Changing gender gap and practice patterns in reproductive endocrinology and infertility subspecialists in the United States: a Society for Reproductive Endocrinology and Infertility report.

OBJECTIVE: To identify changes in current practice patterns, salaries, and satisfaction by gender and by years in practice among board-certified reproductive endocrinology and infertility (REI) subspecialists in the United States. DESIGN: Cross-sectional web-based survey including 37 questions conducted by the Society for Reproductive Endocrinology and Infertility. SETTING: Not applicable. PATIENT(S): None. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): The primary outcome measures were total compensation and practice patterns compared by gender and the type of practice. The secondary outcomes included demographics, the number of in vitro fertilization cycles, surgeries performed, and the morale of survey respondents. RESULT(S): There were 370 respondents (48.4% women and 51.4% men). Compared with a similar survey conducted 6 years earlier, a 27% increase in the number of female respondents was observed in this survey. There was a marginally significant trend toward lower compensation for female than male REI subspecialists (17% lower, $472,807 vs. $571,969). The gap was seen for responders with ≥10 years' experience, which is also when there was the largest gap between private and academic practice (mean $820,997 vs, $391,600). Most (77%) felt positively about the current state of the reproductive endocrinology field, and >90% would choose the subspecialty again. CONCLUSION(S): There has been a substantial increase in the number of recent female REI subspecialists showing less disparity in compensation, and the gap appears to be closing. There is an increasing gap in compensation between private and academic practices with ≥5 years of experience. Reproductive endocrinology and infertility remains a high morale specialty.

Basics of practice management: managing many for the care of one.

In today's changing health care landscape, it has become necessary that providers have a fundamental understanding of practice management as pertinent to the care they provide. The reproductive endocrinology and infertility (REI) practice is a uniquely complex setting with many component parts, necessitating frequent assessment and collaboration to provide safe, quality, and cost-effective care. In this review, we aim to describe the basics of medical practice management, divided into six sections: practice models; operations; patient safety; patient experience; employee recruitment; development, and satisfaction; and technology. These topics will be presented with a focus on the application of these principles to the REI practice.

Precision Medicine in Diabetes: A Consensus Report From the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD).

The convergence of advances in medical science, human biology, data science, and technology has enabled the generation of new insights into the phenotype known as "diabetes." Increased knowledge of this condition has emerged from populations around the world, illuminating the differences in how diabetes presents, its variable prevalence, and how best practice in treatment varies between populations. In parallel, focus has been placed on the development of tools for the application of precision medicine to numerous conditions. This Consensus Report presents the American Diabetes Association (ADA) Precision Medicine in Diabetes Initiative in partnership with the European Association for the Study of Diabetes (EASD), including its mission, the current state of the field, and prospects for the future. Expert opinions are presented on areas of precision diagnostics and precision therapeutics (including prevention and treatment), and key barriers to and opportunities for implementation of precision diabetes medicine, with better care and outcomes around the globe, are highlighted. Cases where precision diagnosis is already feasible and effective (i.e., monogenic forms of diabetes) are presented, while the major hurdles to the global implementation of precision diagnosis of complex forms of diabetes are discussed. The situation is similar for precision therapeutics, in which the appropriate therapy will often change over time owing to the manner in which diabetes evolves within individual patients. This Consensus Report describes a foundation for precision diabetes medicine, while highlighting what remains to be done to realize its potential. This, combined with a subsequent, detailed evidence-based review (due 2022), will provide a roadmap for precision medicine in diabetes that helps improve the quality of life for all those with diabetes.

Cost-effectiveness of Diabetes Prevention Interventions Targeting High-risk Individuals and Whole Populations: A Systematic Review.

OBJECTIVE: We conducted a systematic review of studies evaluating the cost-effectiveness (CE) of interventions to prevent type 2 diabetes (T2D) among high-risk individuals and whole populations. RESEARCH DESIGN AND METHODS: Interventions targeting high-risk individuals are those that identify people at high risk of developing T2D and then treat them with either lifestyle or metformin interventions. Population-based prevention strategies are those that focus on the whole population regardless of the level of risk, creating public health impact through policy implementation, campaigns, and other environmental strategies. We systematically searched seven electronic databases for studies published in English between 2008 and 2017. We grouped lifestyle interventions targeting high-risk individuals by delivery method and personnel type. We used the median incremental cost-effectiveness ratio (ICER), measured in cost per quality-adjusted life year (QALY) or cost saved to measure the CE of interventions. We used the $50,000/QALY threshold to determine whether an intervention was cost-effective or not. ICERs are reported in 2017 U.S. dollars. RESULTS: Our review included 39 studies: 28 on interventions targeting high-risk individuals and 11 targeting whole populations. Both lifestyle and metformin interventions in high-risk individuals were cost-effective from a health care system or a societal perspective, with median ICERs of $12,510/QALY and $17,089/QALY, respectively, compared with no intervention. Among lifestyle interventions, those that followed a Diabetes Prevention Program (DPP) curriculum had a median ICER of $6,212/QALY, while those that did not follow a DPP curriculum had a median ICER of $13,228/QALY. Compared with lifestyle interventions delivered one-on-one or by a health professional, those offered in a group setting or provided by a combination of health professionals and lay health workers had lower ICERs. Among population-based interventions, taxing sugar-sweetened beverages was cost-saving from both the health care system and governmental perspectives. Evaluations of other population-based interventions-including fruit and vegetable subsidies, community-based education programs, and modifications to the built environment-showed inconsistent results. CONCLUSIONS: Most of the T2D prevention interventions included in our review were found to be either cost-effective or cost-saving. Our findings may help decision makers set priorities and allocate resources for T2D prevention in real-world settings.

Career Advancement: Meeting the Challenges Confronting the Next Generation of Endocrinologists and Endocrine Researchers.

CONTEXT: Challenges and opportunities face the next generation (Next-Gen) of endocrine researchers and clinicians, the lifeblood of the field of endocrinology for the future. A symposium jointly sponsored by The Endocrine Society and the Endocrine Society of Australia was convened to discuss approaches to addressing the present and future Next-Gen needs. EVIDENCE ACQUISITION: Data collection by literature review, assessment of previously completed questionnaires, commissioning of a new questionnaire, and summarization of symposium discussions were studied. EVIDENCE SYNTHESIS: Next-Gen endocrine researchers face diminishing grant funding in inflation-adjusted terms. The average age of individuals being awarded their first independent investigator funding has increased to age 45 years. For clinicians, a workforce gap exists between endocrinologists needed and those currently trained. Clinicians in practice are increasingly becoming employees of integrated hospital systems, resulting in greater time spent on nonclinical issues. Workforce data and published reviews identify challenges specifically related to early career women in endocrinology. Strategies to Address Issues: Recommendations encompassed the areas of grant support for research, mentoring, education, templates for career development, specific programs for Next-Gen members by senior colleagues as outlined in the text, networking, team science, and life/work integration. Endocrine societies focusing on Next-Gen members provide a powerful mechanism to support these critical areas. CONCLUSIONS: A concerted effort to empower, train, and support the next generation of clinical endocrinologists and endocrine researchers is necessary to ensure the viability and vibrancy of our discipline and to optimize our contributions to improving health outcomes. Collaborative engagement of endocrine societies globally will be necessary to support our next generation moving forward.

Financial Analysis of Behavioral Health Services in a Pediatric Endocrinology Clinic.

OBJECTIVE: This article addresses a current need in psychological practice by describing a financially feasible model that moves toward integrated care of behavioral health services in a pediatric endocrinology clinic. METHODS: Financial information (costs and revenue associated with behavioral health services) for the clinic, over an 18-month period (July 2012 to December 2013), was obtained through the hospital's financial department. The clinic meets one half day per week. RESULTS: Over the 18-month period, the behavioral health services generated a net gain of $3661.45 in the favor of the clinic. We determined that the psychologist and clinical psychology residents needed to see a total of four patients per half-day clinic for the clinic to "break-even." CONCLUSIONS: We describe one financially feasible way of integrating behavioral health services into a pediatric endocrinology clinic in the hope that this will be generalizable to other medical settings.

Worldwide research productivity in the field of endocrinology and metabolism--a bibliometric analysis.

INTRODUCTION: Recently, significant contributions to the study of endocrinology and metabolism have been made. The national contribution, however, has not been reported. The aim of this study was to assess national efforts in the field of endocrinology and metabolism. MATERIAL AND METHODS: A Web of Science search was performed using subject categories "endocrinology & metabolism" to identify articles published from 2010 to 2014. The total and per capita numbers of articles and citations were analysed for different countries. RESULTS: A total of 79,394 articles were published on endocrinology and metabolism from 2010 to 2014. Most were published in North America, East Asia, and Europe. The majority (82.28%) were reported by authors in high-income countries, 17.64% were published in middle-income countries, and only 0.08% were published in low-income countries. Authors in the United States published the most articles (27.38%), followed by China (7.22%), Italy (5.70%), the United Kingdom (5.6%), and Japan (5.54%). Articles published by authors in the United States had the most citations (260,934). A positive correlation was found between the number of publications and population/gross domestic product (GDP; p < 0.01). When normalised to population size, the ranking for the most publications was Denmark, Sweden, and the Netherlands; when normalised to GDP, the ranking was Denmark, Greece, and the Netherlands. CONCLUSIONS: The majority of endocrinology and metabolism articles were published by authors from high-income countries with few from low-income countries. The United States was the most productive country. However, when population size and GDP were considered, some European countries were ranked higher.

Extensive expertise in endocrinology: UK stance on adult GH replacement: the economist vs the endocrinologist.

In the UK, through the use of a forced economic model, endocrinologists are in the curious position of offering GH replacement to some patients with severe GH deficiency (GHD) but withholding it from other patients with even more severe GHD. This approach is counter-intuitive to endocrine practice in treating endocrine deficiency states. For all other endocrine deficiencies, one would opt for treating those with the most severe biochemical evidence of deficiency first. If this endocrine approach was applied to adult GH replacement in an era of rationing, one would start with the GHD patients with a pathologically low IGF1 level. Given that the prevalence of subnormal IGF1 levels in a GHD population is age-dependent, this would result in GH replacement being offered to more young adult onset (AO) GHD and childhood onset GHD adults, and less often to middle-aged and elderly AO GHD adults. This in itself has the added advantage that the skeletal benefits appear more real in the former cohort of patients.

Managing a solo practice.

Our health care system has been facing significant changes over the past 20 years with the introduction of health maintenance organizations plus the seismic changes associated with the introduction of the Patient Protection and Affordable Health Care Act and accountable care organizations. Lower reimbursements by health plans and the need for significant infrastructure investments in information technology such as electronic medical records have also put major financial and organizational strains on solo practices. Although it is unknown how these changes will have an impact on reproductive endocrinologists, consolidation and mergers seem to be on the rise in anticipation of the coming tsunami. Many solo physicians have cherished the freedom and opportunity of small practices, but it appears that the delivery system of the future will be dramatically different.

Molecular genetic testing in endocrinology - a practical guide.

OBJECTIVE: To discuss the factors to consider when evaluating patients with a suspected genetic endocrine disorder, so as to guide practicing endocrinologists through the process of genetic testing and result interpretation. METHODS: The author's experience and review of appropriate literature have been used to give a personal perspective on the role of genetic testing in hereditary endocrine disorders. RESULTS: Recent advances in our understanding of genetics and genomics have uncovered that they have a far more important role in the pathogenesis of endocrine disease than previously appreciated. Not only are we expanding our understanding of rare mendelian disorders such as multiple endocrine neoplasia type 1 and 2, but we are also beginning to understand the clinical significance of genetic factors in the pathogenesis of common disorders such as obesity and dyslipidemia. CONCLUSIONS: It can be difficult to appreciate the clinical significance and utility of genetic testing that is currently available, and the interpretation of genetic test results can be challenging. Decisions on whether genetic testing is needed should be made on a case-by-case basis, with the endocrinologist and geneticist working together from the outset.

Principles and clinical applications of liquid chromatography - tandem mass spectrometry for the determination of adrenal and gonadal steroid hormones.

Liquid-chromatography - tandem mass spectrometry (LC-MS/MS) is becoming the method of choice for clinical steroid analysis. In most instances, it has the advantage of higher sensitivity, better reproducibility and greater specificity than commercial immunoassay techniques. The method requires only minimal sample preparation and a small sample volume. Furthermore, it has the potential to analyze multiple steroids simultaneously. Modern instruments guarantee high throughput, allowing an affordable price for the individual assay. All this makes LC-MS/MS an attractive method for use in a clinical setting. Reliable reference ranges for the detected analytes are the pre-requisite for their clinical use. If these are available, LC-MS/MS can find application in congenital disorders of steroid metabolism, such as congenital adrenal hyperplasia, disorders of sex development and disorders of salt homeostasis, as well as in acquired disorders of steroid metabolism, such as primary aldosteronism, Cushing's disease, Addison's disease, and hyperandrogenemia, as well as in psychiatric disease states such as depression or anxiety disorders. The principles of LC-MS/MS for steroid measurement, the pros and cons of LC-MS/MS compared with conventional immunoassays and the possible applications in clinical routine, with a special focus on pediatric endocrinology needs, are discussed here.

Glycemic control and type 1 diabetes: the differential impact of model of care and income.

OBJECTIVE: To examine the effect of model of care (specialist care vs. shared care), and income, on glycemic control in a sample of young people with type 1 diabetes. METHODS: A total of 158 children and young people with type 1 diabetes, aged 8-19 yr, and their families, were recruited independent of their source of care as part of a longitudinal, cross-sectional exploratory study. At enrollment, participants completed a series of questionnaires and underwent a structured interview to gather data regarding the type of specialist and healthcare services attended, as well as demographic, healthcare, and self-care information. Capillary sample was taken for HbA1c determination. RESULTS: The mean HbA1c for the group as a whole was 8.6 ± 1.4%. There was no effect for model of care on glycemic control. However, young people living in households with a family income of less than AUS$83,000 (US$73,500) per year had a significantly higher mean HbA1c than their counterparts reporting a higher household income (8.8 ± 1.4% vs. 8.3 ± 1.1%; p = 0.019). CONCLUSION: Although no differences were found with respect to the short-term impact of specialist vs. shared care, it is evident that more support is required to improve glycemic control in this sample of young people where the mean level of HbA1c was significantly higher than target. Further research is also indicated to determine the relationship between glycemic control and socioeconomic status.

[Social-sanitary situation in Marañón's work in the context of the fight against infectious diseases]. / La cuestión sociosanitaria en la obra de Marañón en el contexto de la lucha contra las enfermedades infecciosas.

Gregorio Marañón y Posadillo (1887-1960), played a leading role in the birth of endocrinology in Spain as is well known. However, his medical work included other important and significant fields. Thus, it was especially in the 1910s and 1920s, when Marañón dealt with the social-sanitary situation in madrid probably due to his professional attachment to the treatment of several infectious diseases and epidemic outbreaks. Actually, since 1911 onwards, he was in charge of the wards of infectious diseases in the Hospital General de Madrid where he had the opportunity of treating an important number of patients suffering from this type of pathology and, as a consequence, in the following years he published several articles in medical journals and presented in the Royal Academy of Medicine in Spain, some reports on infectious diseases and the Spanish health and social conditions at the time. This paper try to analyze this field of Marañón's social and scientific activity.