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How to Meet New Diabetes Recommendations: Focus on Individualized Care

BOSTON – As complex as they seem, the new evidence-based clinical practice recommendations from the American Diabetes Association (ADA) essentially boil down to one underlying recommendation: treat patients as individuals.

Or, so say two experts from the Joslin Diabetes Center, Beth Israel Deaconess Medical Center, and Harvard Medical School, who reviewed the yearly recommendations.

In a commentary published recently in Annals of Internal Medicine, Giulio R. Romeo, MD, and Martin J. Abrahamson, MD, emphasize three important new topic areas that affect how primary care physicians treat patients:

  • A change in body mass index (BMI) cut points for prediabetes and type 2 diabetes screening for Asian patients, who tend to have more visceral fat, even at lower BMIs;
  • A new way to look at blood glucose targets, basing them on the individual patients’ age, comorbid conditions, life expectancy, as well as their motivation and preferences;
  • An emphasis on treating diabetes patients’ cardiovascular risk with statins, rather than just focusing on number goals, such as systolic and diastolic blood pressure.

The commentary notes that metformin remains the gold standard for initial treatment of diabetes.

“With the exception of sodium-glucose cotransportor 2 inhibitors, which are a welcome addition to the increasing pharmacologic armamentarium, not much has changed in the combination therapy algorithm,” Romeo and Abrahamson point out. “Metformin continues to stand out as the preferred initial treatment choice.”

The decisions become a bit more complex when metformin alone it not sufficient to help patients reach their hemoglobin A1c goals. While a major study is looking at the efficacy of four different classes of medication – a sulfonylurea, a dipeptidyl peptidase 4 inhibitor, a glucagon-like peptide-1 receptor agonist and insulin glargine – the results of the GRADE study will not be available until 2020.

“In the absence of robust comparative effectiveness data,” the commentators write, “the Standards advocate tailoring combination drug choices based on such factors as risk for hypoglycemia, effects on weight, side effects and cost.”

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PCR for the Vitals

Most General Pediatricians Happy with First Job’s Work-Life Balance

ANN ARBOR, MI – With the majority of general pediatricians seeking work-life balance as their primary career goals, most report that they have found it in their first job.

In fact, more than two-thirds believe their current position is consistent with their career goals, according to a study published recently in the journal Pediatrics.

For the study, University of Michigan researchers surveyed 2,327 general pediatricians taking their initial board certification examinations.

"There are frequent concerns about whether new physicians are being matched with positions that meet their career ambitions, and we found that for pediatricians, the news is quite good," said lead author Gary Freed, MD, MPH, founding director of the Child Health Evaluation and Research (CHEAR) Unit at the University of Michigan Health System and professor of pediatrics at C.S. Mott Children's Hospital. "The vast majority, over 80%, of new pediatricians were very satisfied with their first jobs after completing residency and how it matches with their future plans."

The majority, 69%, of the new pediatricians said lifestyle and family considerations were the most important considerations for their first job. While women were most likely to provide that response, it also was endorsed by more than half of men.

At the same time, only 2% of respondents said earning potential was the most important factor in first job selection, and 9% said debt at the end of training was the most important consideration.

"It's important to look at whether first jobs lined up with career goals in order to understand what leads to job and career satisfaction for the new generation of pediatricians and to help us identify future workforce and training needs," Freed explained.

Of the 17% who are not satisfied with how they spend time at work, a common reason was that they would prefer to spend more time in patient care and less on administration tasks. Interestingly, most of the new pediatricians said they wanted to spend most or all of their time providing outpatient care to children with little interest in inpatient care or research.

The survey also found that more women than men plan to work part time at some point in the next five years, although more than 1 in 7 pediatricians who are considered part time in their first job stated they worked more than 40 hours a week.

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Transition to Alternative Payment Method Challenging for Practices

SANTA MONICA, CA – Alternative payment models are being touted as a way to improve quality and reduce costs, but physician practices are struggling to meet the challenges without help in managing the onslaught of data and the requirements of different payers.

That’s according to a new joint study by the RAND Corporation and the American Medical Association.

One way that physician practices are responding is by partnering or merging with other medical practices or hospitals in order to better support the investments necessary to succeed in new payment models, such as in care managers and information technology.

“We found that changing the payment system probably isn't enough to ensure that patient care will improve,” said Mark W. Friedberg, MD, MPP, the study's lead author and a senior natural scientist at RAND, a nonprofit research organization. “For alternative payment methods to work best, medical practices also need support and guidance. It's the support that accompanies a new payment model, plus how well the model aligns with all of a practice's other incentives, that could determine whether it succeeds.”

For the research on how alternative healthcare payment models are affecting physicians and medical practices in the United States, researchers conducted case studies of 34 physician practices in six diverse geographic markets – Little Rock, AR; Orange County, CA; Miami; Boston; Lansing, MI; and Greenville, SC. Researchers also spoke to the leaders of 10 payer organizations, nine hospitals or hospital systems, seven local medical societies and five Medical Group Management Association chapters.

The payment models included:

  • episode-based and bundled payments
  • shared savings
  • pay-for-performance
  • capitation
  • retainer-based practices

Also reviewed were how practices fared with accountable care organizations and medical homes, two new organizational models.

Physicians generally agreed that transition to alternative payment models increased patients’ access to care. While practice leadership were optimistic about alternative payment models, however, other physicians often expressed some apprehension, especially about new documents requirements, according to the report.

None of the practices reported financial hardship because of their transition to an alternative payment system, with the most difficult issues being operational, such as the inability to offset costs of pricey information systems because crucial data is missing. In addition, the variety of performance measures and requirements by a large numbers of payers can overwhelm practices, the report states.

How physicians are compensated also is an issue, the researchers point out. In alternative payment models, physician practices generally are paid more for improved performance, yet practices often use nonmonetary incentives to encourage physicians to change their decision making.

“Despite the pressure to contain costs, practice leaders are trying to avoid creating situations where doctors are paid more when patients do not get the services they need,” Friedberg explained.

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Physician Recommendations, Race Influence Flu Vaccine Rates

HOUSTON – Here’s a straightforward way to ensure your patients get vaccinated against influenza: Strongly recommend it.

According to a presentation at the recent annual meeting of the American Academy of Allergy, Asthma & Immunology, 90% of patients received vaccination if their physician advocated for it, compared to 58% without the push from the doctor.

Race also was a factor, according to the research conducted by the Henry Ford Health System. The study, based on an anonymous survey at six Henry Ford Internal Medicine and Allergy clinics in metro Detroit between April and August 2013, found that vaccination rates were higher in whites, 93%, and Asians, 84%, compared to African Americans, 62%. Researchers theorized that that African Americans might not trust the vaccination's benefit, noting that, in general, vaccination rates were four times higher among patients who believed immunization protected them vs. those who thought otherwise.

Vaccination rates were not significantly affected, however, by adverse reactions such as soreness at the injection site or fever.

"What our findings show is that we need to improve our communications between physicians and patients about the benefits of the flu vaccination," explained lead author Melissa Skupin, MD, a Henry Ford fellow. "Our study showed the benefit of physicians who take a proactive approach in recommending vaccination to their patients. At the same time, we need to re-think our strategy for addressing the perceptions and myths associated with vaccination. The misinformation out there is pervasive."

The 10-question survey, which asked patients 18 and older if they received a flu vaccination the previous year, their perceptions of vaccination and demographic information, was distributed to 1,200 patients, with 472 completed surveys returned.

“The influenza vaccine is recommended for patients older than 6 months of age, yet the [national Center for Disease Control and Prevention] notes adult vaccination rates to be as low as 45%,” the authors write. “Specific reasons for declining vaccination are not well understood. The aim of this study was to identify factors associated with patients’ likelihood to receive the influenza vaccine to elucidate how to improve vaccination rates.”

In conclusion, they add,” Interventions to increase flu vaccination rates may need to focus on improving physician recommendations and communicating benefits of the vaccine. Better understanding of vaccine perceptions among black individuals is warranted.”

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