Issuu

Physicians office Resource 2021 | Issue 4

™

Resources for You, Your Patients, & Your Practice

TO SCREEN OR NOT TO SCREEN?

Prostate Specific Antigen Testing

DIRECT CONNECTION BETWEEN INEFFICIENCY AND BURNOUT

PATIENT ANXIETY: CREATING A BETTER ENVIRONMENT TO HEAL

PAGE 16

PUBLISHED BY Medical Education Resources, LLC PUBLISHER Aaron R. Medaris amedaris@physiciansofficeresource.com

CEO Andrew C. Nimmo acnimmo@physiciansofficeresource.com

PRESIDENT John D. Pasquale jpasquale@pharmaconnect.com

Getting the most from this guide

BUSINESS MANAGER Marci J. Hills mhills@physiciansofficeresource.com

TRAVEL EDITOR Brandi L. Brower EDITORIAL BOARD Michael Paquin, FHIMSS Barry Craig, MLT (NCA), CLC STAFF WRITER Dylan J. Chadwick

There are two simple ways to request

CREATIVE DIRECTOR PRODUCTION MANAGER Jessica Peterson

information about the products and services

found in Physicians Office Resource. 1. Go to www.PhysiciansOfficeResource.com and enter the four-digit reference number found next to the product or service into the search field, then request additional information, schedule a demo, or speak with a sales agent all with just a simple click of a button. 2. Find the Business Reply Card in this issue, circle the desired reference numbers, complete the form, and drop into any USPS mailbox. A representative will contact you as quickly as possible to answer your questions.

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To continue your free subscription of Physicians Office Resource magazine, please fill out the Business Reply Card (BRC) located within this magazine and drop in any United States Post Office mailbox. If you are a manufacturer of medical products or provide services to medical professionals and would like to advertise your products or services to the nation’s top physicians doing in-office testing, call 801-380-6094 or visit: POR.io for more information.

TO X I C O LO G Y S C R E E N I N G

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IMMTOX™ 270 BENCHTOP ANALYZER Toxicology screening solutions for physician offices, treatment centers and laboratories. n

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COMPLETE LABORATORY SOLUTIONS From consultation, to licensure and compliance, the Abbott Clinical Lab Solutions team has you covered.

CONTACT ABBOTT CLINICAL LAB SOLUTIONS. CALL 888-831-6850 | EMAIL: CLS_SALES@ABBOTT.COM 1. Clinical Laboratory Improvement Amendments (CLIA) © 2020 Abbott. All rights reserved. All trademarks referenced are trademarks of either the Abbott group of companies or their respective owners. Any photos displayed are for illustrative purposes only. MKT52247 REV1 08/20

TABLE OF CONTENTS

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Product Spotlight

ENVOY500+ Delivering Proven Results in Clinical Chemistry The fully automated Envoy500+ is designed to deliver the performance of a large floor model analyzer but provides the cost efficiency of a benchtop analyzer (TPH approx. 490). It enables accurate treatment decisions sooner. Envoy500+ delivers savings the laboratory requires with the following features positive sample and reagent identification, clot detection, liquid level sensing, dry ISE module, reusable glass cuvettes, and many more.

PSA: TO SCREEN OR NOT TO SCREEN? THAT IS THE QUESTION… — There are certain milestones in life that no one looks forward to— having your wisdom teeth pulled. That first mammogram! At the top of the list for men is likely that first rectal exam at 40 or 50 as an initial screening for prostate cancer. But, like those pesky wisdom teeth and the oh-so-important mammogram, screening for prostate cancer is important and necessary. 4 | PHYSICIANS OFFICE RESOURCE

DIRECT CONNECTION BETWEEN INEFFICIENCY AND BURNOUT

— Mark Linzer’s research identified workplace chaos as one of the key predictors of physician stress, burnout, and intention to leave. A recent analysis of the data showed that physicians in clinics with chaotic work environments had significantly more stress and burnout and a higher likelihood of leaving the practice within two years.

PATIENT ANXIETY: CREATING A BETTER ENVIRONMENT TO HEAL

— When asked to describe anxiety, I often defer to the description I’d give my college therapist. Anxiety fits somewhere between “simple worry” and “full-blown panic.” I’d compare it to the dull, but consistent bellowing of a gaggle of monkeys let loose to tromp around the recesses of my brain. Everyone experiences anxiety in some fashion, whether...

FAST AND EASY. ACCURATE RESULTS EVERY TIME. CELL-DYN EMERALD Compact, easy-to-use 3-part differential hematology analyzer provides you with proven methods and technology, including electronic impedance, absorption spectrophotometry, electronic valves, cyanide-free lyse reagent, LCD color touch screen and USB ports. C O M PAC T D E S I G N Conserving valuable laboratory workspace with a small footprint and only 2 reagents plus on-board cleaner.

EASE OF USE • Decreasing manual entry errors and increasing compliance by use of barcoded reagents • Reducing hands-on time with touch-free scheduled daily maintenance, startup and shutdown

F L E X I B L E U S E R I N T E R FAC E • Improving use and easing training of software functions with color touch screen and numeric keypad • Providing positive patient identification with barcode reader for specimens

RELIABILIT Y Helping you keep your commitments

O P T I C A L 3-PA R T D I F F E R E N T I A L Delivering comprehensive results for your doctors and patients

Learn how the CELL-DYN Emerald 22 can help your laboratory operate more efficiently at:

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PRODUCT FOCUS

CHEMISTRY ANALYZERS EASY, INTEGRATED WITH-PATIENT TESTING I-STAT SYSTEM Easy, Integrated With-Patient Testing From Abbott Point of Care

i-STAT System from Point of Care at Abbott

The handheld i-STAT System offers a broad menu of diagnostic tests at the patient’s side in just minutes. With just a few drops of blood, The handheld i-STAT System offers a broad menu of diagnostic tests at the the i-STAT System delivers real time, lab-accurate results for a wide patient’s side inofjust minutes. With just blood a fewgas, drops of blood, the i-STAT range tests, including chemistries, coagulation, cardiac markers, and more. Minimize delays and wasted time with on-side System delivers real time, lab-accurate results for a wide range of tests, tests. Easy, intuitive operation.

9203

including chemistries, blood gas, coagulation, cardiac markers, and more. For intended use and complete product information, visit pointofMinimize delays and wasted time with on-site tests. Easy, intuitive operation. care.abbott. For intendedFor useinand pointofcare.abbott. vitrocomplete diagnosticproduct use only.information, This materialvisit is intended for a U.S.

audience only.This i-STAT is a trademark of a Abbott. Physician For in vitro diagnostic use only. material is intended for U.S. audience only.Office Resourceofi-STAT — US 3064.REV1 i-STAT is a trademark Abbott. Product PhysicianDescription Office Resource i-STAT Product08/20 Description – US 3064.REV1 08/20

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FULL COMPLEMENT OF CLIA-WAIVED BLOOD CHEMISTRY TESTS PICCOLO XPRESS® CHEMISTRY ANALYZER From Abbott Point of Care The Piccolo Xpress Chemistry Analyzer provides physician offices with lab-accurate results for a broad range of CLIAwaived general chemistry tests, including metabolic panels, lipids, live, and kidney function, and more with just 100 microliters of blood. Easy to use, the PIccolo Xpress provides results during a patient’s visit, accelerating treatment decisions, increasing efficiency, and supporting patient satisfaction. Automated quality control on every test helps ensure accuracy.

Full Complemen Piccolo Xpress®

The Piccolo Xpres lab-accurate resu tests, including m with just 100 micr 9204 results during a pa efficiency, and sup every test helps e

For in vitro diagnostic use Piccolo Xpress is a registe Physician Office Resource

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Toxicology Screening Simplified Abbott’s ImmTox 270 Benchtop Analyzer Now with 14 assays CLIA Categorized as Moderate Complexity From Abbott The ImmTox270 benchtop analyzer offers comprehensive toxicology screening solutions for physician offices, treatment centers and independent laboratories. Broad test menu with over 20 assays to choose from including 14 that are now available as moderately complex. With complete laboratory solutions from consultation to licensure, and compliance the Abbott Clinical Laboratory Solutions team has you covered.

View Brochures, Videos & More at POR.io Enter Number 9205 in the Search Area 6 | PHYSICIANS OFFICE RESOURCE

GROW WITH CONFIDENCE

Clinical Systems

Scalable Chemistry Solutions for the physicians office laboratories Reliability and consistency The performance and quality are designed into the complete system across all key components: • analyzer & software • liquid stable reagents • calibrators & controls

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• ISE (Ion-Selective Electrode) • remote diagnostics

ENVOY500+ Larger volume • 20-80 patients per day

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CLIA WAIVED FULL COMPLEMENT OF CLIA-WAIVED

PRODUCT FOCUS

Full Complement of CLIA-waived Blood Chemistry Tests BLOOD CHEMISTRY TESTS PICCOLO ® Piccolo Xpress Chemistry Analyzer from Abbott

XPRESS® CHEMISTRY ANALYZER

The PiccoloFrom Xpress Chemistry Abbott PointAnalyzer of Careprovides physician offices with lab-accurate results for a broad range of CLIA-waived general chemistry The Piccolo Xpress Chemistry Analyzer provides physician tests, including metabolic panels, lipids, and kidney function, offices with lab-accurate results liver, for a broad range of CLIA- and more with just 100waived microliters of blood. Easy to use, the Piccolo Xpress general chemistry tests, including metabolic panels, provides lipids, live, and visit, kidneyaccelerating function, andtreatment more with decisions, just 100 results during a patient’s increasing microliters of blood. EAsy to use, the PIccolo Xpress provides 9209efficiency, and supporting patient satisfaction. Automated quality control on results during a patient’s visit, accelerating treatment decisions, every test helps ensure accuracy. increasing efficiency, and supporting patient satisfaction. Automated quality control on every test helps ensure accuracy. For in vitro diagnostic use only. This material is intended for a U.S. audience only. Piccolo Xpress is View a registered trademark of Abaxis, Inc. and by Abbott Point of Care. Brochures, Videos & distributed More at POR.io Physician Office Resource Piccolo Product Description – US 3065.REV1 08/20

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LAB-ACCURATE RESULTS FOR ACR AND HBA1C

9210

From Abbott With its compact size and panel of tests, the Afinion 2 system is ideal for point-of-care testing in physician offices, clinics, community health centers and hospital out-patient clinics. From just a small urine or fingerstick whole blood sample, lab-accurate results for ACR and HbA1c are made available during the consultation.

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9211

FIRST EVER CLIA WAIVED HEMATOLOGY ANALYZER From Sysmex Faster test results, clinical decisions and greater practice efficiency are coming to physicians’ offices with the first CLIA-waived CBC analyzer. Hematology diagnostics leader Sysmex is bringing more lab testing to the point of care. One of the most common blood tests can be conducted reliably and accurately on-site, in as few as three minutes. The device’s ease of use and innovative technology means in-house staff can operate it in just a few easy steps, without lengthy certification and training. The new Sysmex XW-100 will improve health care efficiency and patient care.

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COVID-19 TESTING BD VERITOR™ PLUS SYSTEM From BD Veritor™

9212

The BD Veritor™ Plus System is a portable, easy-to-use, testing solution for SARS-COV-2*, Flu A+ B and other respiratory tract infections that delivers results in 15 minutes or less. It features two analysis modes that adapt to your workflow, online education tools, and optional reporting capabilities including the BD Synapsys™ Informatics Solution—making it the point-ofcare diagnostic tool you won’t want to be without. *EUA authorized by FDA

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BIOFIRE® RESPIRATORY 2.1-EZ (RP2.1-EZ)1 PANEL (EUA)1

From BioFire

SARS-CoV-2 is everyone’s top suspect, but many other respiratory bugs can cause similar, overlapping symptoms. In your clinic, you can test for 19 common respiratory pathogens, including SARS- CoV-2, with the BioFire RP2.1-EZ Panel (EUA)1—now available under an FDA Emergency Use Authorization. Syndromic testing means all it takes is one test and just 45 minutes to round up SARS-CoV-2—and all the other usual respiratory suspects.

9213

1. This test is not FDA cleared or approved. This test has been authorized by FDA under an EUA for use by authorized laboratories.

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FIRST EUA POINT-OF-CARE (POC/WAIVED/ FINGERSTICK) COVID-19 ANTIBODY TEST NOW AVAILABLE From Carolina Liquid Chemistries

9214

The Fastep® COVID-19 IgG/IgM Rapid Test Device by Assure Tech., distributed in the USA by Carolina Liquid Chemistries, has received FDA Emergency Use Authorization for use with fingerstick whole blood specimens at the point-of-care, i.e. in patient care settings operating under CLIA Certificate of Waiver such as doctor’s offices, hospitals, urgent care centers and emergency rooms rather than having to be sent to a central lab.Refer to carolinachemistries.com for instructions for use, fact sheets, FDA EUA letters, clinical performance studies, and material safety data sheets. Not FDA cleared; only for emergency use under Section 564(b)(1) of the Act, 21 U.S.C. § 360bbb-3(b)(1), unless authorization is terminated or revoked.

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CRYOSURGERY PRODUCT FOCUS

CRYOLAB® MEDICAL From CryoConcepts CryoLab is a desk-top sized unit that delivers cryogen and employs pre-set spray times to ensure safe and effective treatment. Our lighted wand can spray the cryogen from any direction making it easier to treat all locations on the patient. CryoLab® can dispense nitrous oxide or carbon dioxide allowing physicians to treat cosmetically sensitive areas on the face, hands, and chest with less trauma and downtime. —

9215

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HISTOFREEZER® FLEX From CryoConcepts This canister-based devices is the latest advance in portable cryosurgery for the physician office. Its advanced design give doctors the option of using cones or buds to deliver the cryogen to the treatment site. There is no risk of cryogen splattering during treatment and our cryogen stays colder versus other products on the market which lead to better first time outcomes.

9216

—

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CRYOCLEAR® From CryoConcepts 9217

This is a new pen-like cryo devices that dispenses carbon dioxide which is perfect for superficial lesions such as sun spots, age spots, and shin tags. CryoClear® has enough gas to treat between 20 and 30 lesions depending on the size and type. —

View Brochures, Videos & More at POR.io Enter Number 9217 in the Search Area

10 | PHYSICIANS OFFICE RESOURCE

GET BETTER OUTCOMES WITH CRYOSURGERY

NEW FOR

2021!

Your choice of a cryosurgical device has a big impact on patient outcomes. CryoConcepts has the broadest line of cryosurgical equipment in the world and our 28 years of experience is built into every single product.

BETTER DESIGN. BETTER OUTCOMES. BETTER FOR THE ENVIRONMENT. Our world class products include: CryOmega®, a portable pen-like device, CryoLab® Medical, a desktop-sized cryo unit, and Histofreezer® FLEX, our next generation canister that uses both cones and buds AND has the first returnable canister that is better for the environment.

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MAR-115 (Rev 1)

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FLU TESTING PRODUCT FOCUS

HELPING YOU HIT THE MARK IN FLU TESTING 9219

From Acucy® The Acucy® Influenza A&B Test is for the rapid, qualitative detection of influenza A and B viral nucleoprotein antigens from both nasal and nasopharyngeal swabs. Utilizing the Acucy® Reader in either the point-of-care or laboratory setting, workflow flexibility is achieved with both Read Now and Walk Away features. The combination provides clinicians with standardized and definitive result interpretation. —

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CLIA-WAIVED BIOFIRE® FILMARRAY® RESPIRATORY PANEL (RP) EZ From BioFire

9220

The BioFire RP EZ accurately detects and identifies 14 viral and bacterial pathogens—not just Flu A and Flu B—so you can provide your patients with the right treatment, the first time. The test is easy and can be performed right in your office or clinic, with results in about an hour. The BioFire RP EZ is designed to run on a single computer/instrument configuration (EZ Configuration) of the BioFire® FilmArray® 2.0 System.

—

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OSOM ULTRA PLUS FLU A&B TEST 9221

From Sekisui Stronger Clinical Performance Takes Lateral Flow Testing To The Next Level. Providing superior rapid results at the point-of-care. Fast, easy, cost effective so you can test and treat in one visit. • High Performance- Equivalent or exceeding the performance of reader devices, without the need for an instrument • Results in 10 minutes • OSOM® Custom Care- Exceptional Support/Training by licensed medical technologists and experienced healthcare professionals • Made in the USA —

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12 | PHYSICIANS OFFICE RESOURCE

8729

Pinpoint SARS-CoV-2 and 18 other bugs. The new BioFire® Respiratory 2.1-EZ (RP2.1-EZ) Panel1 covers COVID-19 detection in your clinic. SARS-CoV-2 is everyone’s top suspect, but many other respiratory bugs can cause similar, overlapping symptoms. In your clinic, you can test for 19 common respiratory pathogens, including SARSCoV-2, with the BioFire RP2.1-EZ Panel—now available under an FDA Emergency Use Authorization.1.2

9222

Syndromic testing means all it takes is one test and about 45 minutes to round up SARS-CoV-2—and all the other usual respiratory suspects. Rapid answers on a broad range of pathogens can inform patient management and alleviate patients and staff alike. What’s your frontline solution into respiratory season and beyond?

1. This test has not been FDA cleared or approved. This test has been authorized by FDA under an EUA for use by authorized laboratories. This test has been authorized only for the detection and differentiation of nucleic acid of SARS-CoV-2 from multiple respiratory viral and bacterial organisms. This test is only authorized for the duration of the declaration that circumstances exist justifying the authorization of emergency use of in vitro diagnostics for detection and/or diagnosis of COVID-19 under Section 564(b)(1) of the Federal Food, Drug, and Cosmetic Act, 21 U.S.C. § 360bbb-3(b)(1), unless the authorization is terminated or revoked sooner. 2. For use with the CLIA-waived BioFire® FilmArray® 2.0 EZ configuration.

BFR0001-0515-01

To learn more, visit biofiredx.com

PRODUCT FOCUS

HEMATOLOGY ANALYZERS

TURN SMALL PLACES INTO SMART SPACES

9223

From Abbott With reduced budgets, shrinking laboratory space and staffing challenges, many laboratories need a solution that lets them work smarter with less. The CELLDYN Emerald 22 AL is a full performance, automated optical 5-part differential analyzer that delivers smarter results for small to midsize clinical laboratories. • • • •

Compact Design Walkaway Functionality Ease Of Use Smart Safety Features

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EMR Compatable 12 Lead EKG with Interpretation (For iPad, iPhone & other Devices) MOBILE DEVICES!

(PC/Laptop and Mobile Devices sold seperately)

• Latest Technology • Convenient • Affordable • Ultra Portable • User Friendly

EKG for iPad and iPhone

Also works with WINDOWS, MAC, Andorid and tablets

9224

• Made in USA

For Androids, iPads, iPhones and Tablets!

12 Lead iPhone

Contact us for a special offer: 877.646.3300 // medicaldevicedepot.com © 2015 Nasiff Associates. All rights reserved. CardioSuite, CardioCard, CardioECG, CardioStress, CardioHolter, CardioVitals, CardioMedical Center, CardioCard Mobile and Cardio Universal EMR Interface are trademarks of Nasiff Associates.

14 | PHYSICIANS OFFICE RESOURCE

New iPad EKG

EKG w/ interp.

Manufactured in USA by:

9225

The Adview 2 is still the only truly modular diagnostic station that grows with your needs. Start with blood pressure and choose temperature or pulse oximetry option at the time of purchase.

Bionet CardioCare 2000: $1,255.00 Schiller AT-2 Plus: $2,626.00* 9226 *add Spirometry: $649.00 Burdick ELI 280: $4,088.00 Welch Allyn CP150 w/ Interp: $3,465.00

9227 9228

9229

9232

9230 9231

Coaxial Ophth, Fiber Optic Oto, Speucla Dispenser, Aneroid BP, Wall Transformer and Wall Board without Thermometer: $979.00 9233 with Thermometer: $1,416.00

9235

9234

9236

9237

FEATURE

PSA: To Screen or Not to Screen? THAT IS THE QUESTION… BY SEKISUI DIAGNOSTICS

There are certain milestones in life that no one looks forward to—having your wisdom teeth pulled. That first mammogram! At the top of the list for men is likely that first rectal exam at 40 or 50 as an initial screening for prostate cancer. But, like those pesky wisdom teeth and the oh-so-important mammogram, screening for prostate cancer is important and necessary.

16 | PHYSICIANS OFFICE RESOURCE

FEATURE

A policy paper produced by the European Association of Urology1 states that there were approximately 450,000 cases of prostate cancer in Europe in 2018 and 107,000 deaths expected. In 2019, the American Cancer Society estimates2 that there will be about 174,650 new cases of prostate cancer in the U.S. Globally prostate cancer3 is the second most commonly occurring cancer in men and the fourth most commonly occurring cancer overall. That being said, prostate cancer often can be treated successfully. In fact, the localized and regional five-year survival rates4 for this type of cancer are near 100%! As with all cancers, early diagnosis is important. Most prostate cancers are first found5 during screening with a prostate-specific antigen (PSA) blood test or a digital rectal exam (DRE). While prostate cancers usually don’t cause symptoms in the early stages, more advanced cancers are sometimes first found because of symptoms they cause.

So why are there ongoing controversial discussions about PSA screening? Why do the United States and Europe hold different positions regarding some aspects of screening? So What’s the Deal? How can one argue that it’s better not to screen for a cancer? The medical community is divided due to the risk of overdiagnosis and overtreatment. Cancer overdiagnosis6 is the detection of cancer that would not develop any symptoms during a man’s lifetime if not identified by early detection or not result in cancer-related death. Overtreatment refers to unnecessary medical interventions, including extensive treatment for a condition that requires only limited treatment. According to the European Association of Urology1, the risk of overdiagnosis has been estimated to be as high as 40% in screen-detected prostate cancer, leading to unnecessary biopsies and 2021, ISSUE 4 | 17

FEATURE

detection of insignificant cancers, which could lead to overtreatment. In 2012, the U.S. Preventive Services Task Force (USPSTF) actually recommended against7 screening for prostate cancer in all men! However in 2017, the USPSTF released a new draft recommendation for prostate cancer screening encouraging providers7 to inform men ages 55 to 69 about the benefits and harms of prostate cancer screening. Worrying Statistics Practitioners in both the UK and the U.S.1 were advised not to perform PSA for early detection. Two independent studies performed in 2017 and 2018 found that a lack of prostate cancer screening may be reversing1 the trend of declining death rates—meaning mortality from these type of cancer could be on the rise. This year, the European Association of Urology made a call to action8, stating, “Urgent action is required to ensure the new Commission is mandated to support EU Member States in prostate cancer screening in their national cancer plans.” EAU Policy Coordinator Michelle Battye wants the 2003 Council Recommendations on population-based screening to be “urgently reviewed,” with prostate cancer added to the list of cancers to be addressed, and wants member states to bring good practice on prostate cancer screening to the Steering Group on Health Promotion, Disease Prevention and Management of non-communicable diseases. How the U.S. Responded As we briefly mentioned above, in 2017 the USPSTF released new recommendation for prostate cancer screening encouraging providers7 to inform men ages 55 to 69 about the benefits and harms of prostate cancer screening. The American Cancer Society recommends9 that men learn as much as they can about prostate cancer screening risks and benefits and discuss the information with their doctor before deciding whether to be tested. Men at average risk of prostate cancer should have this discussion at age 50. Men at higher than average risk should have the discussion starting at age 40 or 45. The consequences of decreased PSA screening10 are numerous: Increased mortality The effects of non-curative intervention Psychological complications of recurrent prostate cancer So do the risks of prostate cancer screening outweigh the benefits? That’s not a question any man should answer alone—he should discuss the pros and cons of screening with his doctor to make an informed decision. However, physicians should bring this topic to the table at the appropriate time for all affected patients. In the end, prostate cancer screening is important, as it is with all types of available cancer screenings. A little bit of research can inundate you with statistics, recommendations, 18 | PHYSICIANS OFFICE RESOURCE

and lots of other frightening material. What matters is that physicians are aware of recommended guidelines and available screening and treatment options, and that patients are given the information they need to make informed decisions regarding their health. Sekisui Diagnostics offers two tests (please note that only one is currently available in the U.S.). The FastPack® IP Total PSA immunoassay11 is a chemiluminescent immunoassay for the in-vitro quantitative determination of PSA in human serum and plasma as an aid in the management of patients with prostate cancer. It offers results in 12 minutes. The FastPack® IP Free PSA Immunoassay12, not currently available in the U.S., is a chemiluminescent immunoassay for the in-vitro quantitative determination of free prostate-specific antigen (free PSA) in human serum. It is designed for use in conjunction with the FastPack IP System for calculating the ratio of free/total PSA, expressed as a percentage (percent free PSA). A free PSA test13 can be used instead of a biopsy if PSA levels are slightly elevated, and may be used to determine how aggressive a recurring cancer is.

References: 1. http://epad.uroweb.org/wp-content/uploads/EAU_policy-briefing_PSA.pdf 2. https://www.cancer.org/cancer/prostate-cancer/about/ key-statistics.html 3. https://www.wcrf.org/dietandcancer/cancer-trends/ prostate-cancer-statistics 4. https://www.cancer.org/cancer/prostate-cancer/detection-diagnosis-staging/survival-rates.html 5. https://www.cancer.org/cancer/prostate-cancer/detection-diagnosis-staging/how-diagnosed.html 6. https://www.ncbi.nlm.nih.gov/pmc/articles/ PMC3540879/ 7. https://health.gov/news-archive/blog/2017/07/ prostate-cancer-screening-recommendations-an-update-from-uspstf/index.html 8. https://uroweb.org/epad19-european-psa-screeningprogramme-is-on-its-way-part-2/ 9. https://www.cancer.org/latest-news/prostate-cancer-screening-faq.html 10. https://www.physiciansweekly.com/the-unintended-consequences-of-decreased-psa-screening/ 11. https://www.sekisuidiagnostics.com/products-all/fastpack-ip-prostate-specific-antigen-psa-immunoassay/ 12. https://www.sekisuidiagnostics.com/products-all/fastpack-ip-free-psa-immunoassay/ 13. https://www.healthline.com/health/prostate-cancer-free-psa#purpose

Importance of Vitamin D Testing Vitamin D deficiency is a growing concern worldwide. Increasing research is now uncovering evidence illustrating the importance of vitamin D in overall patient care and in COVID-19 outcomes. Ensuring proper Vitamin D levels in patients can help reduce bone fractures, produce stronger immune systems, and improve brain/mental health function for children, adults, and the elderly. The FastPack® IP Vitamin D Immunoassay provides a rapid quantitative result in any size physician laboratory in 12 minutes allowing for immediate treatment or monitoring and increased patient satisfaction.

9238

Vitamin D, PSA, Testosterone, SHBG, TSH, Free T4 and hCG

For more information call 888-616-0537, Option 2 or visit us at fastpack-poc.com.

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IMPORTANT SAFETY INFORMATION WARNINGS AND PRECAUTIONS Few cases (0.36%) of adverse reactions of cystitis, pyelonephritis and other upper urinary tract infection (UTI) have been reported in Phexxi® clinical studies. Of these, one case of pyelonephritis was considered serious and required hospitalization. Avoid use of Phexxi® in females of reproductive potential with a history of recurrent urinary tract infection or urinary tract abnormalities. ADVERSE REACTIONS Most common adverse reactions were vulvovaginal burning sensation, vulvovaginal pruritus, vulvovaginal mycotic infection, urinary tract infection, vulvovaginal discomfort, bacterial vaginosis, vaginal discharge, genital discomfort, dysuria, and vulvovaginal pain. 9.8% of male partners reported local discomfort. Patients should be counseled on the following: • To contact and consult with their healthcare provider for severe or prolonged genital irritation or if experiencing urinary tract symptoms. • To discontinue Phexxi® if they develop a local hypersensitivity reaction. • That Phexxi® does not protect against HIV infection or other sexually transmitted infections. • To avoid Phexxi® use with vaginal rings.

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Dispense: # 12 applicators NDC: 69751-100-12 Refill: 11

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To report SUSPECTED ADVERSE REACTIONS, contact Evofem at toll-free phone 1-833-EVFMBIO or you may contact FDA at 1-800-FDA-1088 or www.fda.gov/medwatch. INDICATIONS AND USAGE Phexxi® (lactic acid, citric acid, and potassium bitartrate) vaginal gel 1.8%, 1%, 0.4% is indicated for the prevention of pregnancy in females of reproductive potential for use as an on-demand method of contraception. LIMITATIONS OF USE Phexxi® is not effective for the prevention of pregnancy when administered after intercourse. Please see full Prescribing Information for Phexxi®. Please see Brief Summary on the following page. Phexxi is a registered trademark of Evofem Biosciences, Inc. Trademarks, registered or otherwise, are the property of their respective owner(s). © 2021 Evofem Biosciences, Inc. • EVFM-US-001042 • January 2021 • Produced in USA.

Among subjects who used PHEXXI in Studies 1 and 2, 1.6% discontinued from the clinical trials due to an adverse reaction. The most common adverse reactions leading to study discontinuation were vulvovaginal burning sensation (0.7%); and vulvovaginal pruritus and vulvovaginal discomfort (0.1% each).

BRIEF SUMMARY: Consult the Package Insert for complete Prescribing Information INDICATIONS AND USAGE PHEXXI® is indicated for the prevention of pregnancy in females of reproductive potential for use as an on-demand method of contraception. LIMITATIONS OF USE PHEXXI is not effective for the prevention of pregnancy when administered after intercourse. WARNINGS AND PRECAUTIONS Cystitis and Pyelonephritis Among 2804 subjects who received PHEXXI in Studies 1 and 2, 0.36% (n=10) reported adverse reactions of cystitis, pyelonephritis, or other upper urinary tract infection (UTI). Of these, one case of pyelonephritis was considered serious and required hospitalization. Avoid use of PHEXXI in females of reproductive potential with a history of recurrent urinary tract infection or urinary tract abnormalities. ADVERSE REACTIONS Clinical Trials Experience Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of a drug cannot be directly compared to rates in the clinical trials of another drug and may not reflect the rates observed in practice. The safety of PHEXXI (pre-filled applicator with 5-gram dose) has been evaluated in two clinical trials (Study 1 and Study 2) in 2804 subjects (over 19,000 cycles of exposure). The racial/ethnic distribution was 66% White, 27% Black or African American, 2% Asian, 1% American Indian or Alaska Native, 0.3% Native Hawaiian or Pacific Islander, and 5% other; 32% of the study population was Hispanic. Study 1 included a one-year extension phase where 342 U.S. subjects were exposed to PHEXXI for 13 cycles. Hypersensitivity Reaction: Of the 2804 PHEXXI-treated subjects in Studies 1 and 2, one subject reported a suspected drug hypersensitivity. Avoid PHEXXI use in females of reproductive potential with suspected hypersensitivity to the ingredients in PHEXXI. The most common adverse reactions (≥10%) in the U.S. population in Studies 1 and 2 (n = 2480) were: vulvovaginal burning sensation (18.0%) and vulvovaginal pruritus (14.5%). The majority of these adverse reactions were mild and few led to discontinuation. Table 1 summarizes the most common adverse reactions (≥ 2%) reported by subjects using PHEXXI in the U.S. Table 1. Adverse Reactions that Occurred in ≥ 2% of Subjects Who Used PHEXXI to Prevent Pregnancy (Studies 1 and 2 – U.S. population only)

Adverse Reaction Vulvovaginal Burning Sensation Vulvovaginal Pruritus Vulvovaginal Mycotic Infection* Urinary Tract Infection†,‡ Vulvovaginal Discomfort Bacterial Vaginosis Vaginal Discharge Genital Discomfort Dysuria Vulvovaginal pain

PHEXXI (N=2480) (%) 18.0 14.5 9.1 9.0 9.0 8.4 5.5 4.1 3.1 2.1

*Includes preferred terms (PT) vulvovaginal mycotic infection and vulvovaginal candidiasis. † Includes PTs urinary tract infection, streptococcal urinary tract infection, Escherichia urinary tract infection, and urinary tract infection bacterial. ‡ Does not include PTs cystitis, kidney infection, and pyelonephritis [see Warnings and Precautions (5.1) of PHEXXI Full Prescribing Information].

Adverse Reactions in Male Partners: Among male partners of subjects who used PHEXXI for contraception in Study 2, 9.8% (131 of 1330) reported symptoms of local discomfort (burning, itching, pain, and “other”). Of these local discomfort symptoms, 74.7% were mild, 21.4% were moderate, and 3.9% were severe. Two subjects discontinued participation in the study due to male partner symptoms. USE IN SPECIFIC POPULATIONS Pregnancy Risk Summary There is no use for PHEXXI in pregnancy; therefore, discontinue PHEXXI during pregnancy. There are no data with the use of PHEXXI in pregnant women or animals. In the U.S. general population, the estimated background risk of major birth defects and miscarriage in clinically recognized pregnancies is 2 to 4 percent and 15 to 20 percent, respectively. Lactation Risk Summary There are no data on the presence of lactic acid, citric acid, and potassium bitartrate or their metabolites in human milk, the effects on the breastfed infant, or the effects on milk production. Pediatric Use The safety and effectiveness of PHEXXI have been established in females of reproductive potential. Efficacy is expected to be the same for post-menarchal females under the age of 17 as for users 17 years and older. The use of PHEXXI before menarche is not indicated. PATIENT COUNSELING INFORMATION See FDA-approved patient labeling. Advise the patient to read the Patient Information and FDA-approved patient labeling (Instructions for Use). Advise the patient: • To intravaginally administer the contents of one pre-filled single-dose applicator of PHEXXI before each episode of vaginal intercourse and to administer an additional dose if intercourse does not occur within one hour of administration [see Dosage and Administration (2.1) of PHEXXI Full Prescribing Information]. • To consult their healthcare provider for severe or prolonged genital irritation [see Adverse Reactions (6.1) of PHEXXI Full Prescribing Information]. • To discontinue PHEXXI if they develop a local hypersensitivity reaction [see Adverse Reactions (6.1) of PHEXXI Full Prescribing Information]. • To contact their health care provider if experiencing urinary tract symptoms [see Warnings and Precautions (5.1) of PHEXXI Full Prescribing Information]. • That PHEXXI does not protect against HIV infection and other sexually transmitted infections.

Manufactured for Evofem, Inc., a wholly owned subsidiary of Evofem Biosciences, Inc., 12400 High Bluff Drive, Suite 600, San Diego, CA 92130 Phexxi is a registered trademark of Evofem Biosciences, Inc. © 2020 Evofem Biosciences, Inc. U.S. Patent 6,706,276 REFDOC-001013 To report SUSPECTED ADVERSE REACTIONS, contact Evofem at toll-free phone 1-833-EVFMBIO or you may contact FDA at 1-800-FDA-1088 or www.fda.gov/medwatch.

IMMUNOASSAY ANALYZERS

From Sekisui Diagnostics The FastPack® IP System is a fully automated quantitative immunoassay analyzer designed for use in the Physician Office laboratory. Utilizing sophisticated chemiluminescence technology, the FastPack® IP System provides the capability to produce complex immunoassay results in 12 minutes or less with a push of a button. Menu includes Vitamin D, Testosterone, TSH, Free T4 PSA and hCG.

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LABORATORY SERVICES MEDICUS LIS From Medicus LIS

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If you are considering in-house lab testing, including Covid-19 testing and required reporting to state agencies, connecting Lab to LIS and EHR makes the process of test orders to completed results much easier. Providers receive test results posted to patient charts in real-time, expediting patient care, saving time, money and even preparing for lab test reimbursement goals. Link Your Lab with Medicus LIS today! Contact us: 888-643-8081 sales@medicuslis.com —

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MAKE LABORATORY COMPLIANCE AND INSPECTION EASIER From My Inspection Make laboratory compliance and inspections easier by changing how you document, save and retrieve all information necessary to meet CLIA and accreditation regulations. With two unique electronic tools My Compliance Manual and MyInspection™ Software, the guesswork and tedious task of interpreting and documenting policy, procedure, forms, charts and logs is over. Your lab will be compliant, have less paper, and be inspection ready.

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2021, ISSUE 4 | 23

PRODUCT FOCUS

FULLY AUTOMATED QUANTITIVE IMMUNOASSAY ANALYZER

9239

SPIROMETRY PRODUCT FOCUS

SPIROMETRY IS EASY From MicroDirect

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Unless the equipment is easy to use, it will not be fully utilized by your staff. The MicroLab and MicroLoop are menu driven via a large graphic display and the test takes less than five minutes to perform. The easy-to-read reports, quality checks and built-in interpretation assist with your diagnosis. Your office sees patients with indications for spirometry on a daily basis. Accurately and quickly diagnosis them so you can properly treat them.

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MICRO 1 SPIROMETER From MicroDirect Specifically designed for situations where low cost precision spirometry measurements are required, the Micro I Spirometer measures the following parameters FEV1, FVC, PEF, FEF25-75, EEV6, FEV1/FVC, FEV1/FEV6, FEF25 and FEF25 that cn be displayed along with percent predicted and post bronchodilator comparisons and provide an optional printout if needed. Extremely lightweight and portable making it suitable for hospital outreach clinics, bedside screenings, health fair screenings and other situations where remote testing is required.

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PORTABLE, SINGLE CLICK OPERATION SPIROMETER 9244

From MicroDirect The MicroDirect SpiroUSB many features include single click operation of all main functions, full ATS/ERS test quality checks, real time Flow/Volume and Volume/ Time traces, a choice of child incentive displays, choice of predicted values, estimated lung age, pre/post bronchodilator comparisons and can be used on multiple PC’s with dongle software protection key. The child incentive display and ATS quality checks ensure maximal results every time. Use with a laptop for true portability.

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ASSESSING AND MONITORING COVID-19 PATIENTS. Urgent care facilities, primary care practices, and other outpatient settings at the front lines of the COVID-19 pandemic need on-site testing solutions to support patient assessment and monitoring. With-patient testing can lead to better healthcare performance by facilitating decisions that can optimize patient outcomes in real time, improving the quality of patient care.

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For facilities treating COVID-19 patients, having rapid, accurate diagnostic test results may be useful when assessing or monitoring patients for: • C-Reactive Protein (CRP) Levels may be elevated in COVID-19 cases, especially severe cases.2-15 • Liver, Kidney and Cardiac function Elevated levels of the following biomarkers may be indicators of COVID-19 severity:16-27 - Alanine Aminotransferase (ALT)16,17,20-27 - Albumin (ALB)16,19-22,25-27 - Aspartate Aminotransferase (AST)16,17,19-21,23-26 - Creatine Kinase (CK)16,18,20,22-24 - Creatinine (CREAT)16,22,23,25,27 - Total Bilirubin (TBILI)16,20,25,27

ON-SITE TESTING MADE EASY: PICCOLO XPRESS.® The Piccolo Xpress portable diagnostic analyzer offers a full complement of blood chemistry tests, including CLIA-waived tests. Get accurate results in minutes, at the point-of-care. SEE A LIST OF KEY PICCOLO XPRESS PANELS ON BACK.

For in vitro diagnostic use only. The Piccolo Xpress does not directly diagnose COVID-19.

KEY PICCOLO XPRESS PANELS. CLIA-WAIVED PANELS

MODERATELY COMPLEX PANELS

Comprehensive Metabolic Panel

BioChemistry Panel Plus

Na+, K+, CI-, tCO2, Ca, BUN, Crea, Glu,

ALB, ALP, ALT, AMY, AST, BUN, Ca,

ALB, ALP, ALT, AST, TP, tBIL, eGFR*

Crea, Glu, GGT, TP, UA, CRP, eGFR*

MetLyte 8

MetLyte Plus CRP

Na+, K+, Cl-, tCO2, BUN, Crea, Glu,

CK, eGFR*

CK, CRP, eGFR*

Liver Panel Plus

Hepatic Function Panel

ALB, ALP, ALT, AMY, AST, GGT,

ALB, ALP, ALT, AST, tBIL, dBIL, TP

tBIL, TP

*Calculated

To learn how the Piccolo Xpress portable diagnostic analyzer can help transform your patient care, contact your Abbott Point of Care Representative or visit www.pointofcare.abbott 1.

2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14.

The Governing Board The American Association for the Study of Liver Diseases, Released: April 7, 2020. CLINICAL INSIGHTS FOR HEPATOLOGY AND LIVER TRANSPLANT PROVIDERS DURING THE COVID-19 PANDEMIC. Guan WJ et al. medRxiv preprint 2020; doi: https://doi.org/10. 1101/2020.02.06.20020974 Chen N et al. Lancet 2020; 395: 507–13 ; https://doi. org/10.1016/S0140-6736(20)30211-7 Cao W et al. medRxiv preprint 2020; doi: https://doi. org/10.1101/2020.02.23.20026963 Shi H et al. Lancet Infect Dis 2020 ; https://doi.org/10.1016/ S1473-3099(20)30086-4 Shi S et al. Jama Cardiology 2020; published online March 25; doi:10.1001/jamacardio.2020.0950 Xu H et al. medRxiv preprint 2020; doi: https://doi. org/10.1101/2020.03.05.20031591 Young BE et al. JAMA. Published online March 3, 2020; doi:10.1001/jama.2020.3204 Ruan Q et al. Intensive Care Medicine 2020. https://doi. org/10.1007/s00134-020-05991-x Zhou B. Research Square 2020; DOI:10.21203/rs.3.rs-18079/v1 Zhou S et al. AJR 2020; 215:1-8; doi.org/10.2214/AJR.20.22975 Li J et al. medRxiv preprint 2020; doi: https://doi. org/10.1101/2020.02.11.20022053 Deng SQ, Peng HJ. J. Clin. Med. 2020; 9, 575 (Review); doi:10.3390/jcm9020575 Ständiger Arbeitskreis der Kompetenz- und Behandlungszentren für Krankheiten durch hochpathogene Erreger am Robert Koch-Institut (STAKOB). Hinweise zu Erkennung, Diagnostik

15.

16.

17. 18.

19.

20.

21.

und Therapie von Patienten mit COVID-19; Downloaded 13. March 2020; www.rki.de/covid-19-therapie Chinese CoVID Management Guidelines-19, Version 7; published on 3/3/2020 by R.P.C. National Health Commission and the National Administration of Traditional Medicine of R.P.C.; translated by Jinwei Sun, Physician Specializing in Cardiovascular Disorders at the University of Milan-Bicocca Henry et al. 2020 Apr 10 Clinical Chemistry and Laboratory Medicine. Hematologic, biochemical and immune biomarker abnormalities associated with severe illness and mortality in coronavirus disease 2019 PMID: 32286245 DOI: 10.1515/cclm2020-0369. Ferrari et al. 2020 Apr 16 Clinical Chemistry and Laboratory Medicine. Routine blood tests as a potential diagnostic tool for COVID-19 PMID: 3230176 DOI: 10.1515/cclm-2020-0398. Yuan et al. 2020 Mar 29 Inflammation Research. The correlation between viral clearance and biochemical outcomes of 94 COVID-19 infected discharged patients PMID: 32227274 DOI: 10.1007/s00011-020-013242-0. Huang et al. 2020 Feb 15 The Lancet. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China PMID: 31986264 PMCID: PMC7159299 DOI: 10.1016/ S0140-6736(20) 30183-5. Chen et al. 2020 Feb 15 The Lancet. Epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in Wuhan, China: a descriptive study PMID: 32007143 PMCID: PMC7135076 DOI: 10.1016/S0140-6736(20)30211-7. The Governing Board The American Association for the Study of Liver Diseases, Released: April 7, 2020. CLINICAL IN

POINT OF CARE ©Abbott Point of Care Inc. 400 College Road East, Princeton, NJ 08540 (609) 454-9000 (609) 419-9370 (fax) www.pointofcare.abbott For in vitro diagnostic use only.

This material is intended for a U.S. audience only.

COVID-19 Channel Brochure - US 2994Rev.1 09/20 Piccolo Xpress is a registered trademark of Abaxis, Inc. and distributed by Abbott Point of Care. Abaxis 888-3354 Rev A

22.

23.

24.

25.

26.

27.

SIGHTS FOR HEPATOLOGY AND LIVER TRANSPLANT PROVIDERS DURING THE COVID-19 PANDEMIC. Zhou et al. 2020 Mar 28 The Lancet. Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study PMID 32171076 DOI: 10.1016/S0140-6736(20) 30566-3. Guan et al. 2020 Apr 30 The New England Journal of Medicine. The Clinical Characteristics of Coronavirus Disease 2019 in China PMID: 32109013 PMCID: PMC7092819 DOI: 10.1056/NEJMoa2002032. Holshue et al and The Washington State 2019-nCoV Case Investigation Team 2020 Mar 5 The New England Journal of Medicine Case Reports. First Case of 2019 Novel Coronavirus in the United States PMID: 32004427 PMCID: PMC7092802 DOI: 10.1056/NEJMoa2001191. Wu et al. 2020 Mar 13 JAMA Internal Medicine. Risk Factors Associated With Acute Respiratory Distress Syndrome and Death in Patients With Coronavirus Disease 2019 Pneumonia in Wuhan, China PMID: 32167524 PMCID: PMC7070509 DOI: 10.1001/jamainternmed.2020.0994. Chen et al. 2020 May 1 The Journal of Clinical Investigation. Clinical and immunological features of severe and moderate coronavirus disease 2019 PMID: 32217835 PMCID: PMC7190990 (available on 2020-08-01) DOI: 10.1172/ JCI137244. Wang et al. 2020 Apr 23 The Journal of Clinical Investigation Insight. The laboratory tests and host immunity of COVID-19 patients with different severity of illness PMID: 32324595 DOI: 10.1172/jci.insight.137799.

FEATURE

THE DIRECT CONNECTION BETWEEN

INEFFICIENCY AND BURNOUT BY PAUL DECHANT, MD, MBA AND DIANE W. SHANNON, MD

28 | PHYSICIANS OFFICE RESOURCE

An excerpt from Preventing Physician Burnout: Curing the Chaos and Returning Joy to the Practice of Medicine. Mark Linzer’s research identified workplace chaos as one of the key predictors of physician stress, burnout, and intention to leave. A recent analysis of the data showed that physicians in clinics with chaotic work environments had significantly more stress and burnout and a higher likelihood of leaving the practice within two years. These clinics also had significantly more missed opportunities to provide preventative services and had significantly higher rates of medical errors. Our experience and that of many of the physicians we interviewed confirmed the importance of workplace chaos in the development of burnout. Diane identified workplace chaos as the most important factor in the burnout that led her to leave clinical practice. Craig Albanese, MD, MBA, senior vice president and chief operating officer at New York-Presbyterian/ Morgan Stanley Children’s Hospital and Sloane Hospital for Women, pointed to the chaos and unstable work environment as the driver of his increasing interest in taking on administrative roles. He sensed that “there’s got to be a better way.” According to John Toussaint, MD, CEO of the ThedaCare Center for Healthcare Value, the workplace prior to implementing a Lean transformation at ThedaCare was replete with inefficiencies. “Physicians, nurses, and administrators and everybody else were all running around like chickens with their heads cut off because all the processes were chaos. There was no standard work. You did it one way on Monday, another way on Tuesday, and a third way on Wednesday. There was no predictability.” Toussaint told us that he and other leaders hypothesized that if they created predictability through standard work, the organization could focus on defect identification and problem-solving at the source. This approach, they believed, would lead to a more stable environment for caregivers and for patients. He described an informal study he did early in the organization’s Lean journey. He shadowed a nurse for a week with a stopwatch. The results? Three and a half hours of an eight-hour shift were spent searching for supplies. “It was the same for physicians in the office. What they needed was not in the room when they needed it. They didn’t have the information they needed to make decisions. Process after process was so fundamentally broken; it’s understandable why people were very stressed out.” In an interview, James P. Womack, PhD, founder and senior advisor to the Lean Enterprise Institute, described a conversation he had with several residents after delivering a presentation at a prestigious academic hospital. He asked the trainees, “What have you learned about medicine?” One said, “Nothing works, so I’ve learned how to do work-arounds.” The fundamental flaw with work-arounds is that they don’t fix the underlying error-prone and inefficient processes. These work-arounds can make practice feel a bit like a revolving door. As Gene Lindsey, formerly at Atrius Health, put it, “It became obvious to me that some things were beyond our ability to change as individual 2021, ISSUE 4 | 29

“If you step back and look at [burnout symptoms] and get beyond feeling like it is happening because you’re a deficient human being, you realize that these things are happening because you’re functioning in a system that is inhumane and not designed for anyone’s psychological or emotional survival.”

providers. We saw the same problems every day, and just because you solved them one day didn’t mean they wouldn’t come back, because the solutions were work-arounds. They didn’t solve the real problems.” Lindsey told us that at one institution in which he practiced for many years, two awards were given annually to recognize clinicians for stellar patient care. “It occurred to me that they should have been called ‘Band-Aid awards,’ because the system was so dysfunctional it required heroic efforts to provide care.” He noted that such efforts cost the physicians in “personal time and a cascade of other losses.” The physicians were willing to make the effort, but the dysfunctional system was the root cause of these sacrifices. He said, “It’s perverse not to recognize that a lot of their effort was wasted human effort.” Why are practice environments so chaotic and inefficient? In a setting in which errors can have devastating consequences that can be fatal, why are so many workflows inconsistent and unreliable? The simple answer is that the current practice environments were not consciously designed to be efficient and reliable. They developed over time, as multiple improvement initiatives (or external mandates or the personal preference of individual clinicians) changed workflows. The cumulative changes occurred without a careful assessment of the collective impact. The result is the chaos in which most physicians practice every day in both the hospital and office settings. As Robert Wachter of University of California, San Francisco, described it to us, “We have created jobs that are undoable. We have not given a moment’s thought to rethinking the world in which physicians provide care.” A common source of chaos in the clinical workplace is the inefficiency of both administrative and care processes. Physicians perform highly technical work that involves significant quality and safety risks. When physicians express fear that they will inadvertently harm a patient, this anxiety is often reflective

30 | PHYSICIANS OFFICE RESOURCE

of a chaotic workplace. Physicians know what to do, but the disorganized, dysfunctional, unpredictable practice environment in which they work makes it difficult, if not impossible, to do the right thing consistently. Attempting to predict and avoid medical errors in such an environment requires a high degree of vigilance, which is unsustainable in the long term. According to James Hereford, COO of Stanford University Medical Center, this level of vigilance increases the risk of burnout. “The primary contributing factor to burnout is lack of thoughtful processes and support that avoids hero-level work.” We asked Hereford to explain what these processes and support would look like. He told us, “Every ambulatory clinic should have a well-codified prepare-for-visit process. But walk into almost any ambulatory clinic and look for that process, and it is non-existent. Instead, the physician shows up at the appointed time and tries to do his or her best with the summary information in the medical record while trying to engage with the patient. Little wonder it’s a stressful encounter. At the end of the visit, there’s no well-codified process for the patient exit, follow-up, documentation, or coding. We just expect physicians to function well anyway. It’s ridiculous when you say it out loud.” Wayne Sotile has seen a direct connection between inefficiency and burnout. He told us that the primary complaint of the physicians and nurses he’s worked with is inefficiencies in the work setting. Lindsey described it this way: “If you step back and look at [burnout symptoms] and get beyond feeling like it is happening because you’re a deficient human being, you realize that these things are happening because you’re functioning in a system that is inhumane and not designed for anyone’s psychological or emotional survival.” Paul DeChant and Diane W. Shannon are authors of Preventing Physician Burnout: Curing the Chaos and Returning Joy to the Practice of Medicine.

Why You Should Be Doing Spirometry

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9251 It’s Important - Spirometry is the gold standard for the diagnosis and management of both asthma and COPD. It’s Good Medicine - Your patients are correctly diagnosed and treated more accurately and conveniently in your office. The earlier you detect the disease; the easier you can treat it. It’s Easy - A spirometry test takes less than five minutes to perform. It’s Good Business - Office spirometry is third party reimbursable and will pay for itself within the first year of purchase. It’s Safe - The SpiroSafe filter is single use viral/bacterial filters that helps to protect your patients and staff. It is >99% effective against viral and bacterial cross-contamination. Why Micro Direct? - Micro Direct’s spirometry experts will help you choose the right spirometer and then FULLY support your staff from training on how to use the spirometer through billing questions; and all Micro Direct spirometers are backed by a 30-day money back guarantee.

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For adults with intermediate- or high-risk myelofibrosis (MF)1

INTERVENE WITH

JAKAFI® (RUXOLITINIB) AT DIAGNOSIS Ruxolitinib (Jakafi) is a Category 2A* treatment option for both symptomatic lower-risk† and higher-risk MF – in patients with platelets ≥50 x 10 9/L. 2‡ *Category 2A: Based upon lower-level evidence, there is uniform NCCN consensus that the intervention is appropriate.2 † Lower-risk

MF is defined as low or intermediate-1 risk based on DIPSS, DIPSS-Plus, and MYSEC-PM, low or intermediate risk based on MIPSS-70 (threshold of ≤3 prognostic variable points), and very low, low, or intermediate risk based on MIPSS-70+ (version 2.0; threshold of ≤3 prognostic variable points).2 ‡ In patients who are not transplant candidates.

SIGNIFICANTLY MORE PATIENTS RECEIVING JAKAFI EXPERIENCED IMPROVEMENT IN MF-RELATED SPLENOMEGALY1,3,5 COMFORT-I PRIMARY ENDPOINT1,3‡

42%

of patients receiving Jakafi achieved a ≥35% reduction in spleen volume at week 24

patients receiving (P < 0.0001) 0.7% ofplacebo

4.4 years median duration of spleen response among primary responders (n = 65)4§

COMFORT-II PRIMARY ENDPOINT 1,5II

29%

of patients receiving Jakafi achieved a ≥35% reduction in spleen volume at week 48

Indications and Usage Jakafi is indicated for treatment of intermediate or high-risk myelofibrosis (MF), including primary MF, post–polycythemia vera MF and post–essential thrombocythemia MF in adults.

Important Safety Information Treatment with Jakafi® (ruxolitinib) can cause thrombocytopenia, anemia and neutropenia, which are each dose-related effects. Perform a pre-treatment complete blood count (CBC) and monitor CBCs every 2 to 4 weeks until doses are stabilized, and then as clinically indicated Manage thrombocytopenia by reducing the dose or temporarily interrupting Jakafi. Platelet transfusions may be necessary Patients developing anemia may require blood transfusions and/or dose modifications of Jakafi Severe neutropenia (ANC <0.5 × 10 9/L) was generally reversible by withholding Jakafi until recovery Serious bacterial, mycobacterial, fungal and viral infections have occurred. Delay starting Jakafi until active serious infections have resolved. Observe patients receiving Jakafi for signs and symptoms of infection and manage promptly. Use active surveillance and prophylactic antibiotics according to clinical guidelines

of patients receiving best available therapy¶ (P < 0.0001)

Tuberculosis (TB) infection has been reported. Observe patients taking Jakafi for signs and symptoms of active TB and manage promptly. Prior to initiating Jakafi, evaluate patients for TB risk factors and test those at higher risk for latent infection. Consult a physician with expertise in the treatment of TB before starting Jakafi in patients with evidence of active or latent TB. Continuation of Jakafi during treatment of active TB should be based on the overall risk-benefit determination Progressive multifocal leukoencephalopathy (PML) has occurred with Jakafi treatment. If PML is suspected, stop Jakafi and evaluate Advise patients about early signs and symptoms of herpes zoster and to seek early treatment Increases in hepatitis B viral load with or without associated elevations in alanine aminotransferase and aspartate aminotransferase have been reported in patients with chronic hepatitis B virus (HBV) infections. Monitor and treat patients with chronic HBV infection according to clinical guidelines When discontinuing Jakafi, myeloproliferative neoplasm-related symptoms may return within one week. After discontinuation, some patients with myelofibrosis have experienced fever, respiratory distress, hypotension, DIC, or multi-organ failure. If any of these occur after discontinuation or while tapering Jakafi, evaluate and treat any intercurrent illness and consider restarting or increasing the dose of Jakafi. Instruct patients not to interrupt

JAKAFI 3-YEAR AND 5-YEAR OVERALL SURVIVAL ANALYSES Jakafi Jakafi

1.00 1.00

Overall Survival Probability

Overall Survival Probability Overall Survival Probability

Overall Survival Kaplan-Meier Curves Group Overall Survival Kaplan-Meier Curvesby byTreatment Treatment Group a,b in COMFORT-I a,b Overall Survival Kaplan-Meier Curves by Treatment Group in COMFORT-I Overall Survival Kaplan-Meier Curves by a,b in COMFORT-I Treatment Group in COMFORT-I1,4,6,a,b Jakafi

Placebo

51% 51% 51% 40% 40% 40%

Jakafi Placebo Jakafi Placebo (n = 155) (n = 154) (n = 155) (n = 154) % 1-year survivalJakafi 91% Placebo 84%

0.50 0.25 Median 0.25 Median %c 1-year survival 91% 84% crossover c % 3-year survival 70% (n = 154) 61% crossover (n = 155) to Jakafi:% 3-year 0.25 0.00 survival 70% 61% toMedian Jakafi: 9 months % 1-year 0.00 survival 91% 84% % 5-year survival 51% 40% 9crossover months c % 5-year survival 51% 40% % 3-year survival 70% 61% to Jakafi: 0.00 9 months % 5-year survival 51% 40% 0

Number of patients at risk Jakafi 155 148 137 Number of patients at risk Placebo

154

144

119

Jakafi 155 148 137 124 Number 154 of patients at Placebo 144 119risk105 Jakafi 155 148 137 124 Placebo 154 144 119 105

124 105

Time, y

112 Time, 108 85 95

112 95 112 95

108 85 108 85

5 5

Time, y

100 78

100 78 100 78

86 72

86 72 86 72

At 3 years, survival probability was 70% for patients originally randomized to Jakafi and 61% for those originally randomized to placebo1 Overall survival was a prespecified secondary endpoint in COMFORT-I1

Placebo Placebo

1.00 0.75 0.75 0.75 0.50 0.50

COMFORT-I: 5-YEAR ANALYSIS OF JAKAFI AND PLACEBO6

80 59

75 51

80 59 80 59

69 46

75 51 75 51

57 38

69 46 69 46

57 38 57 38

JAKAFI 5-YEAR OVERALL SURVIVAL PROBABILITY WAS 51%4 All patients in the placebo group either crossed over to Jakafi at a median of 9 months or discontinued1 a

The 5-year overall survival analysis is not included in the Full Prescribing Information for Jakafi. Although the

Over3-year overall survival analysis is presented in the Full Prescribing Information, P values and hazard ratios

Over are omitted from the overall survival Kaplan-Meier curves.4 b COMFORT-I was not designed to compare survival probabilities between Jakafi and placebo at 3 or 5 years.4 Over c Patients randomized to placebo were eligible to cross over to receive Jakafi because of progression-driven

events or at the physician’s discretion; however, these patients continued to be grouped within their original randomized assignment for analysis purposes.4 COMFORT-I (COntrolled MyeloFibrosis study with ORal JAK inhibitor Treatment-I) was a randomized, doubleblind, placebo-controlled phase 3 study with 309 patients with intermediate-2–risk or high-risk MF. The primary endpoint was the proportion of patients achieving a ≥35% reduction in spleen volume from baseline to week 24 as measured by CT or MRI.1,3 § Duration of spleen response was defined as the interval between the first spleen response measurement that was a ≥35% reduction from baseline and the date of the first measurement that was no longer a ≥35% reduction from baseline that was also a >25% increase from nadir.4

‡

Adapted with permission from the Journal of Hematology & Oncology.6

COMFORT-II: 5-YEAR ANALYSIS OF JAKAFI AND BEST AVAILABLE THERAPY7

Overall Survival Kaplan-Meier Curves by Treatment Group in COMFORT-II1,7,a,b Jakafi

At 3 years, survival probability was 79% for patients originally randomized to Jakafi and 59% for those originally randomized to best available therapy1 Overall survival was a prespecified secondary endpoint in COMFORT-II1

BAT

Overall Survival Probability

1.0 0.8

56%

0.6 0.4 0.2

Median crossover c to Jakafi: 17 months

0.0

Jakafi (n = 146) 96%

BAT (n = 73) 94%

% 3-year survival

79%

59%

% 5-year survival

56%

44%

% 1-year survival

146 73

130 58

100 35

88 30

61 22

Time, y

Number of patients at risk Jakafi BAT

44%

109 48

JAKAFI 5-YEAR OVERALL SURVIVAL PROBABILITY WAS 56%7 All patients in the best available therapy group either crossed over to Jakafi at a median of 17 months or discontinued1 BAT, best available therapy. a The 5-year overall survival analysis is not included in the Full Prescribing Information for Jakafi. Although the 3-year overall survival analysis is presented in the Full Prescribing Information, P values and hazard ratios are omitted from the overall survival Kaplan-Meier curves.4 b COMFORT-II was not designed to compare survival probabilities between Jakafi and best available therapy at 3 or 5 years.4 c Patients randomized to best available therapy were eligible to cross over to receive Jakafi because of progression-driven events or at the physician’s discretion; however, these patients continued to be grouped within their original randomized assignment for analysis purposes.4 II COMFORT-II (COntrolled MyeloFibrosis study with ORal JAK inhibitor Treatment-II) was a randomized, open-label phase 3 study with 219 patients with intermediate-2–risk or high-risk MF. The primary endpoint was the proportion of patients achieving a ≥35% reduction in spleen volume from baseline at week 48 as measured by CT or MRI.1,5 ¶ Best available therapy in COMFORT-II included hydroxyurea (46.6%) and glucocorticoids (16.4%), as well as no medication, anagrelide, epoetin alfa, thalidomide, lenalidomide, mercaptopurine, thioguanine, danazol, peginterferon alfa-2a, interferon-α, melphalan, acetylsalicylic acid, cytarabine, and colchicine.4

Adapted with permission from Leukemia.7

For more data on long-term results with Jakafi, visit JakafiResults.com or discontinue Jakafi without consulting their physician. When discontinuing or interrupting Jakafi for reasons other than thrombocytopenia or neutropenia, consider gradual tapering rather than abrupt discontinuation Non-melanoma skin cancers including basal cell, squamous cell, and Merkel cell carcinoma have occurred. Perform periodic skin examinations Treatment with Jakafi has been associated with increases in total cholesterol, low-density lipoprotein cholesterol, and triglycerides. Assess lipid parameters 8-12 weeks after initiating Jakafi. Monitor and treat according to clinical guidelines for the management of hyperlipidemia In myelofibrosis and polycythemia vera, the most common nonhematologic adverse reactions (incidence ≥15%) were bruising, dizziness, headache, and diarrhea. In acute graft-versus-host disease, the most common nonhematologic adverse reactions (incidence >50%) were infections and edema Dose modifications may be required when administering Jakafi with strong CYP3A4 inhibitors or fluconazole or in patients with renal or hepatic impairment. Patients should be closely monitored and the dose titrated based on safety and efficacy Use of Jakafi during pregnancy is not recommended and should only be used if the potential benefit justifies the potential risk to the fetus. Women taking Jakafi should not breastfeed during treatment and for 2 weeks after the final dose

Please see Brief Summary of Full Prescribing Information for Jakafi on the following pages. To learn more about Jakafi, visit HCP.Jakafi.com. References: 1. Jakafi [package insert]. Wilmington, DE: Incyte Corporation. 2. Referenced with permission from the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) for Myeloproliferative Neoplasms V.1.2020. © National Comprehensive Cancer Network, Inc. 2020. All rights reserved. Accessed May 21, 2020. To view the most recent and complete version of the guideline, go online to NCCN.org. NCCN makes no warranties of any kind whatsoever regarding their content, use or application and disclaims any responsibility for their application or use in any way. 3. Verstovsek S, Mesa RA, Gotlib J, et al. A double-blind, placebo-controlled trial of ruxolitinib for myelofibrosis. N Engl J Med. 2012;366(9):799-807. 4. Data on file. Incyte Corporation. Wilmington, DE. 5. Harrison C, Kiladjian J-J, Al-Ali HK, et al. JAK inhibition with ruxolitinib versus best available therapy for myelofibrosis. N Engl J Med. 2012;366(9):787-798. 6. Verstovsek S, Mesa RA, Gotlib J, et al; for COMFORT-I Investigators. Long-term treatment with ruxolitinib for patients with myelofibrosis: 5-year update from the randomized, double-blind, placebo-controlled, phase 3 COMFORT-I trial. J Hematol Oncol. 2017;10(1):55. 7. Harrison CN, Vannucchi AM, Kiladjian J-J, et al; on behalf of COMFORT-II Investigators. Long-term findings from COMFORT-II, a phase 3 study of ruxolitinib vs best available therapy for myelofibrosis. Leukemia. 2016;30(8):1701-1707.

BRIEF SUMMARY: For Full Prescribing Information, see package insert. INDICATIONS AND USAGE Myelofibrosis Jakafi is indicated for treatment of intermediate or high-risk myelofibrosis (MF), including primary MF, post-polycythemia vera MF and post-essential thrombocythemia MF in adults. Polycythemia Vera Jakafi is indicated for treatment of polycythemia vera (PV) in adults who have had an inadequate response to or are intolerant of hydroxyurea. Acute GraftVersus-Host Disease Jakafi is indicated for treatment of steroidrefractory acute graft-versus-host disease (GVHD) in adult and pediatric patients 12 years and older. CONTRAINDICATIONS None. WARNINGS AND PRECAUTIONS Thrombocytopenia, Anemia and Neutropenia Treatment with Jakafi can cause thrombocytopenia, anemia and neutropenia. [see Dosage and Administration (2.1) in Full Prescribing Information]. Manage thrombocytopenia by reducing the dose or temporarily interrupting Jakafi. Platelet transfusions may be necessary [see Dosage and Administration (2), and Adverse Reactions (6.1) in Full Prescribing Information]. Patients developing anemia may require blood transfusions and/or dose modifications of Jakafi. Severe neutropenia (ANC less than 0.5 × 109/L) was generally reversible by withholding Jakafi until recovery [see Adverse Reactions (6.1) in Full Prescribing Information]. Perform a pre-treatment complete blood count (CBC) and monitor CBCs every 2 to 4 weeks until doses are stabilized, and then as clinically indicated [see Dosage and Administration (2), and Adverse Reactions (6.1) in Full Prescribing Information]. Risk of Infection Serious bacterial, mycobacterial, fungal and viral infections have occurred. Delay starting therapy with Jakafi until active serious infections have resolved. Observe patients receiving Jakafi for signs and symptoms of infection and manage promptly. Use active surveillance and prophylactic antibiotics according to clinical guidelines. Tuberculosis Tuberculosis infection has been reported in patients receiving Jakafi. Observe patients receiving Jakafi for signs and symptoms of active tuberculosis and manage promptly. Prior to initiating Jakafi, patients should be evaluated for tuberculosis risk factors, and those at higher risk should be tested for latent infection. Risk factors include, but are not limited to, prior residence in or travel to countries with a high prevalence of tuberculosis, close contact with a person with active tuberculosis, and a history of active or latent tuberculosis where an adequate course of treatment cannot be confirmed. For patients with evidence of active or latent tuberculosis, consult a physician with expertise in the treatment of tuberculosis before starting Jakafi. The decision to continue Jakafi during treatment of active tuberculosis should be based on the overall risk-benefit determination. Progressive Multifocal Leukoencephalopathy Progressive multifocal leukoencephalopathy (PML) has occurred with Jakafi treatment. If PML is suspected, stop Jakafi and evaluate. Herpes Zoster Advise patients about early signs and symptoms of herpes zoster and to seek treatment as early as possible if suspected [see Adverse Reactions (6.1) in Full Prescribing Information]. Hepatitis B Hepatitis B viral load (HBV-DNA titer) increases, with or without associated elevations in alanine aminotransferase and aspartate aminotransferase, have been reported in patients with chronic HBV infections taking Jakafi. The effect of Jakafi on viral replication in patients with chronic HBV infection is unknown. Patients with chronic HBV infection should be treated and monitored according to clinical guidelines. Symptom Exacerbation Following Interruption or Discontinuation of Treatment with Jakafi Following discontinuation of Jakafi, symptoms from myeloproliferative neoplasms may return to pretreatment levels over a period of approximately one week. Some patients with MF have experienced one or more of the following adverse events after discontinuing Jakafi: fever, respiratory distress, hypotension, DIC, or multi-organ failure. If one or more of these occur after discontinuation of, or while tapering the dose of Jakafi, evaluate for and treat any intercurrent illness and consider restarting or increasing the dose of Jakafi. Instruct patients not to interrupt or discontinue Jakafi therapy without consulting their physician. When discontinuing or interrupting therapy with Jakafi for reasons other than thrombocytopenia or neutropenia [see Dosage and Administration (2.6) in Full Prescribing Information], consider tapering the dose of Jakafi gradually rather than discontinuing abruptly. Non-Melanoma Skin Cancer Non-melanoma skin cancers including basal cell, squamous cell, and Merkel cell

carcinoma have occurred in patients treated with Jakafi. Perform periodic skin examinations. Lipid Elevations Treatment with Jakafi has been associated with increases in lipid parameters including total cholesterol, low-density lipoprotein (LDL) cholesterol, and triglycerides. The effect of these lipid parameter elevations on cardiovascular morbidity and mortality has not been determined in patients treated with Jakafi. Assess lipid parameters approximately 8-12 weeks following initiation of Jakafi therapy. Monitor and treat according to clinical guidelines for the management of hyperlipidemia. ADVERSE REACTIONS The following clinically significant adverse reactions are discussed in greater detail in other sections of the labeling: • Thrombocytopenia, Anemia and Neutropenia [see Warnings and Precautions (5.1) in Full Prescribing Information] • Risk of Infection [see Warnings and Precautions (5.2) in Full Prescribing Information] • Symptom Exacerbation Following Interruption or Discontinuation of Treatment with Jakafi [see Warnings and Precautions (5.3) in Full Prescribing Information] • Non-Melanoma Skin Cancer [see Warnings and Precautions (5.4) in Full Prescribing Information]. Clinical Trials Experience in Myelofibrosis Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of a drug cannot be directly compared to rates in the clinical trials of another drug and may not reflect the rates observed in practice. The safety of Jakafi was assessed in 617 patients in six clinical studies with a median duration of follow-up of 10.9 months, including 301 patients with MF in two Phase 3 studies. In these two Phase 3 studies, patients had a median duration of exposure to Jakafi of 9.5 months (range 0.5 to 17 months), with 89% of patients treated for more than 6 months and 25% treated for more than 12 months. One hundred and eleven (111) patients started treatment at 15 mg twice daily and 190 patients started at 20 mg twice daily. In patients starting treatment with 15 mg twice daily (pretreatment platelet counts of 100 to 200 × 109/L) and 20 mg twice daily (pretreatment platelet counts greater than 200 × 109/L), 65% and 25% of patients, respectively, required a dose reduction below the starting dose within the first 8 weeks of therapy. In a double-blind, randomized, placebo-controlled study of Jakafi, among the 155 patients treated with Jakafi, the most frequent adverse reactions were thrombocytopenia and anemia [see Table 2]. Thrombocytopenia, anemia and neutropenia are dose-related effects. The three most frequent nonhematologic adverse reactions were bruising, dizziness and headache [see Table 1]. Discontinuation for adverse events, regardless of causality, was observed in 11% of patients treated with Jakafi and 11% of patients treated with placebo. Table 1 presents the most common nonhematologic adverse reactions occurring in patients who received Jakafi in the double-blind, placebo-controlled study during randomized treatment. Table 1: Myelofibrosis: Nonhematologic Adverse Reactions Occurring in Patients on Jakafi in the Double-blind, Placebo-controlled Study During Randomized Treatment Jakafi (N=155) All Gradesa Adverse (%) Reactions 23 Bruisingb Dizzinessc 18 Headache 15 Urinary Tract 9 Infectionsd 7 Weight Gaine Flatulence 5 Herpes 2 Zosterf

Placebo (N=151)

Grade Grade All Grade Grade 3 4 Grades 3 4 (%) (%) (%) (%) (%) <1 <1 0

0 0 0

15 7 5

0 0 0

<1 0

0 0

1 <1

<1 0

0 0

National Cancer Institute Common Terminology Criteria for Adverse Events (CTCAE), version 3.0 includes contusion, ecchymosis, hematoma, injection site hematoma, periorbital hematoma, vessel puncture site hematoma, increased tendency to bruise, petechiae, purpura c includes dizziness, postural dizziness, vertigo, balance disorder, Meniere’s Disease, labyrinthitis d includes urinary tract infection, cystitis, urosepsis, urinary tract infection bacterial, kidney infection, pyuria, bacteria urine, bacteria urine identified, nitrite urine present e includes weight increased, abnormal weight gain f includes herpes zoster and post-herpetic neuralgia a

Description of Selected Adverse Reactions: Anemia In the two Phase 3 clinical studies, median time to onset of first CTCAE Grade 2 or higher anemia was approximately 6 weeks. One patient (<1%) discontinued treatment because of anemia. In patients receiving

Jakafi, mean decreases in hemoglobin reached a nadir of approximately 1.5 to 2.0 g/dL below baseline after 8 to 12 weeks of therapy and then gradually recovered to reach a new steady state that was approximately 1.0 g/dL below baseline. This pattern was observed in patients regardless of whether they had received transfusions during therapy. In the randomized, placebo-controlled study, 60% of patients treated with Jakafi and 38% of patients receiving placebo received red blood cell transfusions during randomized treatment. Among transfused patients, the median number of units transfused per month was 1.2 in patients treated with Jakafi and 1.7 in placebo treated patients.Thrombocytopenia In the two Phase 3 clinical studies, in patients who developed Grade 3 or 4 thrombocytopenia, the median time to onset was approximately 8 weeks. Thrombocytopenia was generally reversible with dose reduction or dose interruption. The median time to recovery of platelet counts above 50 × 109/L was 14 days. Platelet transfusions were administered to 5% of patients receiving Jakafi and to 4% of patients receiving control regimens. Discontinuation of treatment because of thrombocytopenia occurred in <1% of patients receiving Jakafi and <1% of patients receiving control regimens. Patients with a platelet count of 100 × 109/L to 200 × 109/L before starting Jakafi had a higher frequency of Grade 3 or 4 thrombocytopenia compared to patients with a platelet count greater than 200 × 109/L (17% versus 7%). Neutropenia In the two Phase 3 clinical studies, 1% of patients reduced or stopped Jakafi because of neutropenia. Table 2 provides the frequency and severity of clinical hematology abnormalities reported for patients receiving treatment with Jakafi or placebo in the placebo-controlled study. Table 2: Myelofibrosis: Worst Hematology Laboratory Abnormalities in the Placebo-Controlled Studya

Laboratory Parameter Thrombocytopenia Anemia Neutropenia a b

Jakafi Placebo (N=155) (N=151) All Grade Grade All Grade Grade Gradesb 3 4 Grades 3 4 (%) (%) (%) (%) (%) (%) 70 96 19

9 34 5

4 11 2

31 87 4

1 16 <1

0 3 1

Presented values are worst Grade values regardless of baseline National Cancer Institute Common Terminology Criteria for Adverse Events, version 3.0

Additional Data from the Placebo-Controlled Study • 25% of patients treated with Jakafi and 7% of patients treated with placebo developed newly occurring or worsening Grade 1 abnormalities in alanine transaminase (ALT). The incidence of greater than or equal to Grade 2 elevations was 2% for Jakafi with 1% Grade 3 and no Grade 4 ALT elevations. • 17% of patients treated with Jakafi and 6% of patients treated with placebo developed newly occurring or worsening Grade 1 abnormalities in aspartate transaminase (AST). The incidence of Grade 2 AST elevations was <1% for Jakafi with no Grade 3 or 4 AST elevations. • 17% of patients treated with Jakafi and <1% of patients treated with placebo developed newly occurring or worsening Grade 1 elevations in cholesterol. The incidence of Grade 2 cholesterol elevations was <1% for Jakafi with no Grade 3 or 4 cholesterol elevations. Clinical Trial Experience in Polycythemia Vera In a randomized, open-label, active-controlled study, 110 patients with PV resistant to or intolerant of hydroxyurea received Jakafi and 111 patients received best available therapy [see Clinical Studies (14.2) in Full Prescribing Information]. The most frequent adverse reaction was anemia. Discontinuation for adverse events, regardless of causality, was observed in 4% of patients treated with Jakafi. Table 3 presents the most frequent nonhematologic adverse reactions occurring up to Week 32. Table 3: Polycythemia Vera: Nonhematologic Adverse Reactions Occurring in ≥ 5% of Patients on Jakafi in the Open-Label, Active-controlled Study up to Week 32 of Randomized Treatment Jakafi (N=110)

Adverse Reactions Diarrhea Dizzinessb Dyspneac Muscle Spasms Constipation Herpes Zosterd

All Gradesa (%) 15 15 13 12 8 6

Table 3 continued above.

Grade 3-4 (%) 0 0 3 <1 0 <1

Best Available Therapy (N=111) All Grades (%) 7 13 4 5 3 0

Grade 3-4 (%) <1 0 0 0 0 0

Table 3 continued.

Jakafi (N=110) All Gradesa (%) Adverse Reactions Nausea 6 Weight Gaine 6 Urinary Tract Infectionsf 6 Hypertension 5

Best Available Therapy (N=111)

Grade 3-4 (%) 0 0 0 <1

All Grades (%) 4 <1 3 3

Grade 3-4 (%) 0 0 0 <1

National Cancer Institute Common Terminology Criteria for Adverse Events (CTCAE), version 3.0 includes dizziness and vertigo c includes dyspnea and dyspnea exertional d includes herpes zoster and post-herpetic neuralgia e includes weight increased and abnormal weight gain f includes urinary tract infection and cystitis

Table 6: Acute Graft-Versus-Host Disease: Selected Laboratory Abnormalities Worsening from Baseline in the Open-Label, Single Cohort Study Jakafi (N=71) Worst grade during treatment Laboratory Parameter All Gradesa (%) Grade 3-4 (%) Hematology Anemia 75 45 Thrombocytopenia 75 61 Neutropenia 58 40 Chemistry Elevated ALT 48 8 Elevated AST 48 6 Hypertriglyceridemia 11 1

Clinically relevant laboratory abnormalities are shown in Table 4. Table 4: Polycythemia Vera: Selected Laboratory Abnormalities in the Open-Label, Active-controlled Study up to Week 32 of Randomized Treatmenta Jakafi (N=110) All Grade Laboratory Gradesb 3 Parameter (%) (%) Hematology Anemia 72 <1 Thrombocytopenia 27 5 Neutropenia 3 0 Chemistry Hypercholesterolemia 35 0 Elevated ALT 25 <1 Elevated AST 23 0 Hypertriglyceridemia 15 0 a b

Best Available Therapy (N=111) Grade All Grade Grade 4 4 Grades 3 (%) (%) (%) (%) <1 <1 <1

58 24 10

0 3 <1

0 <1 0

0 0 0 0

8 16 23 13

0 0 <1 0

0 0 0 0

Presented values are worst Grade values regardless of baseline National Cancer Institute Common Terminology Criteria for Adverse Events, version 3.0

Clinical Trial Experience in Acute Graft-Versus-Host Disease In a single-arm, open-label study, 71 adults (ages 18-73 years) were treated with Jakafi for acute GVHD failing treatment with steroids with or without other immunosuppressive drugs [see Clinical Studies (14.3) in Full Prescribing Information]. The median duration of treatment with Jakafi was 46 days (range, 4-382 days). There were no fatal adverse reactions to Jakafi. An adverse reaction resulting in treatment discontinuation occurred in 31% of patients. The most common adverse reaction leading to treatment discontinuation was infection (10%). Table 5 shows the adverse reactions other than laboratory abnormalities. Table 5: Acute Graft-Versus-Host Disease: Nonhematologic Adverse Reactions Occurring in ≥ 15% of Patients in the Open-Label, Single-Cohort Study Adverse Reactionsa Infections Edema Hemorrhage Fatigue Bacterial infections Dyspnea Viral infections Thrombosis Diarrhea Rash Headache Hypertension Dizziness a b

Jakafi (N=71) All Gradesb (%) Grade 3-4 (%) 55 41 51 13 49 20 37 14 32 28 32 7 31 14 25 11 24 7 23 3 21 4 20 13 16 0

Selected laboratory abnormalities are listed in Table 6 below National Cancer Institute Common Terminology Criteria for Adverse Events (CTCAE), version 4.03

Selected laboratory abnormalities during treatment with Jakafi are shown in Table 6.

National Cancer Institute Common Terminology Criteria for Adverse Events, version 4.03

DRUG INTERACTIONS Fluconazole Concomitant administration of Jakafi with fluconazole doses greater than 200 mg daily may increase ruxolitinib exposure due to inhibition of both the CYP3A4 and CYP2C9 metabolic pathways [see Clinical Pharmacology (12.3) in Full Prescribing Information]. Increased exposure may increase the risk of exposure-related adverse reactions. Avoid the concomitant use of Jakafi with fluconazole doses of greater than 200 mg daily except in patients with acute GVHD [see Dosage and Administration (2.4) in Full Prescribing Information]. Strong CYP3A4 inhibitors Concomitant administration of Jakafi with strong CYP3A4 inhibitors increases ruxolitinib exposure [see Clinical Pharmacology (12.3) in Full Prescribing Information]. Increased exposure may increase the risk of exposure-related adverse reactions. Consider dose reduction when administering Jakafi with strong CYP3A4 inhibitors [see Dosage and Administration (2.4) in Full Prescribing Information]. In patients with acute GVHD, reduce Jakafi dose as recommended only when coadministered with ketoconazole, and monitor blood counts more frequently for toxicity and adjust the dose if necessary when coadministered with itraconazole. [see Dosage and Administration (2.4) in Full Prescribing Information]. Strong CYP3A4 inducers Concomitant administration of Jakafi with strong CYP3A4 inducers may decrease ruxolitinib exposure [see Clinical Pharmacology (12.3) in Full Prescribing Information]. No dose adjustment is recommended; however, monitor patients frequently and adjust the Jakafi dose based on safety and efficacy [see Clinical Pharmacology (12.3) in Full Prescribing Information]. USE IN SPECIFIC POPULATIONS Pregnancy : Risk Summary When pregnant rats and rabbits were administered ruxolitinib during the period of organogenesis adverse developmental outcomes occurred at doses associated with maternal toxicity (see Data). There are no studies with the use of Jakafi in pregnant women to inform drug-associated risks. The background risk of major birth defects and miscarriage for the indicated populations is unknown. Adverse outcomes in pregnancy occur regardless of the health of the mother or the use of medications. The background risk in the U.S. general population of major birth defects is 2% to 4% and miscarriage is 15% to 20% of clinically recognized pregnancies. Data: Animal Data Ruxolitinib was administered orally to pregnant rats or rabbits during the period of organogenesis, at doses of 15, 30 or 60 mg/kg/day in rats and 10, 30 or 60 mg/kg/day in rabbits. There were no treatment-related malformations. Adverse developmental outcomes, such as decreases of approximately 9% in fetal weights were noted in rats at the highest and maternally toxic dose of 60 mg/kg/day. This dose results in an exposure (AUC) that is approximately 2 times the clinical exposure at the maximum recommended dose of 25 mg twice daily. In rabbits, lower fetal weights of approximately 8% and increased late resorptions were noted at the highest and maternally toxic dose of 60 mg/kg/day. This dose is approximately 7% the clinical exposure at the maximum recommended dose. In a pre- and post-natal development study in rats, pregnant animals were dosed with ruxolitinib from implantation through lactation at doses up to 30 mg/kg/day. There were no drug-related adverse findings in pups for fertility indices or for maternal or embryofetal survival, growth and development parameters at the highest dose evaluated (34% the clinical exposure at the maximum recommended dose of 25 mg twice daily). Lactation: Risk Summary No data are available regarding the presence of ruxolitinib in human milk, the effects on the breast fed child, or the effects on milk production. Ruxolitinib and/or its metabolites were present in the milk of lactating rats (see Data). Because many drugs are present in human milk and because of the potential for thrombocytopenia and anemia shown for Jakafi in human studies, discontinue breastfeeding during treatment with Jakafi and for two weeks after the final dose. Data: Animal Data Lactating rats were administered a single dose of [14C]-labeled ruxolitinib (30 mg/kg) on postnatal Day 10, after which plasma and

milk samples were collected for up to 24 hours. The AUC for total radioactivity in milk was approximately 13-fold the maternal plasma AUC. Additional analysis showed the presence of ruxolitinib and several of its metabolites in milk, all at levels higher than those in maternal plasma. Pediatric Use The safety and effectiveness of Jakafi for treatment of myelofibrosis or polycythemia vera in pediatric patients have not been established. The safety and effectiveness of Jakafi for treatment of steroid-refractory acute graft-versus-host disease (GVHD) have been established for treatment of children 12 years and older. Use of Jakafi in pediatric patients with steroid-refractory acute GVHD is supported by evidence from an adequate and well-controlled trial of Jakafi in adults [see Clinical Studies (14.3) in Full Prescribing Information] and additional pharmacokinetic and safety data in pediatric patients. Jakafi was evaluated in a single-arm, dose-escalation study (NCT01164163) in 27 pediatric patients with relapsed or refractory solid tumors (Cohort A) and 20 with leukemias or myeloproliferative neoplasms (Cohort B). The patients had a median age of 14 years (range, 2 to 21 years) and included 18 children (age 2 to <12 years), and 14 adolescents (age 12 to <17 years). The dose levels tested were 15, 21, 29, 39, or 50 mg/m2 twice daily in 28-day cycles with up to 6 patients per dose group. Overall, 38 (81%) patients were treated with no more than a single cycle of Jakafi, while 3, 1, 2, and 3 patients received 2, 3, 4, and 5 or more cycles, respectively. A protocol-defined maximal tolerated dose was not observed, but since few patients were treated for multiple cycles, tolerability with continued use was not assessed adequately to establish a recommended Phase 2 dose higher than the recommended dose for adults. The safety profile in children was similar to that seen in adults. Juvenile Animal Toxicity Data Administration of ruxolitinib to juvenile rats resulted in effects on growth and bone measures. When administered starting at postnatal day 7 (the equivalent of a human newborn) at doses of 1.5 to 75 mg/kg/day, evidence of fractures occurred at doses ≥ 30 mg/kg/day, and effects on body weight and other bone measures [e.g., bone mineral content, peripheral quantitative computed tomography, and x-ray analysis] occurred at doses ≥ 5 mg/kg/day. When administered starting at postnatal day 21 (the equivalent of a human 2-3 years of age) at doses of 5 to 60 mg/kg/day, effects on body weight and bone occurred at doses ≥ 15 mg/kg/day, which were considered adverse at 60 mg/kg/day. Males were more severely affected than females in all age groups, and effects were generally more severe when administration was initiated earlier in the postnatal period. These findings were observed at exposures that are at least 27% the clinical exposure at the maximum recommended dose of 25 mg twice daily. Geriatric Use Of the total number of patients with MF in clinical studies with Jakafi, 52% were 65 years and older, while 15% were 75 years and older. No overall differences in safety or effectiveness of Jakafi were observed between these patients and younger patients. Clinical studies of Jakafi in patients with acute GVHD did not include sufficient numbers of subjects age 65 and over to determine whether they respond differently from younger subjects. Renal Impairment Total exposure of ruxolitinib and its active metabolites increased with moderate (CLcr 30 mL/min to 59 mL/min) and severe (CLcr 15 mL/min to 29 mL/min) renal impairment, and ESRD on dialysis [see Clinical Pharmacology (12.3) in Full Prescribing Information]. Reduce Jakafi dose as recommended [see Dosage and Administration (2.5) in Full Prescribing Information]. Hepatic Impairment Exposure of ruxolitinib increased with mild (Child-Pugh A), moderate (Child-Pugh B) and severe (Child-Pugh C) hepatic impairment [see Clinical Pharmacology (12.3) in Full Prescribing Information]. Reduce Jakafi dose as recommended in patients with MF or PV and any hepatic impairment [see Dosage and Administration (2.5) in Full Prescribing Information]. Monitor blood counts more frequently for toxicity and consider 5 mg once daily for patients with Stage 3 or 4 liver GVHD [see Dosage and Administration (2.5) and Clinical Pharmacology (12.3) in Full Prescribing Information]. OVERDOSAGE There is no known antidote for overdoses with Jakafi. Single doses up to 200 mg have been given with acceptable acute tolerability. Higher than recommended repeat doses are associated with increased myelosuppression including leukopenia, anemia and thrombocytopenia. Appropriate supportive treatment should be given. Hemodialysis is not expected to enhance the elimination of Jakafi.

Jakafi is a registered trademark of Incyte. All rights reserved. U.S. Patent Nos. 7598257; 8415362; 8722693; 8822481; 8829013; 9079912; 9814722; 10016429 © 2011-2020 Incyte Corporation. All rights reserved. Revised: August 2020 PLR-JAK-00048

FEATURE

Patient Anxiety: CREATING A BETTER ENVIRONMENT TO HEAL BY DYLAN CHADWICK

When asked to describe anxiety, I often defer to the description I’d give my college therapist. Anxiety fits somewhere between “simple worry” and “full-blown panic.” I’d compare it to the dull, but consistent bellowing of a gaggle of monkeys let loose to tromp around the recesses of my brain. Everyone experiences anxiety in some fashion, whether responding to an overwhelming work schedule, an impending deadline or even as a generalized disorder. Physicians certainly aren’t strangers to anxiety-provoking work either, especially those who work in emergency capacities. But while the individual and observable symptoms of anxiety vary from person to person, the overall obstacles it presents are quite uniform. Anxiety and stress are animal instincts, ones which protect us in dangerous situations and motivate us to seek equilibrium and control when we are losing it. However, anxiety can also be an impediment to relationships, an all-encompassing, slippery paralysis that crowds out our ability to think rationally, to make positive judgments and to hear what we most need to hear while in its throes: sound counsel. 36 | PHYSICIANS OFFICE RESOURCE

When a patient visits their physician, they’re prone to feeling a little anxious. Diagnoses and treatment plans, loaded with obtuse medical jargon, can put ones mind in a tailspin and set one’s heart a-flutter. Not exactly prime condition to take medical advice. Wary physicians should consider the implications of a patient’s anxiety when dispensing information, in order to ensure they’re communicating clearly and effectively, and in a way that will benefit the patient long after they’ve left the exam room. Here’s some tips on how physicians can key into those feelings, work within them, and help patients feel less anxious in the process. Open the Floor Effective physicians will work to create an atmosphere in which patients can verbalize their concerns, questions and anxieties, and will work to address those before even moving into a treatment discussion. In an office visit, a patient has many more thoughts going through their minds than what’s on the surface. In these experiences, physicians should open the floor to patients, ensuring them that their questions and concerns are

not only valid, but an integral part of treatment. Some patients may not feel comfortable articulating their inner concerns, and in these circumstances, a warm invitation to do so will carry much weight. A willing and listening ear can also calm the nerves of an argumentative patient. Ultimately, when a patient comes to a physician’s office, they’re bombarded with information that can be both frightening and confusing. Creating a scenario in which they’re given clearance to air out their fears not only helps them manage and regulate their emotions, but also helps the physician tailor treatment specific to their needs in the long run. It also goes without saying that there truly is no patient concern that is “wrong” or unimportant. Uncertainty is an unpleasant feature of many medical experiences, but a physician who will set the tone with warmth and an open mind will help alleviate anxiety’s burden. A Room of One’s Own A medical practice can be stressful environment, especially

when dealing with a pandemic. Patients are surrounded by foreign looking equipment, strange sterile smells, and often the intermittent bustle of physicians, nurses and other specialists conducting serious and time-sensitive work. Environmental distractions can exacerbate a patient’s anxiety, leaving them feeling cagey and alone and in a strange environment outside of their normal comfort zone and preference. It’s beneficial for physicians to help control that environment, and create the most quiet, and private place possible so as to dispense medical information in as clear a manner as possible. Besides ensuring that information isn’t misconstrued, it helps quell the rampant anxiety provoking factors present in a high-energy workplace, putting fretting patients at ease. Words Unspoken Often it’s not just the words one uses, but the body language that accompanies the delivery of those words. It’s important for physicians to remember how their nonverbal body cues will affect a patient’s understanding and emotional processing of the information. Simple things like smiling and maintaining a 2021, ISSUE 4 | 37

FEATURE

“Creating a scenario in which they’re given clearance to air out their fears not only helps them manage and regulate their emotions, but also helps the physician tailor treatment specific to their needs in the long run.”

calm and collected voice and speaking in soft, yet audible tones, can quell the alarming feelings potentially welling up inside a patient’s mind. There’s really no deep and nuggety magical formula for it. Physician’s should simply be nice and relaxed with patients, clear and controlled in their delivery. It lends an air of stability to the proceedings and will help manage the expectations of the room. Silence Isn’t Always a Bad Thing We all hate uncomfortable silences and will often seek to avoid them at all costs. They don’t always indicate that a conversation is going poorly though. In fact, when given such high levels of sensitive information, many patients need some time to process and digest the lofty information they’ve just been given. A well-placed section of “breathing time” is often an indication that new and useful information is being processed. When a physician is hasty to “force” conversation in these instances, they can come off as rude and insensitive. Furthermore, patients may not want to speak at all. While it’s important to always open the floor, physicians must also respect an anxious patient’s desire to simply listen and absorb information. Choices Empower Patients Anxiety makes people feel powerless to their emotions or the circumstance at hand. When confronted with a serious health issue, many patients resort to dread and anxiety because they don’t feel equipped to deal with the problem. Physicians should be sure to outline multiple choices (where applicable) for treatment options. When a patient knows they have choices and options for their treatment, they feel empowered and capable to deal with the problem, and also feel that their physicians are on their “team.” It’s also important to remember that even though a physician knows all the nuances and options of a treatment regimen, a patient may not, or may have a significantly limited understanding of it. Let them know that they have options in how they choose to be treated, and aren’t being forced into something without having an opportunity to weigh out the pros and cons. Enlist the Aid of Family or Trusted Friends There are those circumstances when patient anxiety is

38 | PHYSICIANS OFFICE RESOURCE

extreme and a patient needs someone there to help them on a more intimate emotional level. It’s not uncommon for patients to enlist the aid of a spouse or trusted family member to help them receive their treatment options and have said family member accompany them on their visit. In these circumstances, a level-head and an extra set of ears can ensure they the patient gets the most out of their treatment. Healthcare is a joint effort with patients and their families, and some family members need only to be taught how they can participate. In all circumstances, especially ones which involve rigorous or disruptive treatment, it’s crucial to get family members on board because when patients feel that they have a team of supporters backing them, they no longer feel alone in their problem. Furthermore, family members can help the patient with alternative perspectives or simply just comforting words that a physician simply cannot. Physicians are trained to diagnose and treat every level of medical problem and ailment in the known universe. However, beyond medical diagnoses, an understanding of patient anxiety, and the emotional/logical stranglehold it can wreak on its victims, will improve a physician’s ability to dispense information clearly and concisely, as well as tending to the emotional healing of a patient. References RN, Gina. “How Touch Can Calm Patients.” KevinMD.com. Kevin MD, 19 Jan. 2012. Web. 18 May 2015. Osbourne, Helen, M.Ed. “In Other Words...Know When to Speak and When to Listen...Communicating With People Who Are Anxious or Angry.” Healthliteracy.com. Health Literacy, Oct. 2005. Web. 18 May 2015. Tartakowsky, Margarita, M.S. “3 Practices to Calm An Anxious Mind.” Psychecentral.com. Psyche Central, n.d. Web. 18 May 2015.

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may need more than one refrigerator

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