new line of systemic therapy between March 2019 and August 2020. In order to drill down on the impact of age, half of the patients were between 18 and 64-years-old, while the other half were 65-and-older. The patients’ feelings were tracked via four different survey methods ranking the importance of various outcomes and other preference-assessment tools.

Both younger and older patient groups ranked maintaining independence as the most valued outcome (46.7% for each), followed by survival (36.7% for younger, 23.3% for older), reducing or eliminating pain (16.7% and 6.7%), and reducing or eliminating dizziness, fatigue, and/or shortness of breath (0% and 23.3%).

“Patients with a cancer type that typically has a longer life expectancy often come to understand that the treatment journey is more of a marathon than a sprint. For these patients especially, the impact of treatment on how they feel on a day-to-day basis could impact their decision when choosing between various treatment options,” said Dr. Li. “Ultimately, the decision for a specific treatment is certainly individualized, and we hope that our study sheds light on the need for better communication between care providers and patients with neuroendocrine tumors in order to fully develop personalized treatment plans that are truly in line with the goals of each patient.”

“The study by Li, et. al. highlights the importance of considering the patient perspective when caring for patients with NETs,” agreed Emily Bergsland, MD, Professor of Medicine, UCSF Helen Diller Family Comprehensive Cancer Center, Director of the UCSF Center for Neuroendocrine Tumors, and Chair of the NCCN Guidelines® Panel for Neuroendocrine Tumors, who was not involved with this research. “Using validated surveys, the investigators found that adult patients with advanced NETs strongly value maintaining independence in daily activities over survival. Importantly, only about half of patients felt they shared the same primary treatment goal as their oncologist. The findings suggest a need for further research in this area, so we can better understand how to optimize patient-provider communication and ensure integration of patient preferences in treatment planning and medical decision-making.”

To read the entire study, visit JNCCN.org. Complimentary access to “Patient-Defined Goals and Preferences Among Adults With Advanced Neuroendocrine Tumors” is available until March 10, 2023.

New Journal Leadership

JNCCN is proud to welcome new members to the executive editorial board, who will serve under longtime editor-in-chief Margaret Tempero, MD—also with UCSFoverseeing strategic planning and content for the journal. A review committee selected the five following accomplished oncologists out of a pool of more than 100 qualified applicants:

  • Andrew J. Armstrong, MD, ScM, Professor of Medicine, Surgery, Pharmacology and Cancer Biology, and Director of Research, Duke Cancer Institute Center for Prostate and Urologic Cancer, and Duke University Medical Center
    • Specialties: Genitourinary oncology including bladder, kidney, prostate, and testicular cancers; clinical trials; translation medicine
  • F. Marc Stewart, MD, Professor and Vice Chair, Department of Hematology & Hematopoietic Cell Transplantation, City of Hope
    • Specialties: Medical oncology, hematologic malignancies, leukemia, lymphoma, cell transplantation
  • Amye J. Tevaarwerk, MD, Senior Associate Consultant, Associate Professor, Mayo Clinic Cancer Center
    • Specialties: Hematology/oncology, breast cancer, survivorship, clinic informatics, electronic health records, healthcare technology, coordination of care, quality of care
  • Lauren P. Wallner, PhD, MPH, Associate Professor, Department of Internal Medicine and Epidemiology, and Co-Lead, Cancer Control and Population Sciences Program, University of Michigan Rogel Cancer Center
    • Specialties: Health services researcher, implementation science, breast and   genitourinary cancers, survivorship
  • Mehran Yusuf, MD, Assistant Professor, O’Neal Comprehensive Cancer Center at UAB
    • Specialties: Radiation oncology, head and neck cancers, hematologic malignancies, thoracic cancers, skin cancers, soft tissue sarcomas, central nervous system cancers

They will join continuing Associate Editors June M. McKoy, MD, MPH, JD, MBARobert H. Lurie Comprehensive Cancer Center of Northwestern University; Anthony J. Olszanski, MD, RPhFox Chase Cancer Center; and Kanishka Sircar, MDThe University of Texas MD Anderson Cancer Center.

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About JNCCN—Journal of the National Comprehensive Cancer Network

More than 25,000 oncologists and other cancer care professionals across the United States read JNCCN—Journal of the National Comprehensive Cancer Network. This peer-reviewed, indexed medical journal provides the latest information about innovation in translational medicine, and scientific studies related to oncology health services research, including quality care and value, bioethics, comparative and cost effectiveness, public policy, and interventional research on supportive care and survivorship. JNCCN features updates on the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®), review articles elaborating on guidelines recommendations, health services research, and case reports highlighting molecular insights in patient care. JNCCN is published by Harborside. Visit JNCCN.org. To inquire if you are eligible for a FREE subscription to JNCCN, visit NCCN.org/jnccn/subscribe. Follow JNCCN on Twitter @JNCCN.

About the National Comprehensive Cancer Network

The National Comprehensive Cancer Network® (NCCN®) is a not-for-profit alliance of leading cancer centers devoted to patient care, research, and education. NCCN is dedicated to improving and facilitating quality, effective, equitable, and accessible cancer care so all patients can live better lives. The NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) provide transparent, evidence-based, expert consensus recommendations for cancer treatment, prevention, and supportive services; they are the recognized standard for clinical direction and policy in cancer management and the most thorough and frequently-updated clinical practice guidelines available in any area of medicine. The NCCN Guidelines for Patients® provide expert cancer treatment information to inform and empower patients and caregivers, through support from the NCCN Foundation®. NCCN also advances continuing educationglobal initiativespolicy, and research collaboration and publication in oncology. Visit NCCN.org for more information and follow NCCN on Facebook @NCCNorg, Instagram @NCCNorg, and Twitter @NCCN

An ounce of prevention: Differences in HIV prevention activities among rural and urban physicians

Study shows family medicine physicians in rural areas are less comfortable providing sexual risk reduction counseling to adolescents than urban providers

Peer-Reviewed Publication

TEXAS A&M UNIVERSITY

HIV remains a major public health concern in the United States, with adolescents and young adults (15-24 years old) making up around 20 percent of new infections in the nation each year. Prevention is key to stopping HIV, and the U.S. Food and Drug Administration’s approval of HIV pre-exposure prophylaxis (PrEP) in recent years gave high-risk people a new and effective tool to protect their health.

PrEP is an HIV prevention medicine that must be prescribed by a provider but use among adolescents remains low. Most research into PrEP prescribing practices has focused on urban health care providers and their comfort in prescribing PrEP to adult patients. HIV infections are more prevalent in cities, but infection rates have been increasing in rural areas. At the same time, urban and rural youth engage in higher risk behaviors in roughly equal proportions. Despite this, there has been little focus on rural physician practices and attitudes toward PrEP, which could help improve HIV prevention efforts for rural youth.

In a new study, Christopher Owens, PhD, assistant professor at the Texas A&M University School of Public Health, analyzes factors related to PrEP prescribing comfort among rural and urban physicians in the United States. The study, published in The Journal of Rural Health, used data from a survey of 256 physicians to determine how aware physicians are of PrEP, their PrEP prescribing practices, and their comfort level in implementing PrEP clinical activities for adolescents.

Although both rural and urban physicians reported similar proportions of implementing PrEP clinical activities—such as sexual history taking, HIV testing and STI testing—rural physicians reported being less comfortable providing sexual risk reduction counseling to adolescents than urban providers

This study shows an increase in PrEP awareness from previous work and points to differences in comfort with PrEP-related activities between urban and rural providers that warrants further exploration. Future studies should look into how clinical resources, patient and provider demographics and other factors affect these outcomes.

This study and further research could help develop trainings and improvements to clinical resources, especially for physicians in rural communities where HIV infection rates are rising. HIV remains a significant health issue in both rural and urban communities, but it is important to increase rural physician’s comfort level in implementing PrEP-related clinical activities.

Low-carb diet may help patients with diabetes achieve better weight loss and glucose control in short term compared to a low-fat diet

Embargoed News from Annals of Internal Medicine

Peer-Reviewed Publication

AMERICAN COLLEGE OF PHYSICIANS


Below please find summaries of new articles that will be published in the next issue of Annals of Internal Medicine. The summaries are not intended to substitute for the full articles as a source of information. This information is under strict embargo and by taking it into possession, media representatives are committing to the terms of the embargo not only on their own behalf, but also on behalf of the organization they represent.
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1. Low-carb diet may help patients with diabetes achieve better weight loss and glucose control in short term compared to a low-fat diet
Abstract: https://www.acpjournals.org/doi/10.7326/M22-1787
URL goes live when the embargo lifts
A randomized controlled trial of more than 100 persons with type 2 diabetes found that a low-carbohydrate, high-fat, calorie unrestricted diet helped patients achieve better weight loss and glucose control over a 6-month intervention compared to a high-carb, low-fat diet. The changes were not sustained 3 months after the intervention, suggesting a need for long-term dietary changes to maintain meaningful health benefits. The findings are published in Annals of Internal Medicine.

More than 480 million people worldwide are affected by type 2 diabetes. More than half of persons with diabetes also have nonalcoholic fatty liver disease (NAFLD), which can progress to cirrhosis and impair liver function. Prior studies suggest that weight loss improves both diabetes control and NAFLD and restriction of carbohydrate intake improves the control of blood sugar levels.

Researchers from the University of Southern Denmark, Odense, Denmark, randomly assigned 165 persons with type 2 diabetes to either a LCHF diet or a HCLF diet for 6 months. Participants in both groups were asked to eat the same number of calories equal to their energy expenditure. Participants on the low carb diet were asked to eat no more than 20% of their calories from carbohydrates but could have 50- 60% of their calories from fat and 20-30% from protein. Patients on the low-fat diet were asked to eat about half of their calories in carbohydrates and the rest evenly split between fats and proteins. The authors found that persons on the low carb diet reduced hemoglobin A1c by 0.59 percent more than the low-fat diet, and also lost 3.8 kg more weight compared to those in the low-fat group. The low carb dieters also lost more body fat and reduced their waist circumference. Both groups had higher high-density lipoprotein cholesterol and lower triglycerides at 6 months. However, changes were not sustained 3 months after the intervention, suggesting that dietary changes need to be sustained over the long term to maintain effects. The liver was not affected by the high fat intake in the low-carb group: The researchers found no difference on the amount of liver fat or inflammation between the two groups.

Media contacts: For an embargoed PDF, please contact Angela Collom at acollom@acponline.org. To speak with corresponding author Aleksander Krag, MD, PhD, please email Camila Dalby Hansen at Camilla.Dalby.Hansen@rsyd.dk.
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2. Nirmatrelvir plus ritonavir may reduce risk for hospitalization or death from COVID-19
Abstract: https://www.acpjournals.org/doi/10.7326/M22-2141
URL goes live when the embargo lifts
A retrospective cohort study of more than 44,000 nonhospitalized persons diagnosed with COVID-19 found that nirmatrelvir plus ritonavir reduced the overall risk of hospitalization and death. The study is published in Annals of Internal Medicine.

In the EPIC-HR (Evaluation of Protease Inhibition for Covid-19 in High-Risk Patients) trial, nirmatrelvir plus ritonavir led to an 89% reduction in hospitalization or death among unvaccinated outpatients with early COVID-19. The World Health Organization recommended nirmatrelvir plus ritonavir in April 2022, but only for the highest-risk persons and advised against use in most vaccinated and other lower-risk persons. The clinical impact of nirmatrelvir plus ritonavir among vaccinated populations is uncertain.

Researchers from Brigham and Women's Hospital and Harvard T.H. Chan School of Public Health studied 44,551 nonhospitalized persons with COVID-19 aged 50 years or older in the Mass General Brigham healthcare system to assess whether nirmatrelvir plus ritonavir could reduce the risk for hospitalization or death in the setting of prevalent SARS-CoV-2 immunity and immune-evasive SARS-CoV-2 lineages. More than 90% of participants had at least 3 vaccine doses at the time of the study. During the study period, 28.1% of participants received nirmatrelvir plus ritonavir and 71.9% did not. The authors found that recipients of nirmatrelvir plus ritonavir had 40% lower risk for hospitalization and 71% lower risk of death, although the risk for either was already very low (less than 1%). Overall, the mortality rate among persons prescribed nirmatrelvir plus ritonavir was 0.55% and 0.97% among persons who were not. The authors note that among those who were diagnosed as outpatients, Black, Hispanic, or Latinx patients had much lower rates of prescription of nirmatrelvir plus ritonavir. To realize the public health potential of outpatient COVID-19 therapy, clinicians must address this gap and these disparities.

Media contacts: For an embargoed PDF, please contact Angela Collom at acollom@acponline.org. To speak with corresponding author Scott Dryden-Peterson, MD, MSc, please contact Mark Murphy at mmurphy90@bwh.harvard.edu.
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3. Early engagement with affected communities helped to control mpox outbreak in Montreal
Abstract: https://www.acpjournals.org/doi/10.7326/M22-2699
URL goes live when the embargo lifts
An analysis of the first large mpox outbreak in North America found that early, sustained engagement and rapid offering of preexposure vaccination to affected communities successfully controlled the spread of the outbreak. The analysis is published in Annals of Internal Medicine.

Mpox is historically endemic to west and central Africa but spread significantly in other countries in 2022, primarily among the men who have sex with men (MSM) community. During this time, Montreal, Quebec, Canada, emerged as the site of the first large outbreak in North America.

Researchers from McGill University Health Centre, Montreal, Canada characterized and analyzed the epidemiologic, clinical, and demographic data from 402 persons with probable or confirmed cases of mpox in Montreal and the public health response by Montreal Public Health. The authors report that Montreal experienced its initial mpox outbreak in May 2022, followed by two peaks in early June and early July. This was followed by a decline in cases. Nearly all reported cases were among MSM who likely acquired the infection through sexual contact. Montreal public health authorities acted quickly to lead interventions to control the transmission. These interventions included early and sustained engagement with the affected communities; alerting clinicians to promote rapid case detection and reporting; performing case investigation and contact tracing; and contributing to the development of interim guidance on diagnostic testing, case and contact management, and recommended infection and control prevention measures. According to the authors, the prompt recognition of the importance of preexposure vaccination in at-risk populations and the extended offer of MVA-BN to tourists coming to Montreal led to many being vaccinated. They add that increasing and supporting equitable access to vaccines for at-risk populations worldwide should be a global priority for the prevention and control of mpox.

Media contacts: For an embargoed PDF, please contact Angela Collom at acollom@acponline.org. To speak with the corresponding author, Sapha Barkati, MD, MSc, email sapha.barkati2@mcgill.ca.
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4. Physicians discuss strategies for managing chronic insomnia
All Beyond the Guidelines discussions are based on Grand Rounds from Beth Israel Deaconess Medical Center
Abstract: https://www.acpjournals.org/doi/10.7326/M22-2817
URL goes live when the embargo lifts
In a new Annals ‘Beyond the Guidelines,’ a clinical psychologist and sleep physician debate the management of a patient with chronic insomnia who has been treated with medications. All ‘Beyond the Guidelines’ features are based on the Department of Medicine Grand Rounds at Beth Israel Deaconess Medical Center (BIDMC) in Boston and include print, video, and educational components published in Annals of Internal Medicine.

Insomnia, which is characterized by persistent sleep difficulties in association with daytime dysfunction, is a common concern in clinical practice. Chronic insomnia disorder is defined as symptoms that occur at least 3 times per week and persist for at least 3 months. Recent guidelines published by the American Academy of Sleep Medicine (AASM) recommended multicomponent cognitive behavioral therapy (CBT) and a limited number of medications that might be useful for insomnia.

BIDMC Grand Rounds discussants, Eric S. Zhou, PhD, an Assistant Professor at Harvard Medical School and a clinical psychologist at Dana-Farber Cancer Institute, and Eric Heckman, MD, an Instructor at Harvard Medical School and sleep specialist and pulmonologist at Beth Israel Deaconess Medical Center, discuss the case of a 64-year-old man who experienced difficulty getting to sleep and early morning awakening for decades. The patient was prescribed zolpidem many years ago, which was initially taken as needed but now is a daily necessity to get to sleep. More recently, trazodone was added to his regimen. The patient has also been diagnosed with obstructive sleep apnea (OSA).

In their assessment, both Drs. Zhou and Heckman agree that CBT is the preferred intervention in the patient’s situation. Dr. Heckman would first evaluate and treat the patient for OSA and other comorbid conditions such as restless leg syndrome that might affect his sleep, while Dr. Zhou would dispel the commonly held belief that patients all require 8 hours of sleep per night as part of his treatment. Dr. Zhou and Mr. F would also collaborate on identifying his individual sleep need through a structured process involving sleep restriction and, subsequently, expansion. Dr. Heckman would consider a streamlined, clinic-based behavioral intervention focusing on sleep restriction and stimulus control if CBT was not accessible or acceptable to the patient. He would not insist on discontinuation of medications immediately but would attempt to stop trazodone followed by reduction in the dose of zolpidem over time as tolerated.

A complete list of ‘Beyond the Guidelines’ topics is available at www.annals.org/grandrounds.

Media contacts: For an embargoed PDF, please contact Angela Collom at acollom@acponline.org. For an interview with the discussants, please contact Kendra McKinnon at Kmckinn1@bidmc.harvard.edu.
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Also new in this issue:
Monoclonal Gammopathy of Undetermined Significance
Wilson I. Gonsalves, MD; S. Vincent Rajkumar, MD
In the Clinic
Abstract: https://www.acpjournals.org/doi/10.7326/M22-2016