NetWorks: Mass shootings, MACRA, asthma in pregnancy Disaster Response Practice Operations Transplant Women’s Health


 

Mass shootings

There are multiple definitions for a mass shooting. Some definitions require a certain number of people be killed. Some definitions require a certain number of people be shot. Some definitions do not include gang violence. Regardless of the definition used, the number of mass shootings in the United States is increasing.

There are also multiple definitions of what qualifies as a medical disaster. These definitions can be summarized with the statement that a medical disaster is an event that produces a number of casualties that overwhelms the local health system.

Dr. John Gaillard

Dr. John Gaillard

In the first 31 days of 2017, there have been 30 shootings in the United States, in which four or more people were injured (www.gunviolencearchive.org/reports/mass-shooting). On average, 309 people are shot every day in the United States. Ninety-three (30%) of those victims die of their injuries (www.bradycampaign.org/key-gun-violence-statistics).

Most mass shootings fit the definition of a medical disaster. When a mass shooting occurs, medical resources are diverted from current patients to those injured in the shooting. Patients with acute medical problems unrelated to the shooting must endure a prolonged wait for medical care.

The CHEST Disaster Response NetWork feels that it is necessary to take action to reduce the number of mass shootings. Unlike natural disasters, mass shootings are man-made. As such, we should proactively work to prevent them. Prevention is a large part of medicine. Working together with community leaders, law enforcement, and government officials, we can and should work to eliminate mass shootings so that we can minimize gun-related injury and death.

MACRA: Reincarnation of Medicare physician reimbursement model

In April 2015, President Obama signed the Medicare Access and CHIP Reauthorization Act (MACRA) eradicating the detested sustainable growth rate (SGR) formula. If this is your first dive into MACRA as an eligible professional (EP), it may be a bit baffling trying to understand its impact on your practice.

Dr. Humayan Anjum

Dr. Humayan Anjum

MACRA affects physician offices, not hospitals. For 2017-2018, EPs include physicians, physician-assistants, nurse practitioners, clinical nurse specialists, and nurse anesthetists. Providers in their first year of Medicare participation or with a low Medicare volume are excluded. Additionally, there are two participation pathways, Merit-Based Incentive Payment System (MIPS), which combines the current Physician Quality Reporting System, Value Modifier, and Meaningful Use programs into a single pay-for-performance payment system; or Alternative Payment Models (APMs) that provide incentives in certain alternative payment models based on proposed CMS criteria. Accountable Care Organizations, Patient-Centered Medical Homes, and Bundled Payment Models are a few examples of an APM.

Under MIPS, rules are divided into four categories. During the first year, each category will make up a certain percentage to the physician’s overall score, which will result in a penalty or payment as a lump sum in 2019. If you are an Advanced APM in 2017 and receive 25% of Medicare payments or see 20% of your Medicare patients through this model, you can earn up to a 5% incentive payment in 2019.

The performance period started on January 1, 2017. Submission of performance data is due by March 31, 2018. MACRA is complicated and here to stay. Learn and educate yourself to avoid downward payment adjustment. For full details, please visit https://qpp.cms.gov/docs/QPP_Executive_Summary_of_Final_Rule.pdf.

References

1. CMS MACRA Proposed Rule. http://1.usa.gov/1PpBpMt

2. CMS MACRA Executive Summary. https://qpp.cms.gov/docs/QPP_Executive_Summary_of_Final_Rule.pdf

3. American Medical Association. http://bit.ly/1miEtBD

4. Policy and Medicine. MACRA http://bit.ly/1PTLkKa. MIPS http://bit.ly/20RoMzZ. APMs http://bit.ly/1OlxoxH

Frailty in lung transplantation

Two of the greatest challenges in lung transplantation are to identify optimal transplant candidates and to help those transplant recipients thrive in the years following surgery. Frailty is emerging as a marker of increased posttransplant morbidity and may represent an area where both the recipient selection process and posttransplant outcomes can be optimized. Described by some as “biologic age” rather than “chronologic age,” frailty is a syndrome of functional impairment and weakness that predisposes to adverse health outcomes. The adverse effects of frailty have been described in multiple clinical scenarios, including the ICU, chronic lung diseases, heart failure, liver transplant, kidney transplant, geriatrics, and others.

Dr. Michael E. Wilson

Dr. Michael E. Wilson

Approximately 10% to 45% of lung transplant patients are considered to be frail, depending on the measurement used. In a cohort of lung transplant recipients, frail patients had increased 1-year mortality (21.2% increase) and 3-year mortality (24.8% increase), compared with nonfrail patients (Wilson et al. J Heart Lung Transplant. 2016;35[2]:173-178). In a cohort of patients on the lung transplant waiting list, frailty was associated with an increased risk of delisting or death before lung transplant (Singer et al. Am J Respir Crit Care Med. 2015;192[11]:1325-1334). In addition, frailty may be associated with an increased risk of hospital readmissions and acute rejection following transplant (Wilson et al. J Heart Lung Transplant. 2016;35[4]:S317).

Remaining challenges include determining which clinical assessments best define frailty in the lung transplant population, documenting the adverse effects of frailty in well-designed multicenter prospective studies, and developing interventions to mitigate the adverse effects of frailty.

Asthma treatment during pregnancy

Asthma is common in pregnancy, occurring in 3% to 8% of pregnant women. While the course of asthma during pregnancy is variable, the objectives of asthma treatment do not change and aim to prevent acute exacerbations and optimize management. Uncontrolled asthma is associated with an increased risk of perinatal morbidity. Published guidelines on pharmacologic therapies during pregnancy recommend the same step-wise approach as in nonpregnant women.

Dr. Mariam Louis

Dr. Mariam Louis

Despite this, many providers are reluctant to prescribe medications during pregnancy, and data show a reduction of refills of asthma medications during pregnancy, likely due to safety concerns. Some recent studies have suggested an increase in major congenital anomalies among pregnant asthmatics using ICS (Garne E et al. BJOG. 2016;123[10]:1609-18), albeit with large confidence intervals. These findings have not been consistently confirmed (Kallen B et al. Eur J Clin Pharmacol. 2007;63:383-8). Furthermore, studies showing a dose response association of ICS with congenital anomalies (Blais L et al. J Allergy Clin Immunol. 2009;124[6]:1229-34) suggest that disease severity may be a confounder in these associations.

The diagnosis of asthma, the use of other concurrent medications, and medication compliance may all be potential confounders. ICS use in pregnancy was associated with endocrine and metabolic disturbances in the offspring in a national cohort (Tegethoff M et al. Am J Respir Crit Care Med. 2012;185[5]:557-63). However, this study did not report on systemic steroid use, asthma severity, or details of these disturbances.

Dr. Ghada Bourjeily

Dr. Ghada Bourjeily

In summary, ICS use remains justifiable in pregnancy (Smy L et al. Can Fam Physician. 2014;60[9]:809-12) as the risk of untreated or poorly treated asthma outweighs the possible risk of ICS use, especially when alternative drugs such as systemic steroids are not without risk. Ultimately, it should be stressed that asthma control is the goal of treatment. This should be achieved with close interaction between the pregnant woman and her health-care provider.

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