TTHealthWatch is a weekly podcast from Texas Tech. In it, Elizabeth Tracey, director of electronic media for Johns Hopkins Medicine in Baltimore, and Rick Lange, MD, president of Texas Tech Health El Paso, look at the top medical stories of the week.
This week’s topics include patellar resurfacing with total knee replacement, long-term outcomes for CAR-T therapy, tranexamic acid in routine surgery, and patient messaging trends.
Program notes
0:40 Electronic patient messaging
1:40 Not baked into the usual workday
2:40 Managing patient expectation
3:33 Tranexamic acid in noncardiac surgery
4:33 Almost 9,000 patients enrolled
5:30 Does it increase venous thromboembolism (VTE)?
6:31 U.K. attempted 10 years ago
7:00 CAR-T therapy outcomes 10 years later
8:01 Somewhere between 10% to 15% would have relapsed
9:03 Patellar resurfacing in total knee replacement
10:00 More quality-adjusted life years (QALYs) than those without resurfacing
11:00 More people alive in the knee-resurfacing group
12:34 End
Transcript:
Elizabeth: Should patellas be resurfaced when someone has a total knee replacement?
Rick: What is the long-term outcome of CAR T-cell therapy for lymphoma?
Elizabeth: What about tranexamic acid? Should we be using it for routine types of surgery?
Rick: And national trends in patient messaging.
Elizabeth: That’s what we’re talking about this week on TTHealthWatch, your weekly look at the medical headlines from Texas Tech University Health Sciences Center in El Paso. I’m Elizabeth Tracey, a Baltimore-based medical journalist.
Rick: And I’m Rick Lange, president of Texas Tech Health El Paso.
Elizabeth: Rick, how about if we turn straight to JAMA? Both of us get inundated on a regular basis with electronic messaging, and this is taking a look at, goodness, what is happening to the inbox and the text messaging and MyChart for physicians around the nation.
Rick: Well, you nailed it. National trends in patient messaging, and other people would call it the growing electronic inbox, as the editorialist mentioned.
Investigators examined approximately 8 billion encounters from 2020 through 2025 from the Epic electronic medical record. It looks like the patient portal messaging and the electronic health record has evolved to a central way of delivering care now. And what they discovered was that patient-authorized messages increased 153%. Office visits only increased about 17%. Telephone encounters only declined slightly, about 6%. Clinician and staff-authored messages increased by 24% as well.
This national trend is concerning for several reasons. It’s not baked into our usual workday. How do you make the right workflow? Because sometimes physicians aren’t seeing patients every day of the week. There’s oftentimes a team approach. Who should be answering the message? Should it be physicians? Should they be triaged? Finally, how do you bill for it? We need to align staffing. We need to align reimbursement. We need to look at technology. We have to look at quality, too. And then finally, how does this contribute to clinician burnout?
Elizabeth: I think it’s unquestionable that the volume of these things is really overwhelming. And I would just note that at Hopkins, in any case, the standard reply message is, we will respond to this within 3 business days, in an attempt to set expectation so that patients aren’t expecting that they’re going to get a response right away. And there’s also prompting relative to, if this is an urgent matter, please utilize the phone versus this system.
Rick: Right. And I can understand why patients do this. It’s convenient. I agree with you that managing these expectations is incredibly important. Even if we said we’re going to do it within 3 days, but we don’t allow sufficient time for the physician or their staff to accomplish these things, it’s clear electronic medical records and answering these messages after hours on weekends definitely contribute to physician burnout.
Elizabeth: Unquestionably. Another thing I would note is that frequently patients get study and test results in off-hours. And then they respond to that and ask about those specific things. That’s not to advocate for, look, we got to hang on to your test results until your physician has had a chance to review them. And it may also be an opportunity to manage expectation.
Rick: It is. Many patients now go online, and when they see an abnormal test result that may be relatively insignificant, but the fact that it’s outside the range of normal, then they’re contacting their healthcare provider.
Elizabeth: Right. Let’s turn to the New England Journal of Medicine. It’s something that we have talked about many times over our decades of podcasting, and that’s the use of tranexamic acid to reduce bleeding. In this case, it’s in major noncardiac surgery and it utilizes a hospital policy for the administration of tranexamic acid.
This is a multicenter, double-blind, cluster-randomized, placebo-controlled trial involving patients who are undergoing noncardiac surgery who are at high risk for red-cell transfusion. They assigned hospitals in Canada at 4-week intervals to a hospital-wide policy of intraoperative tranexamic acid or placebo. And their primary outcomes were transfusion of red cells during the index hospitalization and diagnosis of venous thromboembolism, or VTE, within 90 days. They had almost 9,000 patients enrolled across these 10 Canadian hospitals.
And interestingly, a population that has been excluded from lots of these kinds of studies in the past — those undergoing oncologic surgery — accounted for almost 61% of all of these folks who enrolled in this study. The percentage of patients who received a red-cell transfusion during their hospitalization was 7.4% in the tranexamic acid group and almost 10% in the placebo group. VTE was virtually the same between those two groups. And so the editorialist says, hey, if there was ever a clarion call to using tranexamic acid, this is it.
Rick: Elizabeth, it’s been around for 60 years now. You give a single dose before the operation starts and it’s meant to reduce surgical bleeding. If people have perioperative bleeding, it increases the risk of prolonged hospital stay, death, and readmission later. The concern in the past is, does it increase the risk of having venous thromboembolism? The previous studies weren’t able to exclude that, and so a lot of hospitals have been reluctant to implement using tranexamic acid, and a lot of surgeons have as well. Although I must say that it’s used in almost all cardiac surgery and hip and knee surgery.
This study is great in that it reduced perioperative bleeding by about 25% to 30%. And by the way, that’s what every other study is showing. And it also showed that it didn’t increase the risk of having clots, even in those that had cancer surgery. This ought to close the door on that particular question.
The other thing, by the way, Elizabeth, this was a very practical study. They used electronic medical records to both randomize individuals and also to collect the data. They were able to enroll over 500 patients a week. They had very robust follow-up, about 98% completeness, and at a reduced cost. So this study is important for a number of reasons.
Elizabeth: I also would just cite the editorialist who says, gosh, in the U.K., they attempted to get implementation of tranexamic acid in surgery. And 10 years later, they still have about a third of their eligible surgical patients not receiving this treatment. What do we need? We need leadership. And we need, just as they do in this study, this hospital-wide policy. This is the standard of care.
Rick: That’s how they did it. Every hospital acted as its own control. So you’re right, it needs to be a part of the routine treatment.
Elizabeth: Remaining in the New England Journal of Medicine, what about those CAR-Ts?
Rick: For certain cancers — lymphoma being one of them, B-cell lymphoma — we can take the individual’s T cells, sensitize them to receptors on the B cells, and we do that in a lab, then we inject them into the person. They’re meant to attack the cancerous B cells. And that’s what CAR-T therapy is. It stands for anti-CD19 chimeric antigen receptor T-cell therapy. It is a standard treatment now for those that have relapsed or refractory lymphomas.
This particular study looked at 38 patients who were involved in the original CAR-T therapy studies and now had a 10-year follow-up. No relapses had occurred in any of these patients after 5.4 years. And the 10-year, lymphoma-free survival was 32% for those that had large B-cell lymphoma and almost 50% among those that had follicular lymphoma. They very rarely had a secondary primary cancer, about 20% of individuals. Although if you just look at statistics, somewhere between 10% and 15% would develop it, probably related to the chemotherapy that they had received before.
Elizabeth: CAR-T cells, of course, are being expanded in many different venues, not just in B-cell lymphomas — in other blood cancers, have recently been shown to be helpful in solid tumors. The technique has also improved a lot in order to raise these things and increase their longevity. This is a great retrospective analysis. I’m not sure how informative it is right now because CAR-Ts are really a very different animal at this point.
Rick: Well, they are. The chemotherapy is very different as well. This is the longest follow-up of any study that we’ve had. It has a relatively small number of patients. To know that it’s durable out to 10 years is still pretty impressive.
Elizabeth: And we’re going to see a lot more about CAR-Ts. They have become so much easier to develop and keep in the body being active.
Let’s turn to The Lancet and also look at a long-term study, this notion of patellar resurfacing if you’re having a total knee replacement. This study was initiated in 1999 in the U.K. They enrolled 1,715 participants with a mean age of 70 years, all of whom, of course, required a total knee replacement. And they randomly assigned about half the group to patellar resurfacing when they did that and about half to no resurfacing. And what they were trying to decide was, gosh, should we be doing this resurfacing simultaneously with the total knee replacement?
What they showed was that yes, in fact, there is a difference over this 20 years of follow-up that is in favor of the simultaneous or the concomitant patellar resurfacing with the knee replacement. Those folks who did have their patella resurfaced accrued significantly more quality-adjusted life years, or QALYs, than the nonresurfaced group. And when you look at the numbers in terms of assets that are required — money to do the resurfacing — it’s about the same. It definitely comes out in favor of the resurfacing strategy.
What I thought was interesting was how much their numbers declined over those 20 years. So that in their final analysis, they really only had about 250 of the 1,700 participants were still alive in order to report on them or had complete data. They also note that in the U.S., for example, the vast majority, 94% of people who have total knee replacement do have patellar resurfacing right now, while in other countries, it’s much less than that.
Rick: Let’s look at their knee pain score. Of course, there’s really no difference between the two groups. It showed that there were more people alive in the patellar-resurfacing than in the nonresurfacing. I just think it happened to be just a luck of the draw.
You might say, well, those that had the knee resurfacing exercised more and they were more likely to live longer. It’s a small number of patients. I do agree with you that there’s no significant difference between the cost. There was no significant difference among the number of people that had to have their knee re-operated. Overall, I’m not sure there’s any difference between the two. And I think whatever the surgeon feels more comfortable doing is probably best for the patient.
Elizabeth: I think I would probe U.S. surgeons who do these total knees and ask them about patellar resurfacing, and why it appears that the strong preference domestically is to do it.
Rick: Yep. And, Elizabeth, you’re right. I think there’s this perception that you’re going to get a better result in the long term and that’s why 90% of U.S. orthopedists do it. Conversely, in the United Kingdom, they’re not convinced. And therefore, only 4% of orthopedic surgeons do it. Are we going to change the physicians in the United States? Nope. Are the British physicians going to do anything different? I don’t think so either.
Elizabeth: I would comment that my hope is that we’re going to end up with something that helps to restore cartilage in aging knees, so we don’t even have to consider total knees in the long haul.
Rick: Right. And parenthetically, even the knees that we’re replacing now are much different than they were 20 years ago.
Elizabeth: On that note then, that’s a look at this week’s medical headlines from Texas Tech. I’m Elizabeth Tracey.
Rick: And I’m Rick Lange. Y’all listen up and make healthy choices.
