Bulletin Allegheny County Medical Society
February 2022
Take That, Pharma Bros Online Physician Reviews
Neurological options for your patients.
Stuart Silverman, MD
When your patients need world-class specialty care, AHN has physicians with the right expertise — like our new neurologist.
– West Penn Hospital
Neurologist Locations: AHN Neurology – Waterworks – Aliquippa – Grove City
Dr. Silverman provides expert evaluation and individualized treatments for optimal patient health.
Specialties: Interventions for disorders of the brain and nervous system, including complex neurological conditions Experienced care and management for patients with multiple sclerosis
To refer your patient, call 412-578-3925 Most major insurance plans are accepted.
11/21 Z MX1108361 ACMS Silverman 7.5”w x 9.75”h
Allegheny County Medical Society
Bulletin February 2022 / Vol. 112 No. 2
Opinion
Departments
Articles
Editorial ....................................5 Society News .........................14 Materia Medica .......................20 • Take That, Pharma Bros • 30th Annual Virtual Clinical Update • Finerenone (Kerendia®) Deval (Reshma) Paranjpe, MD, MBA, FACS
in Geriatric Medicine
Arianna Sprando, PharmD and Alicia Faggioli, PharmD, BCPS
Society News .........................16 Legal Summary .....................24 Editorial ....................................8 • Pittsburgh Ophthalmology • COVID-19 and Disciplinary Actions • Experience Counts Society 57th Annual Meeting Richard H. Daffner, MD, FACR
Alliance News ........................18 Perspective ............................11 • ACMS Alliance Holiday Party 2021 • Online Physician Reviews Timothy Lesaca, MD
against Physicians: Medical Boards or State Legislature? By Beth Anne Jackson
Special Report .......................26 • REPORTABLE DISEASES 2021: Q1-Q4
On the cover Pittsburgh Sunrise Terence Starz, MD Dr. Starz specializes in Rheumatology & Clinical Immunology
Bulletin Medical Editor Deval (Reshma) Paranjpe (reshma_paranjpe@hotmail.com) Associate Editors 2022 Executive Committee and Board of Directors President Peter G. Ellis President-elect Matthew B. Straka Vice President Raymond E. Pontzer Secretary Mark A. Goodman Treasurer Board Chair Patricia L. Bononi DIRECTORS 2022 William F. Coppula Micah A. Jacobs Keith T. Kanel G. Alan Yeasted Alexander Yu 2023 Steven Evans Bruce A. MacLeod Amelia A. Pare Maritsa Scoulous-Hanson Adele L. Towers 2024 Douglas F. Clough Kirsten D. Lin Jan B. Madison Raymond J. Pan
PEER REVIEW BOARD 2022 Niravkumar Barot Kimberly A. Hennon 2023 Lauren C. Rossman Angela M. Stupi 2024 Marilyn Daroski David J. Levenson
PAMED DISTRICT TRUSTEE G. Alan Yeasted COMMITTEES Awards Mark A. Goodman Bylaws Raymond E. Pontzer Finance Keith T. Kanel Membership Matthew B. Straka
Douglas F. Clough (dclough@acms.org) Richard H. Daffner (rdaffner@acms.org) Kristen M. Ehrenberger (kehrenberger@acms.org) Anthony L. Kovatch (mkovatch@comcast.net) Joseph C. Paviglianiti (jcpmd@pedstrab.com) Anna Evans Phillips (evansac3@upmc.edu) Andrea G. Witlin (agwmfm@gmail.com)
Nominating Chair Raymond E. Pontzer
ADMINISTRATIVE STAFF
ACMS ALLIANCE
Interim Chief Executive Officer Lisa Olszak Zumstein (lisa@acms.org)
Co-Presidents Patty Barnett Barbara Wible
Vice President—Operations and Physician Services Nadine M. Popovich (npopovich@acms.org) Director of Publications Cindy Warren (cwarren@pamedsoc.org)
Recording Secretary Justina Purpura Corresponding Secretary Doris Delserone Treasurer Sandra Da Costa Assistant Treasurers Liz Blume Kate Fitting
www.acms.org
Improving Healthcare through Education, Service, and Physician Well-Being.
EDITORIAL/ADVERTISING OFFICES: Bulletin of the Allegheny County Medical Society, 850 Ridge Avenue, Pittsburgh, PA 15212; (412) 321-5030; fax (412) 321-5323. USPS #072920. PUBLISHER: Allegheny County Medical Society at above address. The Bulletin of the Allegheny County Medical Society is presented as a report in accordance with ACMS Bylaws, Articles 6, 8, and 11. The Bulletin of the Allegheny County Medical Society welcomes contributions from readers, physicians, medical students, members of allied professions, spouses, etc. Items may be letters, informal clinical reports, editorials, or articles. Contributions are received with the understanding that they are not under simultaneous consideration by another publication. Issued the third Saturday of each month. Deadline for submission of copy is the SECOND Monday preceding publication date. Periodical postage paid at Pittsburgh, PA. Bulletin of the Allegheny County Medical Society reserves the right to edit all reader contributions for brevity, clarity and length as well as to reject any subject material submitted. The opinions expressed in the Editorials and other opinion pieces are those of the writer and do not necessarily reflect the official policy of the Allegheny County Medical Society, the institution with which the author is affiliated, or the opinion of the Editorial Board. Advertisements do not imply sponsorship by or endorsement of the ACMS, except where noted. Publisher reserves the right to exclude any advertisement which in its opinion does not conform to the standards of the publication. The acceptance of advertising in this publication in no way constitutes approval or endorsement of products or services by the Allegheny County Medical Society of any company or its products. Annual subscriptions: $60 Advertising rates and information available by calling (412) 321-5030 or online at www.acms.org. COPYRIGHT 2022: ALLEGHENY COUNTY MEDICAL SOCIETY POSTMASTER—Send address changes to: Bulletin of the Allegheny County Medical Society, 850 Ridge Avenue, Pittsburgh, PA 15212. ISSN: 0098-3772
Editorial
Take That, Pharma Bros Deval (Reshma) Paranjpe, MD, MBA, FACS
H
“
ometown boy makes good”. I’m talking about famous Pittsburgh export and billionaire Mark Cuban’s latest venture, Cost Plus Drugs, a national online pharmacy which promises generic drugs priced strictly at cost plus 15% markup and pharmacist fee. The pharmacy doesn’t accept insurance, so patients pay directly. Patients can purchase medications outright with a prescription, and the prices are often far less than the copays they would ordinarily pay using their insurance. Cost Plus Drugs has also established its own pharmacy benefit manager and is building a Dallas production facility to manufacture its own generics in the US. Cost Plus Drugs ships to all 50 states. Radiologist and child prodigy Alex Oshmyansky MD, Ph.D. is the inventor and CEO of Cost Plus. Oshymyansky pitched Cost Plus Drugs to Cuban, who believed and invested in the concept. The aim is to reduce the cost and thereby expand access to lifesaving prescription drugs upon which many Americans depend. Cost Plus negotiates directly with manufacturers, bypassing middlemen and pharmacy
benefit managers. This represents a massive disruption to a prescription drug industry which has made significant and onerous markups routine.
The most notorious example of outrageous markups in recent years was the doing of so-called “Pharma Bro” Martin Shkreli, who in 2015 acquired the manufacturing license for Daraprim and raised the price 56x, from $13.50 to $750 per tablet. Not to be outdone, Mallinckrodt Pharmaceuticals acquired and raised the price of corticotropin, a drug invented in 1952, from $40 per vial in 2000 to around $40,000 per vial today under the brand name Acthar Gel. Both drugs are vital and life-saving—the former is an antiparasitic agent and the latter an anti-seizure agent. The intent of the acquisitions and price hikes in both cases was to make the drug in question a massive “cash cow” for the pharmaceutical company. However, patients who needed these drugs for
their very survival suddenly found themselves being bankrupted and/or at risk of dying. Some of the savings that Cost Plus offers are modest. Some are astounding. Atorvastatin, which retails for $55.80, is only $3.60 for a 30day supply. Imatinib, the generic for Gleevec, would be $2502 for a 30-day supply; at Cost Plus, a 30-day supply is only $17.10. Cost Plus does not yet offer insulin or ophthalmic drops, but it does offer 100 commonly used vital medicines from antihypertensives to SSRIs to antibiotics with at least 90% savings on many of them. Currently, 10% of all Americans have had to skip medication doses due to cost. That figure increases significantly among lower income brackets and the elderly. We all know that being priced out of access to medications causes decreased compliance, poorer outcomes/quality of life and increased morbidity/ mortality among our patients. Cost Plus Drugs could be a lifesaver and a gamechanger for patients who cannot afford their medications, people on fixed incomes, and everyone else. Continued on Page 6
ACMS Bulletin / February 2022
5
Editorial From Page 5
Patients sign up online at www. costplusdrugs.com, and contact their physician. As the physician, you can e-prescribe or phone or fax in your patient’s prescriptions, ideally using Cost Plus’s downloadable prescription form. The website provides you with all relevant numbers, and the process is simple for both physician and patient. My first thought was that a physician must have helped to create this (with his or her elderly parents acting as quality control testers). Thoughtfully designed, intuitive and simple, the interface and process are both incredibly easy to navigate even for technologically challenged patients (or physicians!). I encourage you to look at the website and scroll through the list of available medications; you will be
6
pleasantly surprised if not shocked. The provenance of these generics is not given, but they will soon be made on U.S. soil at Cost Plus Drugs’ Dallas manufacturing facility. As with any potentially new and disruptive service, caveat emptor. Elizabeth Holmes and Theranos promised to be the future of laboratory testing and we all saw the debacle of fraud that was eventually exposed. However, this service appears to have a solid business plan and relies on existing technology and suppliers, merely changing the business model to the patient’s advantage. Cost Plus Drugs isn’t the only game in town—literally. Pittsburgh’s own Blueberry Pharmacy (412-612-2279) is another nationally recognized disruptor of the prescription drug industry, albeit with far less press coverage. Based in West View, Blueberry Pharmacy
is a brick-and-mortar independent pharmacy offering a membership model. A membership fee ($60/year or $18/quarter) offers access to similar prices as those offered by Cost Plus Drugs for generic drugs. In addition, patients can receive assistance in finding deep discounts and coupons for brand name drugs. Visit www.blueberrypharmacy.com for details. This editorial does not constitute an endorsement by either me or ACMS for either Cost Plus Drugs or Blueberry Pharmacy, but encourages you to explore these two resources and determine your own considered opinion. My only conclusion is this: good things come from Pittsburgh. The opinion expressed in this column is that of the writer and does not necessarily reflect the opinion of the Editorial Board, the Bulletin, or the Allegheny County Medical Society.
www.acms.org
Editorial
Thank you for your membership in the Allegheny County Medical Society The ACMS Membership Committee appreciates your support. Your membership strengthens the society and helps protect our patients.
Please make your medical society stronger by encouraging your colleagues to become members of the ACMS. For information, call the membership department at (412) 321-5030, ext. 109, or email membership@acms.org.
ACMS Bulletin / February 2022
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Editorial
Experience Counts Richard H. Daffner, MD, FACR
L
ife is a journey of learning. The human brain is like a small computer with almost unlimited storage space. In medical school we were given large amounts of information, some of which we wondered if we would ever use. Each one of these facts, however, was stored in one of our cerebral recesses, to be recalled at the appropriate time – if ever. Likewise, the other things we learn on life’s journey are available for recall to be used on a moment’s notice. And sometimes, those facts or skills may have been learned decades before. Every summer (except for 2020, due to the pandemic), for the past 40 years, I have been attending a scout camp in North Carolina with my troop. Many years ago, the camp program included several challenge events that would test the outdoor skills for the scouts and their leaders. Mark, one of our younger leaders, entered a team from our troop. Our four-person team consisted of Mark, Jim, Debra, one of the moms who accompanied her sons to camp, and me. Mark and Jim are Eagle Scouts. I had only achieved the Star rank as a boy. However, I had completed the highest level of adult leader training – the Wood Badge program, which emphasized not only leadership skills, but also honed our outdoor skills. Debra had no outdoor 8
skills, but more importantly, was a mature adult. The event presented five challenges to each team, which began when each team member was given a mountain bicycle to ride through the course. At the first station we were given three wooden ridge poles (used for tents) and a coil of rope and told to use those materials to devise a way to move one member of our team and their bike to the next station. Mark, Jim, and I quickly lashed the poles together in a triangle, put the triangle over our own bikes and carried Debra and her bike to the next station. We did this without the triangle falling apart, and without Debra or her bike falling off. The next station was at the waterfront where we were given three inflated inner tubes, life vests, a canoe, two paddles (for the four of us), and more rope. Our challenge was to move our team and our bikes across the lake. We quickly tied the inner tubes to the triangle to make a raft and securely lashed the four bikes on top. Then the four of us got into the canoe. Mark sat in front, and I took the stern. Mark, the youngest of our team was overpowering my paddling and I told him that he could paddle, and I would steer. We made it safely to the other side of the lake without tipping over or donating a bike to the lake. Once there, we removed our bikes and
were told to follow the trail to the next challenge, after we left the canoe and our makeshift raft. At the next station, our challenge was for each member to raise a log on a rope over a bar that had been lashed between two trees. Mark, Jim, and I quickly tied a timber hitch and raised the log. Fortunately, the rules allowed us to coach Debra so that she could tie the timber hitch and likewise, raise the log. The same station had an additional challenge. One member of our group had to light a strike-anywhere match using a hand axe (hatchet). We elected Jim, a machinist, whom we knew from observation on previous service projects, that he had a knack for precision and excellent hand-eye coordination. He lit the match on the first attempt. Our final challenge was to make a small fire and burn a string suspended two feet over the fire. As we started our fire the wind began blowing the flames sideways, away from the string. We gathered ourselves on the windward side of the fire to form a human windbreak, and completed our assigned task, long before any of the youth teams appeared. The camp staff in charge told us that we had set a record for the shortest time for completing the challenges for the whole summer. www.acms.org
Editorial Debra was impressed. She said, “ I can’t believe we actually beat a group of kids.” “Well,” I said, “We had three advantages. First, we had teamwork; second, we had adult problem-solving skills; and third, three of us had better scouting skills than any of the members of the other teams. Experience counts.” Several years ago, at our own scout camp I was summoned by Scott, one of the camp medics, an EMT, to advise him on the removal of a turtle hook (a large fishhook) from a camper’s leg. He had spent an hour trying to coax the barb free using the “string method”, something I had never found to be successful. When I arrived and assessed the situation, I said, “Well, now it’s time for Plan A.” “ I thought I was using Plan A,” Scott said. “No,” I replied, “You’re using Plan D.” I looked at the boy and told him to grit his teeth, and as he did, I quickly advanced the hook until the barb had penetrated the skin. I then cut the barb off with the wire cutter on my Leatherman® multitool and pulled the remainder of the hook back out. This was classic wilderness first aid, something I had originally learned decades earlier when I was a Boy Scout. While Scott was dressing the punctures, I called the Emergency Department at Allegheny General and asked the attending staff physician if the boy needed to be given antibiotics. The hook had come directly from a new package and had never been used, so I was advised to look at the wound in the morning and check for any signs of infection. The next morning, the boy was fine. Again, experience counts. ACMS Bulletin / February 2022
I did my diagnostic radiology residency in the “Pre-CT era” in the early 1970’s. Our main imaging modality was radiography, supplemented by gastrointestinal barium studies, intravenous urography, and angiography. The development of ultrasound and CT in the mid to late 70’s and MRI a decade later dramatically changed diagnostic imaging and made many of those old studies obsolete. My partner, Irwin (Irv) Beckman, who also trained at the same time as me, and I were the senior members of our group. Irv and I became the “go-to guys” for any unusual findings on chest or abdominal x-rays. (I was also the expert on bone x-rays). Experience counts. I trained at Duke, which like UPMC
today, was considered a leading tertiary care institution. I also worked as faculty there for seven years. There, in addition to the “usual” diseases and injuries, we frequently encountered medical exotica. Most of us will agree that once exposed to an unusual finding or a rare disease, we will never forget it. Figure 1 is a close-up view from a chest x-ray on an infant with irritability, soft tissue swelling, and tenderness in his jaw and clavicles. There is periosteal new bone formation along the lower mandible and both clavicles (arrows). My residents thought the child had osteomyelitis. I told them this was classic Caffey disease (infantile cortical hyperostosis). This self-limiting entity, originally described by Pittsburgh’s
Fig. 1. Caffey disease in a six-month-old infant. Detail of mandible and upper chest shows diffuse periosteal new bone formation along the body of the mandible and clavicles (arrows) Continued on Page 10
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Editorial Editorial Rear End Gastropub & Garage,
From Page 9 St., Etna 399 Butler
For a culinary cross-country road John Caffey1 (the “Father of Pediatric trip, stop in this converted auto service Radiology”) was first thought to be station for a taste of roadside delights caused by a virus. We now know it from coast to coast from Chef Anthony is a genetic disorder caused by a Tripi. Twenty draft beers and fun mutation of the COL1A1 gene that is cocktails to boot. responsible for making type 1 collagen. Adda Bazaar, 725 Penn Ave., On interviewing the child’s mother, I Downtown learned that she had a similar illness The newest of Adda Coffee & Tea as a small child in the 1950’s. I had House’s multiple downtown cafes. Adda seen a case with identical findings is the term for the long Bengali tradition thirty years earlier as a resident. Again, of stimulating intellectual discourse with experience counts. friends over tea and coffee. Here’s your In radiology, we frequently use the chance to try the art of Adda, with a term “Aunt Minnie” to describe findings selection of fine teas and coffees. or diagnoses that are considered Three Bakery Square delights: “classic”. The term “Aunt Minnie” is AVP, Bakery Square, 6425 Penn believed to have been coined in the Ave., East Liberty 1940s by the late Dr. Ben Felson, Fans of Big Burrito’s Alta Via pizza a radiologist at the University of in Fox Chapel can venture to Bakery Cincinnati, who used it to describe Square to try the casual California style radiologic findings so specific and Italian cuisine of its cousin, AVP. Enjoy seasonal vegetable-forward dishes as well as pizzas and sandwiches for lunch and dinner seven days a week. täkō, Bakery Square, 6425 Penn Ave., East Liberty Love the downtown Richard DeShantz jewel of a restaurant called täkō, but can’t get a reservation in the crowded space? Come enjoy its vast Bakery Square outpost, complete with 5000 square feet of space and both indoor and outdoor dining. Galley – Bakery Square, 6425 Penn Ave., East Liberty Galley – Bakery Square is the
latest branch of the Galley restaurant incubator concept, featuring the same formula as its Galley compelling thatsister theresites wasFederal no realistic on the Northdiagnosis. Side and Or, the inStrip District differential other location. Four emerging chefs are words, to paraphrase Dr. Felson: “If it selected open theirMinnie, own restaurant looks liketoyour Aunt then it is within the space, with 12-18 months to your Aunt Minnie.” winVeteran over anphysicians, audience and establish their in all brand. You can try a little of specialties, have thousandseverything of from allMinnies” four restaurants the “Aunt stored in during the recesses same meal – heaven for foodies. of their brains. They’ve “been there Honey, andTupelo seen that”. And100 thatWest is whyStation Square Drive, South Side experience counts. Craving fried green tomatoes, buttermilk biscuits, shrimp and grits andReference: banana pudding – and oh yes, fried and waffles? Tupelo J 1. Cchicken affey J. Infantile cortical hyperostosis. Honey Café1946; will29:541-559. open this fall in Station Pediatr Square to remedy that, in style. Con Alma Downtown, 613 Penn Ave., Dr. Downtown Daffner is a retired radiologist The new jewel ofcurmudgeon, the Downtown and board-certified who Cultural District features insanely good practiced at Allegheny General Hospital Miami/Latin/Caribbean along for over 30 years. He iscuisine Emeritus with live jazz. Clinical Professor of Radiology at Gaucho Parrilla Argentina, 146 Temple University School of Medicine. Sixth St., Downtown The resident jewel of the Downtown Cultural District dazzles with an incredible array of steaks and wood fired meats with a variety of sauces and accompaniments. Takeout and dine-in available. Wild Child, 372 Butler St., Etna The opinion expressed this column is that of The brainchild ofinChef Jamilka the writer and does not necessarily reflect the opinion of theChild Editorial Board, the Bulletin, Borges, Wild emphasizes coastal or the Allegheny County Medical Society. and island cuisine and is sure to delight. Mount Oliver Bodega, 225 Brownsville Road, Mt. Oliver
Chef Kevin Sousa’s new project will combine a wine shop, bar and pizzeria in the former Kullman’s Bakery space. Sustainable, biodynamic and organic wines from around the world will be featured along with a down to earth, rustic menu. Nonalcoholic wines and cocktails also will be showcased. G’s On Liberty, 5104 Liberty Ave., Bloomfield G’s turns former Alexander’s Italian Bistro into a seasonal scratch kitchen with creative food and cocktails. Coming in the fall. And finally … Chengdu Gourmet, McKnight Road, Ross Township Chengdu Gourmet (the beloved James Beard-nominated Squirrel Hill hole-in-the-wall Sichuan restaurant that regularly inspires pilgrimages from all over Western PA) is planning an outpost on McKnight Road at the site of the former Oriental Market, in the plaza next to Red Lobster. This will offer a much larger dining space – 6,000 square feet – and an expanded dining menu. Something to look forward to in early 2022. Enjoy, and be safe. Dr. Paranjpe is an ophthalmologist and medical editor of the ACMS Bulletin. She can be reached at reshma_paranjpe@hotmail.com. The opinion expressed in this column is that of the writer and does not necessarily reflect the opinion of the Editorial Board, the Bulletin, or the Allegheny County Medical Society.
Improving Healthcare through Education, Service, and Physician Well-Being. ACMS Bulletin / August 2021 10
223 www.acms.org
Perspective Perspective
Online Physician Reviews Timothy Lesaca, MD Online physician reviews have generated impassioned critiques both pro and con. Although physician online rating sites have provided an impressive volume of potentially useful feedback information, physicians had not necessarily responded favorably to the abrupt exposure to occasional negative reviews. This is in stark contrast to patient rights advocates who believe that doctors should be subjected to the same public scrutiny as any other service or business provider. There is value in receiving useful feedback regardless of one’s station in life. A potentially constructive reviewer, however, might be negatively balanced by a disgruntled individual intent on ruining a doctor’s reputation. In the context of a small sample size, one negative review can tremendously downgrade a doctor’s overall online reputation. This becomes more egregious when the patient’s reasoning involves basic disagreements on the doctor’s assessments and treatment recommendations. Whether this all seems fair or not, online reviews for doctors are now considered the most important factor among many patients in choosing a new health care provider. Recent surveys indicate that online information has become more important in
selecting a physician then another doctor’s referral. Similar surveys indicate that over 80% of respondents went online to read the reviews of a doctor after receiving the referral from another provider. None of this should be particularly surprising, considering the growing consumerism of health care, and the strong momentum created by the COVID-19 pandemic toward online activities. Digital preference for investigating providers existed well before the pandemic, but COVID-19 accelerated this process dramatically. In choosing a new primary care physician for example, approximately 50% of patients first go online to review the doctor, whereas only about 20% seek recommendation from another health care provider. According to Press Ganey, search engines such as Google are the most used digital references accessed by patients to find a doctor. The leading website destinations for a doctor search include WebMD, Healthgrades, Facebook, and independent hospital websites. Somehow it seems reasonable to expect that patients who find their physicians online will also rely heavily upon online resources to provide feedback on those doctors. It is also equally logical to understand the
skepticism felt by many doctors who worry that physician online rating sites encourage destructive acting out by begrudged patients who might not necessarily understand the technical aspects of health care delivery. Furthermore, there is justifiable frustration in that physicians are usually unable to refute negative reviews without jeopardizing patient confidentiality. Patient empowerment and selfexpression in health care does not occur in a vacuum, as the Center for Medicare and Medicaid Services has an established set of core quality measures for health care, with patient experience being one of the critical domains. Furthermore, traditional government and health care organizations have routinely initiated surveys incorporating patient-reported outcome measures in their routine questionnaires. Within the context of these developments, physician online reading sites had become a consumer driven alternative and perhaps a cathartic outlet for patients to provide instant feedback on their health care experiences. Even if one were to stipulate the argument that online review sites such as Vitals, Healthgrades, RateMDs, and Continued on Page 12
ACMS Bulletin / February 2022
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Perspective Perspective Editorial 399 Butler St., Etna Yelp are benign and well-intended, they For a culinary cross-country road also have the intrinsic flaw of reviewers trip,having stop intothis converted auto service not prove that they received station for a taste of roadside delights care from the doctors they critique. from coast to coast from Chef Anthony Anyone, from a disgruntled neighbor Tripi. Twenty draft beers and fun to an angry ex-boyfriend could post a cocktails review to boot.for any clinician. The negative Adda limitationsBazaar, imposed725 by Penn HIPAAAve., on the Downtown ability to verify the identities of patients The newest of media Adda Coffee & Tea posting on social platforms House’sthe multiple cafes. Adda reduce validitydowntown of the reviews. The is the term for the long Bengali tradition ethical implications of anonymous of stimulating intellectual discourse with reviews are equally troubling, due to friends over tea and coffee. Here’s your concern that erroneous reviews could chance to trytothedamage art of Adda, with a be recorded the doctor’s selection of fine teas and coffees. reputation and practice. Three Bakery Square delights: Rather than subjective reviews, AVP, Bakery Square, 6425 Penn there are objective outcome measures Ave., East which couldLiberty be utilized for the same Fans of determining Big Burrito’s aAlta Via pizza purpose of doctor’s in Fox Chapelincluding can venture to Bakery competency, posted records Square to try the casual California of probations, board certifications, style Italian cuisine of its cousin, AVP. Enjoy educational achievements, seasonal vegetable-forward dishes malpractice claims, and morbidity/ as well asstatistics. pizzas and sandwiches mortality Interestingly andfor lunch and dinner seven days a week. unfortunately, most studies show at Bakery Square, 6425 Penn besttäkō, a weak correlation between webAve., East Liberty based rating and these more objective Love the downtown measurements. FurtherRichard limitations of DeShantz jewel of a rating restaurant called the online physician concept täkō, butsample can’t get a reservation in have the involve size. Most doctors crowded space? Come enjoy its vast only a small number or reviews despite Bakery thousands Square outpost, complete with seeing of patients. Some 5000 square feet of space and both active physicians who have seen many indoor and of outdoor dining. thousands patients over the years Galley – Bakery Square, 6425 have no reviews whatsoever. Penn Ave., East Liberty Galley – Bakery Square is the
latest branch of the Galley restaurant incubator concept, featuring the same The paramount issue is whether formula as its sister sites Federal Galley patient online reviews reflect physician on the North Side themore Strip District competence. Oneand of the location. Four emerging chefs interesting articles addressingare this selected to open their own question was published in restaurant the Mayo within Proceedings the space, with 12-18inmonths Clinic Journal 2018. to Up winthat over an audience and had establish to point in time there been their no brand. Youcomparing can try a little of everything research physicians with from all four restaurants negative online reviews during versusthe those same meal – heaven for foodies. without negative reviews regarding Tupelo Honey, 100satisfaction West Station industry-vetted patient Square such Drive,asSouth SideGaney. surveys the Press fried greenthe tomatoes, ThisCraving study compared group of buttermilk biscuits, shrimp and grits physicians with negative online reviews and banana pudding – andnegative oh yes, versus physicians without fried chicken and waffles? Tupelo reviews and found that there was no Honey Café will open this fall in Station Square to remedy that, in style. Con Alma Downtown, 613 Penn Ave., Downtown The new jewel of the Downtown Cultural District features insanely good Miami/Latin/Caribbean cuisine along with live jazz. Gaucho Parrilla Argentina, 146 Sixth St., Downtown The resident jewel of the Downtown Cultural District dazzles with an incredible array of steaks and wood fired meats with a variety of sauces and accompaniments. Takeout and dine-in available. Wild Child, 372 Butler St., Etna The brainchild of Chef Jamilka Borges, Wild Child emphasizes coastal and island cuisine and is sure to delight. Mount Oliver Bodega, 225 Brownsville Road, Mt. Oliver
Chef Kevin Sousa’s new project will combine adifference wine shop, andPress pizzeria statistical in bar formal in the former Kullman’s Bakery space. Ganey patient satisfaction survey Sustainable, biodynamic and organic results. The lack of a correlation wines from around the world between online reviews and will be featured along withsatisfaction a down to earth, institutional patient surveys rustic menu. Nonalcoholic wines and strongly suggests that the motivation cocktails will be showcased. for online also negative reviews is not a G’s On Liberty, 5104 Liberty Ave., completely understood phenomenon Bloomfield and drawing conclusions regarding G’s turns former Alexander’s physician competency would be Italian Bistro into aif not seasonal kitchen premature totally scratch inappropriate. withDespite creative food and cocktails. the societal cognitive Coming in the fall. physician online dissonance regarding And finally … rating sites, they have proliferated Chengdu Gourmet, McKnight to the point that many doctors now Road, Ross Township feel the need to attempt to elicit Chengdu Gourmet (the beloved James Beard-nominated Squirrel Hill hole-in-the-wall Sichuan restaurant that regularly inspires pilgrimages from all over Western PA) is planning an outpost on McKnight Road at the site of the former Oriental Market, in the plaza next to Red Lobster. This will offer a much larger dining space – 6,000 square feet – and an expanded dining menu. Something to look forward to in early 2022. Enjoy, and be safe.
“
“
FromRear PageEnd 11 Gastropub & Garage,
Dr. Paranjpe is an ophthalmologist and medical editor of the ACMS Bulletin. She can be reached at reshma_paranjpe@hotmail.com. The opinion expressed in this column is that of the writer and does not necessarily reflect the opinion of the Editorial Board, the Bulletin, or the Allegheny County Medical Society.
Improving Healthcare through Education, Service, and Physician Well-Being. ACMS Bulletin / August 2021 12
www.acms.org 223
Perspective Perspective favorable online reviews from patients. Healthgrades, for example, has a policy encouraging doctors who have received unsatisfactory patient scores to encourage even more patients to go online and complete surveys based upon the presumption that more favorable reviews will mitigate the negative impact of the unsatisfactory reviews. This policy however is in violation of the National Association of Social Workers and The American Psychological Association Code of Ethics. Both associations state that it is unethical to elicit or solicit testimonials or endorsements from patients as this would be an example of undue influence and exploitation of vulnerability. The American Medical Association has no similar policy, but that is not necessarily an absolution. The financial incentives for Healthgrades to increase their online traffic are obvious, as Healthgrades is owned by the corporation Red Ventures, an America media company owning several television media channels as well as having purchased Bankrate Inc. for $1.24 billion in cash in 2017. RateMDs, which is owned by the Canadian mass media company Torstar Corporation, has a protocol which will allow a doctor to ostensibly ‘claim’ his or her profile including all comments, and for a monthly fee of $179 can hide up to three negative comments, as well as place banner ads on the website for promotion. For a fee of $359 a month the doctor’s banner will appear in three times more spots than the lower priced package. The lack of transparency in this matter results in the public being unaware of the financial incentives at play. ACMS Bulletin / February 2022
The moral paradox in this high-tech gambit begs the question of whether doctor online rating sites are mindfully intended to provide the opportunity for consumers to share constructive criticism for the betterment of everyone concerned, as opposed to being part of a multimillion-dollar industry carefully formatted and designed to financially hold hostage the reputation of doctors. The other question at hand is whether we risk enabling a nefarious enterprise by our participation in it. Online physician rating sites are not going away. I took a personal interest in this subject when I read a review suggesting that I received my medical degree from Amazon (the company, not the rainforest). Had I been so fortunate, it would have cost less, and would have been delivered to my house in 24 hours. The American Medical Association provides some useful suggestions on how to deal with negative online reviews. If you are somehow able to unobtrusively determine who submitted the review, you might consider contacting this individual personally just see if there can be amicable compromise which would motivate the patient to remove the negative review. Personally, I would be very selective as to who I would use a strategy with. Another option would be to establish your own online profile and encourage nonanonymous feedback. Eventually, one must address the philosophic question of whether one or two bad reviews would truly destroy your life or your reputation. The natural reaction when one’s feelings are hurt is to immediately respond. Often, this is what resulted in the patient posting the online response.
Immediate emotional responses are often a mistake, therefore becoming angry in attempting to respond in turn would be an equally big mistake. It is also important to remember in the context of these situations that HIPAA always applies. A patient’s disclosure is not permission for the doctor to make equal disclosures. Finally, despite the natural inclination to do otherwise, don’t cognitively block the feedback outright. There might be an opportunity for growth. If not, you could always cheer yourself up and buy a medical degree from Amazon, like I did.
References:
ndrew M. Placona, Cheryl Rathert. (2022) A Are Online Patient Reviews Associated With Health Care Outcomes? A Systematic Review of the Literature. Medical Care Research and Review 79:1, 3-16. L ee, V. S. (2017a). Transparency and trust: Online patient reviews of physicians. New England Journal of Medicine, 376(3), 197-199. urphy GP, Radadia KD, Breyer BN. M Online physician reviews: is there a place for them? Risk Manag Healthc Policy. 2019 May 15; 12:85-89. idmer RJ, Maurer MJ, Nayar VR, Aase W LA, Wald JT, Kotsenas AL, Timimi FK, Harper CM, Pruthi S. Online Physician Reviews Do Not Reflect Patient Satisfaction Survey Responses. Mayo Clin Proc. 2018 Apr;93(4):453-457.
The opinion expressed in this column is that of the writer and does not necessarily reflect the opinion of the Editorial Board, the Bulletin, or the Allegheny County Medical Society.
13
Society News
30th Annual Virtual Clinical Update in Geriatric Medicine–March 31 through April 1 The 30th Annual Clinical Update in Geriatric Medicine will be held virtually on March 31–April 1, 2022. Presented by the Pennsylvania Geriatrics Society—Western Division (PAGS-WD), UPMC/University of Pittsburgh Aging Institute and the University of Pittsburgh School of Medicine Center for Continuing Education in Health Science, the conference provides an evidencebased approach to help clinicians take exceptional care of elderly patients. The virtual offering includes an outstanding agenda of lectures and panel discussions, including live question-and-answer sessions, vendor halls and opportunities to engage in conversations with speakers, exhibitors, and fellow attendees. With the fastest-growing segment of the population comprised of individuals more than 85 years of age, this conference is a premier educational resource for healthcare professionals involved in the direct care of older people. As the recipient of the American Geriatrics Society State Achievement Award for Innovative Educational Programming, the Clinical 14
Daniel Forman, MD
Deirdre O’Neill, MD, MSc,
Parag Goyal, MD, MSc
Lewis Lipsitz, MD
FRCPC
Mary Tinetti, MD
Update attracts prominent national and international lecturers and nationally renowned local faculty. Continuing Medical Education credits are available to participants. Course Directors, Shuja Hassan, MD; Neil Resnick, MD; and Lyn Weinberg, MD, along with the planning committee, are delighted to welcome distinguished guest faculty Lewis Lipsitz, MD Professor of Medicine, Harvard Medical School; Chief Academic Officer and Irving and Edyth S. Usen and Family; Director of the Hinda and Arthur Marcus Institute for Aging Research, Hebrew Senior Life; Chief, Division of Gerontology, Beth Israel Deaconess Medical Center; and Editor-in-Chief, Journal of Gerontology www.acms.org
Society News
Medical Sciences. Dr. Lipsitz will present, Falls and Syncope— Red Flags. Mary Tinetti, MD, is the Gladys Philips Crofoot Professor of Medicine (Geriatrics), Epidemiology, and Public Health at Yale School of Medicine and Yale New Haven Health. Her current research and clinical focus are on clinical decision-making for older adults in the face of multiple health conditions, measuring the net benefit and harms of commonly used medications, and the importance of cross-disease universal health outcomes. Dr. Tinetti will present, Aligning Care with Patient’s Priorities.
ACMS Bulletin / February 2022
Back by popular demand, a Geriatric Cardiology Expert Panel will be part of the agenda. Featured faculty include Parag Goyal, MD, MSc, assistant professor, Weill Cornell Medicine, New York. Dr. Goyal has joint appointments in the Division of Cardiology as a heart failure cardiologist and in the Division of General Internal Medicine as a member of the Health Services Research core faculty. Daniel Forman, MD, Professor of Medicine, Division of Geriatric Medicine University of Pittsburgh School of Medicine; Chair, Geriatric Cardiology, UPMC, Director, Cardiac Rehabilitation VA Pittsburgh
Healthcare System. Deirdre O’Neill, MD, MSc, FRCPC, Assistant Professor, Division of Cardiology, Department of Medicine University of Alberta, Alberta, Canada. All three physicians will participate in a live, rapid-fire question-and-answer session. To view the complete conference agenda and details on registration, please visit: https://dom.pitt.edu/ugm/. Registration is now open! Members of the PAGS-WD receive a discount when registering. To check on your membership status, please contact Mary Ellen Muth at memuth@acms.org
15
Society News
Pittsburgh Ophthalmology Society 57th Annual Meeting and Ophthalmic Personnel Meeting slated for March 11, 2022 The Pittsburgh Ophthalmology Society,
under the leadership of President Marshall W. Stafford, M.D. is pleased to announce the 57th Annual Meeting and the 42nd Meeting for Ophthalmic Personnel, scheduled for March 11, 2022, will be in-person events. Both meetings will take place at the Omni William Penn Hotel in Pittsburgh, PA. We look forward to offering an engaging and robust experience for attendees and exhibitors and are committed to providing a safe, productive, and welcoming environment in which to learn and gather. Registrations for both the Annual Meeting and ophthalmic personnel meeting are being accepted at www.pghoph.org. The Society is pleased to welcome Uday Devgan, M.D., FACS as the 41st annual Harvey E. Thorpe Lecturer. Dr. Devgan is in private practice at Devgan Eye Surgery, Los Angeles; Partner, Specialty Surgical Center, Beverly Hills; and the Original Cataract Coach.
Uday Devgan, M.D., FACS— Dr. Devgan is truly world renowned in the field of ocular surgery. He has taught surgery in 40 countries and writes teaching columns in eye surgery journals which are distributed worldwide. He has written more than 200 books, chapters, medical papers, and journal articles about techniques of cataract, lens, and LASIK surgery. These writings as well as his instructional surgical videos have helped thousands of ophthalmologists and their patients. Participating distinguished guest faculty:
Emily Chew, M.D.—
Chris Albanis, M.D.—
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Associate, The University of Chicago; Chairperson, Advocate Christ Medical Center, Department of Ophthalmology Chicago, IL. She teaches residents at The University of Chicago as a Clinical Assistant in the Department of Ophthalmology and Visual Science. Her pleasure in teaching extends to her colleagues, which has earned her several invitations to lecture on various ocular diseases nationally and internationally. She also serves as the Chair of Ophthalmology at Advocate Christ Medical Center. Dr. Albanis serves in many leadership roles with the Illinois Society of Eye Physicians and Surgeons and the American Academy of Ophthalmology, where she advocates for the needs of doctors and patients of Illinois.
Comprehensive Ophthalmology and Refractive Surgery, Chief Medical Officer, Ocular Partners, Inc; President, Arbor Centers for EyeCare; Clinical
Director of the Division of Epidemiology and Clinical Applications (DECA), at the National Eye Institute, the National Institutes of Health in Bethesda, Maryland. She is also the Chief of the Clinical Trials Branch. Dr. Chew is a medical retina specialist and has had extensive experience in designing and implementing clinical trials (of Phases 1, 2 and 3) at the NIH Clinical Center. Dr. Chew has a strong www.acms.org
Society News clinical and research interest in diabetic eye disease and age-related eye diseases. She has thoroughly worked on analyzing the data from the Early Treatment Diabetic Retinopathy Study (ETDRS) and she continues to manage and analyze data from the Age-Related Eye Disease Study (AREDS).
Vermeil, Ville de Paris. He was elected to the: Academia Ophthalmologica Internationalis, Académie des Sciences-Institut de France, German National Academy of Sciences Leopoldina, National Academy of Technologies of France, Association of American Physicians and American Ophthalmology Society. Dr. Sahel is Honoris Causa doctorate of University of Geneva and held the Technological Innovation Chair at the Collège de France (2015-2016). He is a member of several Editorial Scientific Advisory Boards, including Science Translational Medicine.
José Alain-Sahel, M.D.— Distinguished Professor and Chairman; The Eye and Ear Endowed Chair Department of Ophthalmology; Director, UPMC Eye Center University of Pittsburgh School of Medicine Pittsburgh, PA. Dr. Sahel is a clinicianscientist conducting research on vision restoration focusing on cellular and molecular mechanisms underlying retinal degeneration, and development of treatments for currently untreatable retinal diseases. He co-authored over 660 peer-reviewed articles and 40 patents. Dr. Sahel is recipient of numerous awards including the Foundation Fighting Blindness (FFB) Trustee Award, Alcon Research Institute Award for Excellence in Vision Research, Grand Prix NRJNeurosciences-Institut de France, Foundation Fighting Blindness Llura Liggett Gund Award, CharpakDubousset Award, Médaille Grand ACMS Bulletin / February 2022
Steven R. Sarkisian, Jr., M.D.— Founder, and CEO of Oklahoma Eye Surgeons, PLLC. Dr. Sarkisian specializes in premium cataract surgery and glaucoma surgery, with a special interest in helping his patients be glasses-free and performing minimally invasive glaucoma surgery (MIGS). He implants premium lenses with cataract surgery and was the first in Oklahoma to implant the PanOptix trifocal lens. This is the newest premium lens, and now for the first time, we can treat distance, intermediate, and near vision, as well as astigmatism, all at the same time. He was also the first surgeon
in Oklahoma to perform the iStent, iStent Inject, the Xen Gel Stent, and canaloplasty. He was the first in the U.S. to use the OMNI device and the first in the world to use the TRAB360 and VISCO360 surgical systems, the predicate devices to the OMNI. For more information on the Annual meeting please visit the POS website at www.pghoph.org or contact Nadine Popovich, Administrator at npopovich@ acms.org or to 412.321.5030.
The 42nd Annual Meeting for Ophthalmic Personnel, presented by the Pittsburgh Ophthalmology Society (POS) This will run concurrently with the POS Annual Meeting Friday, March 11, 2022. Application to IJCAHPO has been submitted for attendees to earn a maximum of 7 credit hours. Course directors Pamela Rath, M.D., Avni Vyas, M.D., and Zachary Koretz, M.D. have prepared an exceptional educational offering for Ophthalmic staff. Highlights of the course include presentations on Neuro-Ophthalmology; Oculoplastics; Interpretation of Fundus/OCT Photos; MIPS; and Biomicroscopy, Angles and Pupils. The conference provides exceptional educational opportunities for ophthalmic personnel in and around the region and continually attracts wellrespected local faculty, who present relevant and quality instruction through numerous breakout sessions. On-line registration begins January 28, 2022, www.pghoph.org. Contact Nadine Popovich, administrator, for details and more information at npopovich@acms.org. 17
Alliance News
ACMS Alliance Holiday Party December 09, 2021 “It is a testament to our members who continue to travel far and wide to reach our special events just to share comraderie and the charitable spirit”— Patty Barnett, Chairman A good time was had by all who attended a long awaited ACMSA party which was planned after a two-year hiatus. Beautiful poinsettias and holiday decor surrounded ACMSA members at South Hills Country Club, sponsored by Club members Dr. and Mrs. Le Wible. Tina Purpura and Dr. Larry Purpura were instrumental in inviting Dr. Withers from Mercy Hospital’s Operation Safety Net, who spoke about the homeless program he directs, and was the fortunate recipient of bags of coats, scarves, gloves and toiletries donated by our members and their guests. Patty Barnett and Dr. Alan Barnett arranged the beautiful invitations and musical entertainment featuring Jerry DeMaria, who offered his renditions of Frank Sinatra, Tony Bennet, Dean Martin and other Rat Pack favorites. Rose Kunkel Roarty raised additional funds with her 50/50 raffle.
Patty Barnett (Holiday Party Chair) & Tina Purpura Dr. James Withers giving talk about Operation Safety Net
Eleanor Corcoran, Rose Kunkel Roarty, Patty Barnett, Kathleen Reshmi, Tina Purpura & Marilyn Lakdawala 18
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Alliance News
Barbara Wible, Monica Wible, Rose Kunkel Roarty, Sandra Dacosta, Tina Purpura, Eleanor Corcoran, Patty Barnett & Marilyn Lakdawala
Drs. Shabbir Lakdawala, Larry Purpura, James Withers (Operation Safety Net), Alan Barnett & Le Wible
Patty Barnett, Charlie Blume & Liz Blume (ACMSA Member) Dr. Alan Barnett, Jerry Demaria (Singer & Entertainer) & ACMSA Chairman Patty Barnett ACMS Bulletin / February 2022
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Materia Medica
Finerenone (Kerendia ) ®
Arianna Sprando, PharmD and Alicia Faggioli, PharmD, BCPS Introduction
Finerenone (Kerendia®) is a nonsteroidal, selective mineralocorticoid receptor antagonist (MRA). In the kidney, aldosterone acts on mineralocorticoid receptors causing an increased concentration of epithelial sodium channels (ENaC) in the collecting duct and stimulation of the Na+/K+ ATPase pump.6 This results in increased sodium reabsorption, water reabsorption, and potassium excretion. MRAs such as spironolactone and eplerenone work to block aldosterone at these receptors and have proven utility in patients with heart failure and refractory hypertension. However, newer evidence has suggested that MRAs can also provide renal protection by blocking aldosterone mediated inflammation, fibrosis, and oxidative stress in the kidneys.7 Many existing MRAs can result in undesirable effects due to nonselectivity resulting in additional anti-androgen and anti-steroidal effects. Additionally, tolerability can be limited due to significant hyperkalemia. Newer generation nonsteroidal MRAs with enhanced selectivity can minimize side effects and potentially reduce discontinuation rates due to hyperkalemia. Finerenone, a novel selective MRA, has been approved
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as the first in its class for use in patients with chronic kidney disease associated with diabetic nephropathy. This medication has been shown to reduce the risk of sustained estimated glomerular filtration rate (eGFR) decline, end stage kidney disease, cardiovascular death, non-fatal myocardial infarction, and hospitalization for heart failure in this patient population.4
Safety
Use of finerenone is contraindicated in patients with adrenal insufficiency or with concomitant use of strong CYP3A4 inhibitors due to increased risk of side effects.4 Safety of finerenone was evaluated in the FIDELIO-DKD phase 3 trial in patients with CKD stages 2-4.1 Incidence of renal-related adverse events were similar between finerenone and placebo. The most prevalent adverse effect observed was hyperkalemia. The study found the incidence of hyperkalemia related to the trial regimen was higher in patients taking finerenone vs. placebo (11.8% and 4.8% respectively), but no fatalities occurred as a result. Similar safety results were also noted in the FIGARO-DKD study phase 3 trial. Adverse events related to the study drug occurred in 15.2% of participants in the finerenone group and 11.3% in the placebo group. Some of the common adverse effects that occurred more frequently in the finereone group
included hyperkalemia, arthralgias, urinary tract infections, and anemia. However, serious adverse events related to the study drug occurred in < 1% in both groups. Incidence of hyperkalemia was also investigated. The incidence of hyperkalemia was greater with finerenone (10.8%) than the placebo group (5.3%). The risk for developing hyperkalemia increases with decreasing kidney function and is greater in patients with higher baseline potassium levels or other risk factors for hyperkalemia. Do not initiate finerenone if serum potassium is >5.0 mEq/L.4
Tolerability
Finerenone is well tolerated by patients. During the FIDELIO-DKD study, the incidence of any adverse event related to the trial regimen reported was 22.9% in the finerenone group and 15.9% in the placebo group. The most common adverse effects that occurred were hyperkalemia (15.8% vs 7.8%) and anemia (7.4% vs. 6.7%).1 Similar results were also found in the FIGARO-DKD study which extended its inclusion criteria to include patients with less severe chronic kidney disease (CKD stages 1-4).2 Aside from hyperkalemia, the incidence of adverse effects in the finereonone group was consistent with the results found in the placebo group. Initiation of Kerendia may cause an initial small decrease in estimated GFR that occurs within the first 4 weeks of starting therapy, and
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Materia Medica then stabilizes. In a study that included patients with chronic kidney disease associated with type 2 diabetes, this decrease was reversible after treatment discontinuation.
Efficacy
The effectiveness of finerenone was studied in two randomized control trials. The FIDELIO-DKD study, a randomized, double blind, placebocontrolled, multi-centered phase 3 trial, studied finerenone 10 mg and 20 mg compared to placebo.1 Patients (n=5674) were stratified based on geographic region, eGFR, and severity of albuminuria. The primary composite outcome assessed was kidney failure, sustained decrease of 40% in the eGFR from baseline, or death from renal cause. Patients already being treated with maximally tolerated reninangiotensin system blockade therapy (angiotensin converting-enzyme inhibitor or angiotensin receptor blocker) were assessed at month 1, month 4, and every 4 months thereafter over a median follow up of 2.6 years. The results indicated that the primary outcome occurred in 17.8% of patients in the finerenone group vs. 21.1% in the placebo group (HR 0.82, 95% CI 0.73-0.93, p = 0.0014). Another phase 3 randomized, double-blind, placebo-controlled, parallel-group, event-driven trial, FIGARO-DKD, assessed a primary composite outcome of cardiovascular death, myocardial infarction, stroke, and hospitalization for heart failure (n=7352).2 Patients in this study were also required to be treated with a maximally tolerated angiotensin converting-enzyme inhibitor or
ACMS Bulletin / February 2022
angiotensin receptor blocker. The primary outcome of this study occurred in 12.4% of patients in the finerenone group vs. 14.2% in the placebo group (HR 0.87, 95% CI 0.76 -0.98, p = 0.03). Both studies continued to support the evidence that finerenone has beneficial cardiovascular and renal outcomes among patients with type 2 diabetes and chronic kidney disease being treated with maximally tolerated renin-angiotensin system blockade therapy. FIDELITY, the prespecified pooled analysis of both FIDELIO-DKD and FIGARO-DKD, results showed the incidence of CV death, MI, stroke, and hospitalization for heart failure for finerenone vs. placebo was 12.7% vs. 14.4% (HR 0.86, 95% CI 0.78-0.95, p = 0.0018). Additionally, the renal outcomes of time to kidney failure, sustained decrease in eGFR from baseline, or renal death, for finerenone vs. placebo was 5.5% vs. 7.1% (HR 0.77, 95% CI 0.67-0.88, p = 0.0002).3
Price
Tablets are supplied in 10 mg and 20 mg strengths. Both strengths cost $22.76 per tablet. Through the Finerenone Official Site, select patients may qualify for a co-pay savings card which allows them to obtain a 30-day supply for as little as $10.00.5
Simplicity
Finerenone is taken orally once daily with or without food. The recommended starting dose is 10 mg or 20 mg; 10 mg doses can be increased after four weeks to a target dose of 20 mg once daily. Dosing is based on eGFR and serum potassium levels. Individuals with eGFR ≥60 mL/ minute/1.73 m2 can be initiated at 20
mg once daily whereas patients with an eGFR ≥25 to <60 mL/minute/1.73 m2 should be initiated at the reduced dose of 10 mg. Use is not recommended if eGFR <25 mL/minute/1.73 m2. Dose adjustments after initiation are dependent on serum potassium levels. Initial doses of finerenone based on eGFR should be maintained in patients with serum potassium levels >4.8-5.5 mEq/L. If the patient’s serum potassium is < 4.8 mEq/L, the dose can be increased to 20 mg daily. However, if serum potassium is >5.5 mEq/L finerenone should be held and reinitiated at 10 mg once daily once the serum potassium is < 5.0 mEq/L. Finerenone has a half-life of 2-3 hours, is 92% protein bound, and undergoes extensive CYP3A4 and to a lesser extent CYP2C8 metabolism, resulting in 44% oral bioavailability. Approximately 80% of the administered dose is excreted in urine. Caution should be used when finerenone is coadministered with inhibitors of CYP3A4. Strong inhibitors may increase the AUC by > 400%, therefore concomitant use is contraindicated.4
Bottom line
Finerenone is a nonsteroidal, selective mineralocorticoid receptor antagonist indicated to reduce the risk of sustained eGFR decline, end stage kidney disease, cardiovascular death, non-fatal myocardial infarction, and hospitalization for heart failure in adult patients with chronic kidney disease associated with type 2 diabetes.4 Finerenone should be added to patients with diabetic nephropathy already on maximally tolerated RAS blockade therapy. It is a well-tolerated Continued on Page 22
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Materia Medica From Page 21
oral agent with the most common side effects being hyperkalemia and anemia.1 Use of this medication is contraindicated in individuals with adrenal insufficiency or concomitant use of strong CYP3A4 inhibitors.4 At the time of authorship, Dr. Arianna Sprando is a PGY-1 Pharmacy resident at UPMC St. Margaret and can be reached at sprandoac2@upmc. edu. Dr. Alicia Faggioli is a PGY-2 Ambulatory Care/Family Medicine resident at UPMC St. Margaret and can be reached at faggioliag@upmc.edu. Dr. Heather Sakely, PharmD, BCPS, BCGP, provided editing and mentoring for this article and can be reached at sakelyh@upmc.edu.
References:
1. Bakris, G. L., Agarwal, R., Anker, S. D., Pitt, B., Ruilope, L. M., Rossing, P., Kolkhof, P., Nowack, C., Schloemer, P., Joseph, A., Filippatos, G., & FIDELIODKD Investigators (2020). Effect of Finerenone on Chronic Kidney Disease Outcomes in Type 2 Diabetes. The New England journal of medicine, 383(23), 2219–2229. 2. Pitt, B., Filippatos, G., Agarwal, R., Anker, S. D., Bakris, G. L., Rossing, P., Joseph, A., Kolkhof, P., Nowack, C., Schloemer, P., Ruilope, L. M., & FIGARO-DKD Investigators (2021). Cardiovascular Events with Finerenone in Kidney Disease and Type 2 Diabetes. The New England journal of medicine, 10.1056/NEJMoa2110956. 3. Kumbhani, D. & Bhatt D. Finerenone in Reducing Cardivascular Mortality and Morbidity in Diabetic Kidney DiseaseFIGARO-DKD (2021). American College of Cardiology. https://www. acc.org/latest-in-cardiology/clinicaltrials/2021/08/25/23/58/figaro-dkd 4. Kerendia (finerenone). Package Insert. Bayer HealthCare Pharmaceuticals Inc; 2021.
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5. Kerendia (finerenone) Tablets (July 2021). Bayer Pharmaceuticals, Inc. https://www.kerendia-us.com/ 6. Rico-Mesa, J. S., White, A., Ahmadian-Tehrani, A., & Anderson, A. S. (2020). Mineralocorticoid Receptor Antagonists: A Comprehensive Review of Finerenone. Current cardiology reports, 22(11), 140. 7. Patel, V, Joharapurkar, A, Jain, M. Role of mineralocorticoid receptor antagonists in kidney diseases. Drug Dev Res. 2021; 82: 341– 363. 8. Bayer Presents New Subgroup Analysis of Prespecified Pooled Analysis of Phase III Studies for KERENDIA® (finerenone) for Chronic Kidney Disease Associated with Type 2 Diabetes with or without SGLT2i Use at Baseline. (Nov 8, 2021). BioSpace. Retrieved December 11, 2021, from https://www.biospace. com/article/bayer-presents-newsubgroup-analysis-of-prespecifiedpooled-analysis-of-phase-iii-studiesfor-kerendia-finerenone-for-chronickidney-disease-associated-with-type2-diabetes-with-or-without-sglt2i-useat-baseline/
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opinion of the Editorial Board, the Bulletin, or the Allegheny County Medical Society.
Improving Healthcare through Education, Service, and Physician Well-Being. / August 2021
ACMS Bulletin / February 2022
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23
Legal Summary
COVID-19 and Disciplinary Actions against Physicians: Medical Boards or State Legislature? By Beth Anne Jackson In July of last year, the Federation of State Medical Boards (FSMB), a national non-profit organization that represents medical boards within the United States, issued a statement warning that physicians could face disciplinary actions, including license suspension or revocation, by their state medical boards for generating and spreading COVID-19 vaccine misinformation and disinformation. Specifically, it stated: Due to their specialized knowledge and training, licensed physicians possess a high degree of public trust and therefore have a powerful platform in society, whether they recognize it or not. They also have an ethical and professional responsibility to practice medicine in the best interests of their patients and must share information that is factual, scientifically grounded and consensus-driven for the betterment of public health. Spreading inaccurate COVID-19 vaccine information contradicts that responsibility, threatens to further erode public trust in the medical profession and puts all patients at risk. In December 2021, FSMB released findings from its annual survey of its member state medical boards that focused on this issue. It states that 67% of state medical boards have seen an increase in complaints related to physician dissemination 24
of false or misleading information, 15 state medical boards had made or published statements about the subject (Pennsylvania has not), and 12 state medical boards have taken disciplinary action against a physician for disseminating false or misleading information.FSMB made further statements of concerns about state legislation purporting to limit medical boards’ ability to take action regarding the spread of misinformation. One such state is Pennsylvania. Rep. Dawn Keefer (R-92nd District) last year introduced a bill (HB 1741) that would specifically authorize “prescribers” to prescribe, and require pharmacists to dispense, otherwise FDA-approved drugs, including hydroxychloroquine sulfate and ivermectin, to a patient with respiratory syndrome-related illness. The “informed consent” of the patient would be required, but proof of exposure or screening for COVID-19 would not be. Moreover, the bill would prohibit licensing boards from considering such prescribing as unauthorized or unprofessional conduct and from imposing administrative or disciplinary actions for prescribing such medications in accordance with the act. A hearing was held on the
bill on December 13, 2021. At the hearing, some physicians testified in favor of the bill, while others, including Pennsylvania Physician General Dr. Denise Johnson, stressed the availability of proven remedies, including vaccinations and FDAapproved treatments for COVID in its early stages. A representative of FSMB also testified against the bill, avoiding specific comment on treatment with hydroxychloroquine sulfate and ivermectin, but stating that HB 1741 “could put patients in jeopardy by undermining the ability of a State Medical Board to properly assess the standard of care and take appropriate action as necessary.” The bill is scheduled for a vote in the House Health Committee on February 7, 2022. If the Committee votes affirmatively on HB 1741, it will then go back to the House, where the Speaker and Majority Leader will determine if, when, and in what order the bill will come up for debate. If the bill comes up for debate, a vote will follow, and if passed, the bill would be referred to the Senate, where it would go through a similar process. There is currently not a companion Senate bill to HB 1741, but one is expected to be introduced soon.
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Editorial Legal Summary
Rear End Gastropub & Garage, 399 Butler St., Etna House Bill 1741cross-country would restrictroad the For a culinary authority trip, stop of in the this Pennsylvania converted autoMedical service Board and other state licensing station for a taste of roadside delights boards to make decisions regarding from coast to coast from Chef Anthony whether a licensed person has Tripi. Twenty draft beers and funmet the standard of care in prescribing cocktails to boot. or dispensing certain Adda Bazaar, 725medications Penn Ave., off-label for COVID. Some may say Downtown thatThe the newest question of boils Addadown Coffeeto&who Teais the bettermultiple arbiter downtown of medicalcafes. practice House’s Adda with respect to COVID: the legislature is the term for the long Bengali tradition or the Medicalintellectual Board? Others would of stimulating discourse with frame the question as one of medical friends over tea and coffee. Here’s your freedom. position, chance toWhatever try the art your of Adda, with a selection of fine teas and coffees. Three Bakery Square delights: AVP, Bakery Square, 6425 Penn Ave., East Liberty Fans of Big Burrito’s Alta Via pizza in Fox Chapel can venture to Bakery Square to try the casual California style Italian cuisine of its cousin, AVP. Enjoy seasonal vegetable-forward dishes as well as pizzas and sandwiches for lunch and dinner seven days a week. täkō, Bakery Square, 6425 Penn Ave., East Liberty Love the downtown Richard DeShantz jewel of a restaurant called täkō, but can’t get a reservation in the crowded space? Come enjoy its vast Bakery Square outpost, complete with 5000 square feet of space and both indoor and outdoor dining. Galley – Bakery Square, 6425 Penn Ave., East Liberty Galley – Bakery Square is the
latest branch of the Galley restaurant Chef Kevin Sousa’s new project will incubator concept, featuring the same combine a wine shop, bar and pizzeria contact Ms.former Jackson is a shareholder in formula your as itsstate sisterrepresentatives sites Federal Galley in the Kullman’s Bakery space. and senators and let them know the Health Care Practice Group of on the North Side and the Strip District Sustainable, biodynamic and organic what a licensed physician thinks. Brown & Fortunato, P.C., which location. Four emerging chefs are wines from around the world willisbe headquartered in Amarillo, Texas, and selected to open their own restaurant featured along with a down to earth, DISCLAIMER: This for serves healthcare providerswines nationally. within the space, witharticle 12-18ismonths to rustic menu. Nonalcoholic and information purposes only and does She is licensed in both Pennsylvania win over an audience and establish their cocktails also will be showcased. not constitute You should andG’s Texas maintains officeAve., in brand. You canlegal try aadvice. little of everything On and Liberty, 5104 an Liberty contact your attorney to obtain the greater Pittsburgh area. She may from all four restaurants during the Bloomfield advice with respect to your specific be reached (724) 413-5414 same meal – heaven for foodies. G’s turnslocally formeratAlexander’s Italian issue or problem. or bjackson@bf-law.com. Her firm’s Tupelo Honey, 100 West Station Bistro into a seasonal scratch kitchen website is www.bf-law.com. Square Drive, South Side with creative food and cocktails. Craving fried green tomatoes, Coming in the fall. buttermilk biscuits,isshrimp andonline grits at: https://www.fsmb.org/advocacy/newsAnd finally … The full statement available and banana pudding – and oh yes, Chengdu Gourmet, McKnight releases/fsmb-spreading-covid-19-vaccine-misinformation-may-put-medicalfried chicken and waffles? Tupelo Road, Ross Township license-at-risk/. Honey Café will open this fall in Station Chengdu Gourmet (the beloved Square to remedy that, in style. James Beard-nominated Squirrel Hill Con Alma Downtown, 613 Penn hole-in-the-wall Sichuan restaurant Ave., Downtown that regularly inspires pilgrimages from The new jewel of the Downtown all over Western PA) is planning an Cultural District features insanely good outpost on McKnight Road at the site of Miami/Latin/Caribbean cuisine along the former Oriental Market, in the plaza with live jazz. next to Red Lobster. This will offer Gaucho Parrilla Argentina, 146 a much larger dining space – 6,000 Sixth St., Downtown square feet – and an expanded dining The resident jewel of the Downtown menu. Something to look forward to in Cultural District dazzles with an early 2022. incredible array of steaks and wood Enjoy, and be safe. fired meats with a variety of sauces and accompaniments. Takeout and Dr. Paranjpe is an ophthalmologist dine-in available. and medical editor of the ACMS Wild Child, 372 Butler St., Etna Bulletin. She can be reached at The brainchild of Chef Jamilka reshma_paranjpe@hotmail.com. Borges, Wild Child emphasizes coastal The opinion expressed in this column is that of and island cuisine and is sure to delight. the writer and does not necessarily reflect the opinion of the Editorial Board, the Bulletin, Mount Oliver Bodega, 225 or the Allegheny County Medical Society. Brownsville Road, Mt. Oliver
Improving Healthcare through Education, Service, and Physician Well-Being. ACMS Bulletin / August 2021 ACMS Bulletin / February 2022
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Special Report
REPORTABLE DISEASES 2021: Q1-Q4
Allegheny County Health Department Selected Reportable Diseases/Conditions Selected Reportable Disease/Condition*
2019
January to December** 2020 2021
AMEBIASIS 1 4 4 CAMPYLOBACTERIOSIS COVID-19
118 0
96
106
54,755
125,170
CRUETZFELDT-JAKOB DISEASE 1 0 0 CRYPTOSPORIDIOSIS 33 12 21 DENGUE FEVER 1 0 1 GIARDIASIS 71 53 61 GUILLAIN-BARRE SYNDROME 3 5 5 HEPATITIS A 8 5 1 HEPATITIS B ACUTE 9 8 0 HEPATITIS B CHRONIC 72 44 42 LEGIONELLOSIS 86 53 63 LISTERIOSIS 3 3 7 MALARIA 3 0 5 MEASLES 7 0 0 MUMPS 3 1 3 NEISSERIA MENINGITIDIS 1 1 0 PERTUSSIS 40 23 3 SALMONELLOSIS
125
87
101
SHIGELLOSIS 16 11 11 SHIGATOXIN-PRODUCING E COLI 24 20 29 STREPTOCOCCUS PNEUMONIAE INVASIVE 43 27 19 TOXOPLASMOSIS 3 0 1 TUBERCULOSIS 11 15 18 TYPHOID FEVER 1 0 1 VARICELLA 28 7 12 WEST NILE VIRUS 0 0 3 ZIKA VIRUS 0 0 0
* Case classifications reflect definitions utilized by CDC Morbidity and Mortality Weekly Report. ** These counts do not reflect official case counts, as current year numbers are not yet finalized. Inaccuracies in working case counts may be due to reporting/investigation lag. NOTE: Disease reports may be filed electronically via PA-NEDSS. To register for PA-NEDSS, go to https://www.nedss.state. pa.us/NEDSS. To report outbreaks or diseases reportable within 24 hours, please call the Health Department’s 24-hour telephone line at 412-687-2243. For more complete surveillance information, see ACHD’s 10-year summary of reportable diseases: https://www.alleghenycounty.us/Health-Department/Resources/Data-and-Reporting/Infectious-Disease-Epidemiology/Epidemiology-Reports-and-Resources.aspx.
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www.acms.org
ACMS/FYI
Retired and Interested in Becoming a Physician Volunteer? Are you retired or retiring and interested in applying as a physician volunteer? With a dogged persistence, Dr. Patricia Canfield uncovered and simplified the process for others, providing ACMS with a shortcut to the application. https://www.dos.pa.gov/ProfessionalLicensing/BoardsCommissions/Nursing/Documents/Applications%20and%20Forms/Volunteer%20License%20Application.pdf According to PAMED, “Volunteer licenses are available to retiring health care practitioners or non-retired practitioners who are not required, because the practitioner is not otherwise practicing medicine or providing health care services in Pennsylvania, to maintain professional liability insurance under the Medical Care Availability and Reduction of Error (MCARE) Act. To qualify for a volunteer license, a physician must currently hold an active unrestricted license.” To learn more about CME requirements, liability protection and other information, visit https://www.pamedsoc.org/list/articles/volunteer-medical-license-pennsylvania According to Dr. Canfield, “Once the application is completed, it must be mailed (versus submitted electronically).” Thank you, Dr. Canfield and all physician volunteers!
ACMS Bulletin / February 2022
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Congratulations to the Photographers whose work was selected for the 2022 year!
January River Lightning Malcom Berger, MD
February Pittsburgh Sunrise Terence Starz, MD
March Tranquility, Cooks Forest Alexanndra Kreps, MD
April Lake McDonald— Glacier Park David Sacco, MD
May Waterfall Nina Verghis, MD
June Sunset Nina Verghis, MD
July Ohiopyle Elias Hilal, MD
August IENHART Mark Thompson, MD
September Tower of Voices at Flight 93 Memorial Robert Cicco, MD
October City of Bridges Elias Hilal, MD
November Perfection Terence Starz, MD
December Shenandoah Sunset Mark Thompson, MD
