2019 August AANnews

VOLUME 33 · ISSUE 8 · AUGUST 2019

DATA NOW AVAILABLE FROM RECORD-BREAKING COMPENSATION AND PRODUCTIVITY SURVEY Compare. Act. Improve.

The results of the 2019 Neurology Compensation and Productivity Survey have been tabulated and are now available for free to the more than 3,000 AAN members who completed the survey. This year‘s record-breaking response helps improve representation across practice types and geographical regions in the results, making it the largest and strongest data set dedicated to neurology and its subspecialties.

If you participated in the survey, you should have received information on how to access the data via the interactive dashboard that allows users to filter the data to see meaningful metrics.

For those who did not participate in the survey, the data are available to AAN members for $600— 50 percent off the nonmember price of $1,200. The data provides remarkable insights for all members of the neurology care team.

Continued on page 8

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Deepest Discounts to Attend Fall Conference End August 15 Be sure to secure your spot for the 2019 AAN Fall Conference before August 15 to take advantage of the biggest registration savings of $200 or more, depending on your AAN member type.

Visit AAN.com/view/19FallConference today to save!

Coming to Las Vegas this October 1820, the Fall Conference is your end-ofContinued on page 5

6 Meet New Board Member,

Shannon M. Kilgore, MD, FAAN

›

August 13 Practice Management Webinar Helps You Increase Revenue Practitioners must be creative about the services they offer in their office to stay afloat. This webinar series will demonstrate how to measure your revenue, identify which practice model works for your clientele, and show how to add potentially revenue-boosting ancillary services to your practice.

Increasing Revenue in Your Practice: Care Models, Ancillary Services, and Other Strategies

12 Neurology® Editorial on

Equity, Diversity, and Inclusion

Continued on page 11

20 AAN Regulatory Advocacy Efforts Receive Award

›

In Multiple

Sclerosis —

GREY MATTERS, TOO

Learn more about Multiple Sclerosis at MSBrainPreservation.com/art © 2019 Celgene Corporation All rights reserved. 04/19 US-CLG-19-0570

AANnews · August 2019

CONTENTS

News Briefs

Cover Data Now Available from Record-breaking Compensation and Productivity Survey

Policy & Guidelines Capitol Hill Report · · · · · · · · 13 AAN Regulatory Advocacy Efforts Receive Award · · · · · 20

Deepest Discounts to Attend Fall Conference End August 15 August 13 Practice Management Webinar Helps You Increase Revenue President’s Column AAN Working to Help Bring Down High Drug Prices · · · · · 4 Meet Your New Board Member Shannon M. Kilgore, MD, FAAN · · · · · · · · · · · · · 6 Tools & Resources Axon Registry Quality Measures Spotlight: Documentation · · · · · · · · · · 7 Journalist Curry Champions Crowdsourcing for Cures · · · · 8 Consider These Tips for Solo and Small Practice Neurologists · · · · · · · · · · · · 10

Conferences & Community Lively, Multicultural Toronto to Host 2020 Annual Meeting · · · · · · ·20 Academic Year Members: It’s Time to Renew! · · · · · · · ·20 Education & Research August Application Deadlines Approaching for Two Research Program Opportunities · · · · · · · · · · · 21 Wide Range of Movement Disorders Is Focus of August Continuum · · · · · · · · · · · · · 21 UCNS Accredits New Fellowship Training Program in Neurocritical Care · · · · · · · 21 Careers · · · · · · · · · · · · · · · 22 Dates & Deadlines · · · · · · · · 23

Neurology ® Editorial: Efforts by the Journal to Promote Perspectives of Equity, Diversity, and Inclusion and Address Disparities · · · · · · · 12

TThe Vision of the AAN is to be indispensable to our members.

The Mission of the AAN is to promote the highest quality patient-centered neurologic care and enhance member career satisfaction.

Contact Information

For advertising rates, contact:

American Academy of Neurology 201 Chicago Avenue Minneapolis, MN 55415

Eileen R. Henry Wolters Kluwer Health | Medical Research Lippincott, Williams & Wilkins

Phone: (800) 879-1960 (toll free) (612) 928-6000 (international) Email:

memberservices@aan.com

Website: AAN.com

Phone: (732) 778-2261 Email: Eileen.Henry@wolterskluwer.com

Comment on Lyme Disease Guideline Draft The Infectious Diseases Society of America, AAN, and American College of Rheumatology are accepting comments on the draft of the “2019 Guidelines for the Prevention, Diagnosis, and Treatment of Lyme Disease.” The guideline in development addresses diagnosis and treatment of Lyme disease and potential tickborne co-infections, human granulocytic anaplasmosis, and babesiosis. The drafts and comment form will be available until August 10, 2019.

AAN Provides 2,000 Brain-saving Bike Helmets As part of its community relations efforts, the AAN gave away 1,000 bike helmets to children and adults on June 22 during its annual public event held at the Academy headquarters, which was covered by the local CBS affiliate. Attendees also had the opportunity to speak with and donate to the American Brain Foundation, and many signed up for a free subscription to Brain & Life® magazine. The AAN donated an additional 1,000 bike helmets to local non-profits in an effort to promote brain safety. 

AAN Chief Executive Officer: Catherine M. Rydell, CAE Editor-in-Chief: John D. Hixson, MD Managing Editor: Angela M. Babb, MS, CAE, APR Editor: Tim Streeter Writers: Ryan Knoke and Sarah Parsons Designer: Siu Lee Email: aannews@aan.com

AANnews is published monthly by the American Academy of Neurology for its 36,000 members worldwide. Access this magazine and other AAN publications online at AAN.com.

The American Academy of Neurology ’ s registered trademarks and service marks are registered in the United States and various other countries around the world.

“American Brain Foundation” is a registered service mark of the American Brain Foundation and is registered in the United States.

President’s Column

AAN Working to Help Bring Down High Drug Prices As I’m sure you’re all aware, the costs of many prescription drugs have grown sky high over recent years. The US spends more than any other country in the world on prescription drugs, both in total spending and per person. In 2015, Americans spent more than $325 billion on prescription drugs and nearly $46 billion of those expenses came in the form of out-of-pocket costs for patients. Spending on drugs is expected to grow to $610 billion by 2020, a 53-percent increase from 2015.

and need additional care, which increases costs to the health care system and perpetuates workforce and access issues.

Physicians are frustrated by the economic barriers to their patients’ care, lack of transparency concerning the true cost of medications, as well as increasing burdens to their practice due to prior authorization.

In our specialty, the drug pricing problem is two-pronged. First, existing neurology medications are seeing significant price increases over time. For example, medications for multiple sclerosis now reach an average cost of more than $80,000 per year. Many drugs have seen price increases of nearly 1,000 percent since they were introduced 20 years ago―even though the medication has not been updated and several competitors have come to market.

Of course, the AAN is not sitting on its hands while this happens. Drug pricing has been one of the top issues at Neurology on the Hill. Action must be taken to ensure that prescription medications are accessible for patients with complex, chronic neurologic conditions. Potential solutions should be affordable, simple, and transparent. Costcontainment efforts must also address the burden on the entire health care system as high prescription drug prices may be shifted and absorbed in ways that negatively impact patient and prescriber access to important medications.

Second, new first-in-class medications for many neurologic diseases that were previously without treatment options are reaching the market. Such ultra-high-cost drugs carry price tags that exceed $500,000 per year in some instances.

The US Food and Drug Administration recently approved onasemnogene abeparvovec-xioi (Zolgensma), a second drug to treat the rare disorder spinal muscular atrophy. This one-time gene therapy treatment will cost $2.1 million. It will compete with nusinersen (Spinraza), which costs $750,000 for the first year of treatment and additional annual treatments costing $375,000 per year per patient.

Given these upward trends, we should not be surprised that one in four Americans reports difficulty affording prescription medications. These patients often are forced to make difficult choices by rationing their meds, abandoning their prescriptions, or cutting other necessary spending to pay for their medicine.

Unfortunately, they’ll likely experience a decline in their health

Stevens

My predecessor, Dr. Ralph Sacco, formed the Neurology Drug Pricing Task Force to study the environment of drugs for neurologic disease and propose ways for the AAN to proactively address the challenges associated with ultrahigh drug costs, including implications at the governmental, institutional, physician, and patient levels. This task force also evaluated other professional and patient advocacy organization positions and considered opportunities for collaborations with other organizations. The recommendations include: Provide rapid guidance to members on new therapies Expand and improve the AAN’s disclosure requirements and processes for all positions of influence within the AAN Form a work group to review AAN industry dependence and principles Use the AAN’s influence to affect change Pilot a value framework tool for one newly approved drug in 2019 Consider additional educational opportunities to improve point-of-care discussions regarding drug cost between members and their patients The AAN also supports proposals that would give federal agencies the authority to negotiate contracts with manufacturers of covered Part D drugs; proposals that promote transparency in prescription drug pricing, the prices paid by insurers, and the prices paid by consumers; proposals that prohibit direct-to-consumer advertising of prescription drugs, as passed by the American Medical Association House of Delegates; and proposals that support the reimportation of the same high-quality prescription drugs from Canada when prices for those prescriptions are less expensive than in the United States.

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AANnews • August 2019

The AAN conducted its own research and published the study “Out-of-pocket Costs Are on the Rise for Commonly Prescribed Neurologic Medications” in Neurology ® on May 1, 2019. The analysis found that the average out-of-pocket costs for people taking medications for multiple sclerosis had risen the greatest over the past 12 years, costing 20 times more in 2016 than in 2004. The study was picked up by the media, including CNN. To read the study, visit n.neurology.org/content/92/22/e2604.

Parallel with the growing media coverage of these high drug costs, there has been greater scrutiny of physicians’ relationships with industry, including allegations of possible kickbacks by pharma companies to some health care professionals. This is a good time to remind our members that they are held to the AAN Professional Code of Conduct, which prohibits kickbacks and financial arrangements that would, solely because of personal gain, influence decisions in the care of patients. The goal of the code is to establish the professional standards that AAN members must or should observe in their clinical, academic, scientific, and personal activities.

Violations of the code may serve as the basis for disciplinary action by the AAN. Coupled with the code, adherence to the AAN Relationships and Conflicts of Interest Policy helps foster the confidence of members and the public in the quality of

the AAN’s publications, programs, and operations. Accurate conflict-of-interest disclosures completed by Academy leadership, education faculty, researchers, media experts, etc., are extremely important—and they are reviewed for adherence to AAN policy.

Transparency is a tool to observe, reduce, and contain the ever-upward spiraling costs of health care in the United States.

Advocacy gives us the power to provide input to our lawmakers and regulators and help shape solutions. Collaboration with others toward mutual goals strengthens our hand, and honesty is the bedrock of any productive, legitimate relationships between physicians, patients, payers, and pharma. These attributes are vital to the success of the AAN, and my hope is that they are embodied in each and every member of our association. 

James C. Stevens, MD, FAAN President, AAN jstevens@aan.com @JimStevensMD on Twitter

Deepest Discounts to Attend Fall Conference End August 15 continued from cover year destination for the hottest topics in the field of neurology, real-world issues in practice management, and innovative science—plus valuable CME. This year’s robust program includes: Neurology updates on the most relevant topics, including headache, sleep, neuro-ophthalmology, autoimmune neurology, neurogenetics, MS, epilepsy, stroke, neuro-oncology, and dementia Practice management programming for neurologists and business administrators covering coding, patient access and engagement, efficiency improvements, team-building approaches, management, and value-based models Innovative science covering topics such as traumatic brain injury, headache, controversies in neurology, and contemporary clinical issues Hands-on training via a half-day Skills Workshop on Neuromuscular Ultrasound (additional fee required) Multiple Sclerosis in the Trenches, Neuroimaging for the General Neurologist, Continuum® Self-assessment, and more

Full-day Pre-conference for APPs—Bring Your Care Team!

A new Advanced Practice Provider Pre-conference is set to debut on October 17, just prior to the AAN Fall Conference. This unique day of continuing education programming will offer excellent networking opportunities and dive deeply into neurology fundamentals, including clinical correlations of neuroanatomy and use, and interpretation of neuroimaging and neurophysiology techniques in clinical practice, as well as common topics in clinical neurology, including headache, spine disorders and radiculopathy, MS, and more. Valuable care team members can attend the APP Pre-conference on a stand-alone basis—but will receive the best value by bundling it with the full Fall Conference! Learn more and register at AAN.com/view/APPConference. 

AANnews • August 2019 5

Meet Your New Board Member

Shannon M. Kilgore, MD, FAAN Shannon M. Kilgore, MD, FAAN, is a newly elected member of the AAN Board of Directors. She is a clinical associate professor of neurology at Stanford University and practices within the Palo Alto Veterans Affairs Health Care System. She serves as the director of Stroke Services and the Palo Alto director of the National VA Parkinson’s Disease Consortium. In June, Kilgore was elected to the AMA Council on Medical Education, which will benefit from her vast experience and leadership in this area.

How did you first get involved as a volunteer on committees/ subcommittees and what moved you to participate?

I had an unusual pathway: I had been involved in the American Medical Association and advocacy as a student and resident, and so I was asked to join the AAN’s delegation to the AMA just after I finished fellowship. That was my first committee, and then by getting to know staff, I spread out in AAN work from there.

I have continued to serve on the delegation and chair the group since 2012.

I have been motivated to raise awareness of neurology’s issues to our colleagues in other specialties and to increase the importance of advocacy in the minds of my fellow AAN members.

Why did you wish to be on the Board of Directors?

Over time, I have been involved in many different aspects of the Academy, including advocacy, education, leadership programs, and publications, and thus I really had a broad view of the excellent work that the AAN does. So, I wanted to lend that perspective to the Board of Directors. The Academy has given me so much that I wanted to give back to the organization that has helped me grow in my career.

What experiences and viewpoints do you bring to this role?

Because of my many years of advocacy experience, I bring the viewpoint of the role of the AAN within the broader group of medical associations and the importance of advocacy for our members and patients. Through my nine years on the ACGME’s

Neurology Review Committee, I have extensive history with education policy, and so can also lend that knowledge to the board.

I am never the expert in the room but am, rather, a polymath, linking people together across areas of expertise.

From your experiences as an AAN leader, what is one of the more common misperceptions members may have about the Academy, and how would you respond to that?

I have learned that often all the acronyms get mixed together in people’s minds. Sometimes neurologists think that the AAN certifies us, when that is actually the ABPN. In addition, I have witnessed in-person conversations in which physicians in practice say that the AAN is only for academic neurologists, and those in academic positions say the Academy is only for practicing physicians! It is hard to communicate the idea that the AAN is working to help all members, but I am going to work with my fellow Board members and staff to increase awareness of the good work the AAN is doing.

In your view, how does the AAN benefit the field of neurology most?

The Academy is a truly outstanding association: supporting research and fostering education, but also helping members in their daily work to be compensated fairly for their time and expertise and to return to the joy in neurology. By taking on all the issues impacting our careers, the AAN truly demonstrates its vision: to be indispensable to our members. 

Are You Getting Your AANe-news?

Don’t miss the latest news headlines from your Academy! As an exclusive member benefit, you should be receiving AANe-news™ the second and fourth Wednesday of each month if your email address is on file. If not, be sure to set your email filter to accept mailer@aan.com as a friendly address. Or update your email address at AAN.com/MemberProfile.

It’s Not Spam... It’s AANe-news!

Tools & Resources

Axon Registry Quality Measures Spotlight: Documentation The Axon Registry® connects with your EHR to extract information from discrete fields as well as free text notes. As neurology practices record much of their patient encounter information in free text notes, the AAN is committed to providing our members with a registry that maximizes all the data from the free text notes. Currently, natural language processing—or artificial intelligence deciphering free text—is limited for use in measuring health care performance. As a result, the Axon Registry provides neurology members with consistent style of documentation suggestions to identify measure requirements via key phrases in the free text notes when data cannot be found via codes or discrete data fields.

The Axon Registry contains more than 50 quality measures, most of which focus on physician or practice processes. There is great interest to add neurologic outcome measures, which may measure direct health care outcomes, adverse events, patient-reported outcomes, or intermediate outcomes. Outcome measures are meaningful to patients, physicians, treatment teams, and payers. With the push to outcome measures, there is a great need to develop consistent documentation styles for neurology. For example, tremor severity may be recorded using a patient-reported outcome scale or by an assessment by the physician of mild, moderate, or severe. Similar challenges have been noted capturing seizure frequency, medication side effects or adverse events, and disease progression for multiple neurologic conditions.

Many outcome measures are number-based and look for a change in a quantified element. This could be a change in the score from a validated tool or a change in the number of falls a patient had (see the July 2019 AANnews article about the many falls measures in the registry at http://bit.ly/2RRqS62). The Axon Registry has learned much about outcome measures in the last two years and quality measures will continue to evolve as natural language processing capabilities progress.

Below are two outcome examples from the Axon Registry demonstrating challenges of consistent free text note documentation and solutions implemented to allow for meaningful outcome comparisons.

Tool + score documentation Several patient-reported outcome measures in the Axon Registry focus on quality of life and depression for patients. Identifying the score for a validated tool includes searching free text notes for the first numeric value within 100 characters from the tool name (PHQ-9, PROMIS, MIDAS, QOLIE-10, etc.). The logic was established in this way to meet current documentation styles that are seen in the Axon Registry. Much of the “tool + score” documentation in the Axon Registry looks like the following: “PHQ-9: 17” “PHQ-9 score = 8” “PHQ-9 questionnaire done w/patient today and result = 15” These above examples would be successfully identified and used in the performance calculations for the measure.

However, when the numeric score is documented before the tool name, when there are two values found, or when the score is not a numeric value, then the numeric value would not be found using the current Axon Registry free text search strategy. Here are some examples that wouldn’t be identified successfully: “Scored 14 on the PHQ-9” “The previous PHQ-9 score is 15 and the current PHQ-9 score is 7” “PHQ-9 screen OK” “PHQ-9 survey done, scored as minimal depression” The above examples are not recommended to identify the score using a validated tool in the Axon Registry.

Number of falls documentation Falls outcome measures are difficult as many outcome measures are looking for the number of falls or if the number of falls has decreased over a period of time. For implementation of these types of measures to be successful, Axon Registry requires specific documentation of the number of falls.

Ideally, your EHR has functionality to document the number of falls and the time period in discrete fields. Unfortunately, discrete field documentation is not available to many physicians. The alternative is to document in a consistent manner with the key phrases the Axon Registry has identified.

In 2018, the Axon Registry piloted a Falls measure specific to Parkinson’s disease, which required key phrasing of “Patient reports [n] falls occurred during the last 6 months.” Even subtle variations of this phrasing, such as “Patient reported [n] falling episodes during the last 6 months,” was difficult to detect. Given these limitations, few practices used the measure, and the measure was retired from the Axon Registry. Key phrases for other falls measures were unified in 2019. Suggested key phrases now include: “[n] + falls since last visit” and “Denies any falls.”

The Axon Registry will continue to evolve to meet member needs.

If you are interested in enrolling, contact registry@aan.com. You can find more individual measure key phrase suggestions at AAN.com/view/AxonQualityMeasures. 

AANnews • August 2019 7

Tools & Resources

Data Now Available from Record-breaking Compensation and Productivity Survey continued from cover Neurologists can: Benchmark compensation and RVUs to others in their subspecialty Find out the average payer mixes for neurologic practices See the average size of other practices and their employee miix

Advanced practice providers can: Discover key productivity and compensation metrics for APPs working in neurology Explore neurology APP salaries using subspecialty data

Business administrators can: Learn the average size of other practices and their use of APPs in their employee mix Discover the payer mix for neurologic practices Benchmark their salary against other practice managers working in neurologic practice settings

NEUROLOGY COMPENSATION AND PRODUCTIVITY YOU

COMPENSATION

YOUR PEERS

How does your compensation compare locally, regionally, nationally?

PRODUCTIVITY

Are you being as productive as you could be?

REVENUE

Are you making the most of your revenue opportunities?

Get the data you need.

To view or purchase the data set, visit AAN.com/view/NCPSurvey.

For more information or assistance, contact benchmark@aan.com. 

Journalist Curry Champions Crowdsourcing for Cures The August/September issue of Brain & Life® features journalist Ann Curry, whose medical show Chasing the Cure uses crowdsourcing to solve undiagnosed disorders. The article looks at the value of crowdsourcing for diagnosing neurologic medical mysteries. (Did you know the American Brain Foundation has a crowdsourcing option? Learn more at AmericanBrainFoundation.org!)

A second feature explores the latest research on early aggressive treatment for newly diagnosed patients with multiple sclerosis and describes some exceptions. The third feature explores the relationship between depression and three neurologic conditions: stroke, epilepsy, Multiple Scl Is Early Aggreerosis and Parkinson’s disease. Experts reveal Treatment Besssive for all Patien t ts? what brain changes cause depression and Nutrition What Fiber Can Do for Your Sym how best to treat it. And the Brain Boost ptoms Exercise Karate for department highlights how anesthesia Parkinson’s Disease can affect people with certain neurologic conditions and the precautions to take to ensure the best outcome after surgery.

Readers of the caregiving story can make use of the expert tips on how to advocate for a loved one—in the doctor’s office, at

8

AANnews • August 2019

the hospital, or at an assisted living facility. Brain & Life helps caregivers navigate the line between supporting their loved ones’ efforts to be their own advocates and advocating on behalf of loved ones who can’t speak for themselves.

Chasing a Cu re

Journalist

Ann Curry uses crowd sourcing to solve me dical myste ries

AU G U S T/S

E P TE M B E

R 2019

Brain & Life magazine is free for AAN members in the United States to distribute to patients, who also can subscribe for free. If you would like to adjust the number of copies you receive for your patients or update your clinic address, email BeGreen@ WasteFreeMail.com. All members have online access to the magazine articles and additional resources at BrainandLife.org. Please share the website with your patients! 

Patients with DRAVET SYNDROME deserve a giant leap forward.

Dravet syndrome is a rare, treatment-resistant developmental epileptic encephalopathy with onset in infancy and serious neurodevelopmental, motor, cognitive, and behavioral consequences that persist into adulthood.1

Dravet syndrome imposes substantial physical, emotional, and ďŹ nancial burdens on patients, caregivers, families, and society.2-4

There is an urgent need for more effective and better-tolerated treatment options that will

Deliver meaningful, consistent, and sustained seizure reduction

Reduce cognitive decline and long-term disability

Increase patient and caregiver freedom and quality of life

Go to DravetUrgency.com to review compelling information that might change the way you think about Dravet syndrome.

References: 1. Dravet C. The core Dravet syndrome phenotype. Epilepsia. 2011;52(suppl 2):3-9. 2. Jensen MP, Brunklaus A, Dorris L, et al. The humanistic and economic burden of Dravet syndrome on caregivers and families: implications for future research. Epilepsy Behav. 2017;70(pt A):104-109.

3. Lagae L, Irwin J, Gibson E, Battersby A. Caregiver impact and health service use in high and low severity Dravet syndrome: a multinational cohort study.

Seizure. 2019;65:72-79. 4. Jensen MP, Liljenquist KS, Bocell F, et al. Life impact of caregiving for severe childhood epilepsy: results of expert panels and caregiver focus groups. Epilepsy Behav. 2017;74:135-143.

Š 2019 Zogenix, Inc. All rights reserved. US-DS-1900001 July 2019

Tools & Resources

Consider These Tips for Solo and Small Practice Neurologists Often, some of the best advice on a problem comes from those who have experienced the problem firsthand. That’s why the AAN offered a panel discussion with solo and small practice physicians at the 2019 Annual Meeting. The event was moderated by Michael Wynn, DO, FAAN, and Erica Austin, DO, both solo physicians and former participants of the AAN’s Practice Ambassador Program― where AAN staff visit small practices to gather feedback and insights about issues facing that practice setting. With more than 50 audience members, the discussion was lively as participants shared tips, tricks, and ideas on how to thrive in today’s changing environment. Below are helpful suggestions from the audience and panel.

Would you recommend going into solo practice?

Yes, because it gives you the autonomy to be the kind of neurologist you want to be You need to be comfortable with trial and error and the unknown Right out of school, it is helpful to have a network to reach out to, so you might consider joining a small practice first Don’t buy an existing practice; set up your own and get your name out there

How do I build my referral network?

Meet primary care physicians (PCP) in the area: share your business card and create an info sheet including your bio, services provided, and contact information Connect with your top referrers: send them a thank you, be available, give them a direct phone line (cell or clinic) Promote access: The number one thing referring physicians want is access for the patients. If you have good access, promote it; include it on your info sheet

Erica Austin, DO, and Michael Wynn, DO, FAAN, led discussion on challenges and solutions for neurology professionals in solo and small practices.

Provide letters and results to PCP in a timely manner; one physician guarantees results to PCPs within five days

How should I diversify income?

Add telestroke shifts with a local or national health system Purchase your building and rent out space Expand clinical services to include workers’ compensation, independent medical exams, or exams at a local prison

How do I negotiate with insurance companies?

Evaluate your billing metrics so you can advocate for yourself Don’t be afraid to advocate for yourself and say no, including terminating contracts if necessary Investigate joining organizations like clinically integrated networks or independent physician organizations that can build an economy of scale when negotiating

10

AANnews • August 2019

How do I manage the burden of prior authorizations (PA)?

If the patient is referred from a PCP, inquire if PCP can help with PA If sending the patient to a large imaging center, ask if they can do the PA Request peer-to-peer reviews; ask for the person’s credentials and let them know you will be documenting their name and the result of the evaluation Look into the payer’s responsibility with regards to prior authorizations: Do they have to supply a peer in the same specialty? Do they have a set time frame in which to respond?

How do I manage HR issues?

Set expectations Draft clear job descriptions Be friendly with your employees, but remember you aren’t their friend. Setting boundaries can make it easier to give feedback or discipline if necessary 

Tools & Resources

August 13 Practice Management Webinar Helps You Increase Revenue continued from cover

Evans

Harness the Power of Your Quality Data with the Axon Registry

Klein

Faculty: David A. Evans, MBA, and Brad C. Klein, MD, MBA, FAAN August 13, 2019, at 12:00 p.m. ET Register by August 12 This webinar will help you learn to: Critically evaluate your revenue cycle and leverage neurology key performance indicators Determine the financial value of ongoing payer relations Identify if, and strategize how, you should incorporate ancillary services into your practice using tools such as the Neurology Compensation and Productivity Report The AAN’s practice management webinars have a new format but the same game-changing expert insights! A live, 30-minute webinar with expert faculty will be held on August 13, followed by several shorter recorded online lectures that go deeper into the topic posted the week of August 18, concluding with a 30-minute live webchat on September 10 for more Q&A. All course materials can be accessed on the new AAN online learning center at Learning.AAN.com.

Learn more and register at AAN.com/ view/pmw19. 

AUGUST 13

12:00 P.M. ET Register by August 12

Got Epic? We can work with them.

The Axon Registry® is a qualified clinical data registry focused on quality improvement in neurologic care. It crunches real-time data for FREE to help your institution: • Create quality improvement projects with your staff • Benchmark your outcomes against others in your institution or nationally • Reduce the burden of unnecessary documentation • Receive credit for multiple MOC requirements • Demonstrate the value of neurology to public and private payers

Put the Axon Registry to work for you. Discover how at

AAN.com/view/GoAxon

Tools & Resources

Neurology® Editorial: Efforts by the Journal to Promote Perspectives of Equity, Diversity, and Inclusion and Address Disparities Authors: Patricia K. Baskin, Kathleen M. Pieper, and Robert A. Gross, MD, PhD, FAAN In February this year, we erroneously published a humanities article that contained racial stereotypes. We retracted the article, expressed our deep regret [1,2], and provided a series of proposed steps to address our processes and culture as related to diversity and inclusion [3]. We have continued to evaluate our editorial processes to ensure that AAN values are represented in the Journal. This editorial is our promised update on the substantive and substantial changes we have made in our editorial processes and editorial team.

The Humanities Section. We suspended the Humanities section of the Journal immediately after the retraction took place and accepted the resignation of the editor of that section.

We have heard from many that they find this section valuable, expressing a desire that we continue this feature. To do so, we will need to assure that processes and personnel are in place that will assure quality and responsibility. This section contains a variety of perspectives and topics, so we will proceed carefully to be sure all content represents the values of the Journal and the Academy. To accomplish this, we will seek the input of our new team of editors (described below), but also a group of persons with sound humanities/journalism credentials; the ultimate goal is to re-establish the section with new editor(s) and sound editorial processes.

New Diversity Associate Editors and Diversity Reviews of Articles. We have recruited two Associate Editors (AEs) for Equity, Diversity, and Inclusion (EDI): Roy H. Hamilton, MD, MS, FAAN, and Holly E. Hinson, MD, MCR, FAAN. Their role includes reviewing papers during the revision stages to assure they present appropriate perspectives when the authors describe particular groups and rationales for these studies, along with reviewing, from a diversity perspective, other commentaries, future Humanities articles, podcasts, and web materials. With their input, processes for reviews of papers have been put in place by Journal staff. In addition to reviewing papers, these AEs will be called upon to help create strategies to increase diversity on our Editorial Board so that the Board will better represent our authors and readers, an ongoing process that we recognize will be iterative (we evaluate Editorial Board needs on a yearly basis).

We will consider hiring external consultants as needed to be sure we are following best practices.

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AANnews • August 2019

Establishment of a Dedicated Site on Diversity Topics. We have recruited a group of three editors, offering a variety of perspectives, to collaborate in creating and maintaining a dedicated online section of the Journal (referred to as a minisite) to highlight EDI content. Those who have agreed to serve include Jeffrey C. McClean II, MD, FAAN; Nicte I. Mejia, MD, MPH, FAAN; and Nicole Rosendale, MD. The site (NPub.edi) has been constructed and populated with links to papers published in Neurology related to these topics, with initial postings by the editors. Our plan includes a new venture, still in the planning stages, that will appear on this site: “Voices”—first-person accounts of those in the neurology field, about their lived experiences (NPub.org/voices).

EDI Awareness Training. We have committed to ongoing awareness training of EDI issues for the Journal editorial team.

At the Editorial Board meeting during the AAN Annual Meeting in Philadelphia in May, we devoted the discussion time to introducing the new EDI AEs and mini-site editors, elaborating on the changes in editorial processes that are taking place, and listening to questions and ideas from board members, who expressed solidarity with the new EDI initiatives and suggested new features to enhance the mini-site. The staff also participated in EDI training provided by the AAN during May and June to increase their awareness of these issues and increase their value as resources to authors, reviewers, and board members in this area. The EDI Editors will conference with all AEs and staff to educate the group further on recognizing and being sensitive to themes related to EDI.

Policy & Guidelines

Style changes. The Editorial Staff reviewed past Journal content to assess terms or phrases that may be considered inappropriate. In addition, a designated staff group was charged with reviewing authoritative style manuals and society and academic documentation to recommend changes to the internal Journal style guide. The resulting document was reviewed by the Journal and Publisher Production groups during the 2019 Annual Meeting. As a result, revisions were made to the style document that is used by Editorial Staff, Production Staff, and copyeditors.

Ongoing Diversity Efforts. To move forward in a positive way, and to engender discussion, we published an invited Special Editorial by Hamilton, et al. (4), which responded to the retracted Humanities article and articulated lessons for the future. We also solicited and published [5] an article by Silver on best practices for achieving gender equity. In addition, for the past year we have been collaborating with members of the AAN to generate data that we plan to publish in an upcoming issue of the Journal, examining gender distributions of officers, award winners, committee members, and Journal authors over the past two decades.

We will continue to work to earn your trust and confidence in our editorial processes. We are here to serve you and we strive ever to improve. 

References 1. Gross RA. Notice of Retraction: “Lucky and the Root Doctor.” Neurology 2019;92:684. n.neurology.org/content/92/14/684. Accessed June 10, 2019.

2. Gross RA. Letter from Journal. AAN.com/view/NeurologyRetractionLetter (February 14, 2019). Accessed June 10, 2019.

3. Gross RA. Editorial Changes at Neurology. Letter to AAN Members.

AAN.com/view/NeurologyEditorialChanges (February 18, 2019) Accessed June 10, 2019.

4. Hamilton RH, McClean JC, Greicius MD, Gamaldo CE, Burrus TM. Rooting out racial stereotypes in Neurology ®: A commentary on “Lucky and the root doctor.” Neurology 2019; 92:1029-1034; (e-published-ahead-of-print May 28, 2019).

5. Silver JK. Understanding and Addressing Gender Equity for Women in Neurology. Neurology 2019 (in press).

Capitol Hill Report Capitol Hill Report presents regular updates on legislative and regulatory actions and how the Academy ensures that the voice of neurology is heard on Capitol Hill. It is emailed to US members twice monthly and is posted at AAN.com/view/ HillReport. Below are some recent highlights.

Bill to Lower Health Care Costs Includes AAN Request The Senate Health, Education, Labor, and Pensions committee passed the Lower Health Care Costs of 2019, a 196-page bill that covers a wide range of health care issues including surprise medical billing and drug pricing. As requested in the AAN’s comments on the draft legislation, the final version included the FAIR Drug Pricing Act, a bill that would require drug manufacturers to notify the Department of Health and Human Services and submit a transparency and justification report 30 days before they increase the price of certain drugs by more than 10 percent in one year or 25 percent over three years.

Chairman Lamar Alexander (R-TN) has indicated work will continue on the bill to address concerns on surprise billing before a full Senate vote. 

AANnews • August 2019 13

NOW APPROVED

Proven efficacy in RMS with a maximum of

20 days

of oral treatment

over 2 years

1,2

INDICATION MAVENCLAD is indicated for the treatment of relapsing forms of multiple sclerosis (MS), to include relapsing-remitting disease and active secondary progressive disease, in adults. Because of its safety profile, use of MAVENCLAD is generally recommended for patients who have had an inadequate response to, or are unable to tolerate, an alternate drug indicated for the treatment of MS. Limitations of Use: MAVENCLAD is not recommended for use in patients with clinically isolated syndrome (CIS) because of its safety profile.

RMS: relapsing forms of multiple sclerosis.

IMPORTANT SAFETY INFORMATION WARNING: MALIGNANCIES and RISK OF TERATOGENICITY ° Treatment with MAVENCLAD may increase the risk of malignancy. MAVENCLAD is contraindicated in patients with current malignancy. In patients with prior malignancy or with increased risk of malignancy, evaluate the benefits and risks of the use of MAVENCLAD on an individual patient basis. Follow standard cancer screening guidelines in patients treated with MAVENCLAD ° MAVENCLAD is contraindicated for use in pregnant women and in women and men of reproductive potential who do not plan to use effective contraception because of the potential for fetal harm. Malformations and embryolethality occurred in animals. Exclude pregnancy before the start of treatment with MAVENCLAD in females of reproductive potential. Advise females and males of reproductive potential to use effective contraception during MAVENCLAD dosing and for 6 months after the last dose in each treatment course.

Stop MAVENCLAD if the patient becomes pregnant CONTRAINDICATIONS ° Patients with current malignancy. ° Pregnant women, and women and men of reproductive potential who do not plan to use effective contraception during and for 6 months after the last dose in each treatment course. May cause fetal harm. ° Patients with human immunodeficiency virus (HIV). ° Patients with active chronic infections (e.g., hepatitis or tuberculosis). ° Patients with a history of hypersensitivity to cladribine. ° Women intending to breastfeed while taking MAVENCLAD tablets and for 10 days after the last dose.

In the pivotal Phase III, randomized, placebo-controlled CLARITY trial, MAVENCLAD demonstrated1-3: ARR (primary endpoint)1

EDSS1-3

ACTIVE T1-Gd+1

ACTIVE T21

RELATIVE REDUCTION IN ARR AT 2 YEARS

REDUCTION IN RISK OF 3-MONTH CONFIRMED EDSS PROGRESSION

REDUCTION IN MEDIAN NUMBER OF ACTIVE T1-Gd+ LESIONS

REDUCTION IN MEDIAN NUMBER OF ACTIVE T2 LESIONS

33% VS PLACEBO

58% VS PLACEBO P<0.001

0.14

MAVENCLAD (n=433)

vs

P<0.05*

MAVENCLAD (n=433)

0.33

placebo (n=437)

vs

placebo (n=437)

0 MAVENCLAD vs

(n=433)

0.33 placebo

(n=437)

0 MAVENCLAD vs

0.67 placebo

P<0.001

HR: 0.67

(n=433)

(n=437)

P<0.001

*Nominal P value.

SIGNIFICANT REDUCTION IN MEAN NUMBER OF ACTIVE T1-Gd+ AND T2 LESIONS Relative reduction in mean number of % active T1-Gd+ lesions MAVENCLAD 0.12 vs placebo (n=433) vs 0.91 placebo (n=437); P<0.0012,3

ACTIVE T1-Gd+

86

ACTIVE T2

Relative reduction in mean number of active % T2 lesions MAVENCLAD 0.38 (n=433) vs 1.43 vs placebo placebo (n=437); P<0.0012,3

73

Patients were eligible if they met certain criteria, including at least 1 MS relapse within the past 12 months, EDSS scores ≤5.5, and <2 prior DMT failures.2 MOST COMMON (>20%) ADVERSE REACTIONS IN CLARITY1 MAVENCLAD (N=440)

Placebo (N=435)

Upper respiratory tract infection

38%

32%

Headache

25%

19%

Lymphopenia

24%

2%

Other adverse reactions reported in ≤10% of patients included nausea, back pain, arthralgia and arthritis, insomnia, bronchitis, hypertension, fever, and depression.

Learn more at MAVENCLAD.com/hcp ARR: annualized relapse rate; CLARITY: CLAdRIbine Tablets treating multiple sclerosis orallY; DMT: disease-modifying therapy; EDSS: Expanded Disability Status Scale; HR: hazard ratio; T1-Gd+: T1 gadolinium-enhanced.

WARNINGS AND PRECAUTIONS

˚

Malignancies: Treatment with MAVENCLAD may increase the risk of malignancy. After the completion of 2 treatment courses, do not administer additional MAVENCLAD treatment during the next 2 years. The risk of malignancy with reinitiating MAVENCLAD more than 2 years after the completion of 2 treatment courses has not been studied. Follow standard cancer screening guidelines in patients treated with MAVENCLAD.

˚

Risk of Teratogenicity: MAVENCLAD may cause fetal harm when administered to pregnant women. In females of reproductive potential, exclude pregnancy before initiation of each treatment course of MAVENCLAD and prevent by the use of effective contraception during MAVENCLAD dosing and for at least 6 months after the last dose of each treatment course. Women who become pregnant during treatment with MAVENCLAD should discontinue treatment.

Please see additional Important Safety Information and Brief Summary of full Prescribing Information, including boxed WARNING on the following pages.

IMPORTANT SAFETY INFORMATION

˚

Lymphopenia: MAVENCLAD causes a dose-dependent reduction in lymphocyte count. In clinical studies, 87% of MAVENCLAD-treated patients experienced lymphopenia. The lowest absolute lymphocyte counts occurred approximately 2 to 3 months after the start of each treatment course and were lower with each additional treatment course. Concomitant use of MAVENCLAD with hematotoxic drugs may increase the risk of adverse reactions because of the additive hematological effects. Monitor lymphocyte counts before and during treatment, periodically thereafter, and when clinically indicated.

˚

Infections: MAVENCLAD can reduce the body’s immune defense and may increase the likelihood of infections.

Infections occurred in 49% of MAVENCLAD-treated patients compared to 44% of patients treated with placebo in clinical studies. The most frequent serious infections included herpes zoster and pyelonephritis. Single fatal cases of tuberculosis and fulminant hepatitis B were reported in the clinical program. Administer live-attenuated or live vaccines at least 4 to 6 weeks prior to starting MAVENCLAD. Screen patients for latent infections; consider delaying treatment until infection is fully controlled. Vaccinate patients antibody-negative to varicella zoster virus prior to treatment. Administer anti-herpes prophylaxis in patients with lymphocyte counts less than 200 cells per microliter. Monitor for infections. In patients treated with parenteral cladribine for oncologic indications, cases of progressive multifocal leukoencephalopathy (PML) have been reported. No case of PML has been reported in clinical studies of cladribine in patients with MS.

˚

Hematologic Toxicity: In addition to lymphopenia, decreases in other blood cells and hematological parameters have been reported with MAVENCLAD in clinical studies. In general, mild to moderate decreases in neutrophil counts, hemoglobin levels, and platelet counts were observed. Severe decreases in neutrophil counts were observed in 3.6% of MAVENCLAD-treated patients, compared to 2.8% of placebo patients. Obtain complete blood count (CBC) with differential including lymphocyte count before and during treatment, periodically thereafter, and when clinically indicated.

˚

Risk of Graft-versus-Host Disease With Blood Transfusions: Transfusion-associated graft-versus-host disease has been observed rarely after transfusion of nonirradiated blood in patients treated with cladribine for non-MS treatment indications.

˚

Liver Injury: In clinical studies, 0.3% of MAVENCLAD-treated patients had liver injury (serious or causing treatment discontinuation) compared to 0 placebo patients. Obtain serum aminotransferase, alkaline phosphatase, and total bilirubin levels prior to treatment. Discontinue if clinically significant injury is suspected.

˚

Hypersensitivity: In clinical studies, 11% of MAVENCLAD-treated patients had hypersensitivity reactions, compared to 7% of placebo patients. Hypersensitivity reactions that were serious and/or led to discontinuation of MAVENCLAD, occurred in 0.5% of MAVENCLAD-treated patients, compared to 0.1% of placebo patients. If a hypersensitivity reaction is suspected, discontinue MAVENCLAD therapy. Do not use MAVENCLAD in patients with a history of hypersensitivity to cladribine.

Adverse Reactions: The most common adverse reactions with an incidence of >20% for MAVENCLAD are upper respiratory tract infection, headache, and lymphopenia.

Drug Interactions/Concomitant Medication: Concomitant use of MAVENCLAD with immunosuppressive or myelosuppressive drugs and some immunomodulatory drugs (e.g., interferon beta) is not recommended and may increase the risk of adverse reactions. Acute short-term therapy with corticosteroids can be administered.

Avoid concomitant use of certain antiviral and antiretroviral drugs. Avoid concomitant use of BCRP or ENT/CNT inhibitors as they may alter bioavailability of MAVENCLAD. Use in Specific Populations: Studies have not been performed in pediatric or elderly patients, pregnant or breastfeeding women. Use in patients with moderate to severe renal or hepatic impairment is not recommended.

Please see Brief Summary of full Prescribing Information, including boxed WARNING on the following pages.

Visit MAVENCLAD.com/hcp to learn more about this new treatment REFERENCES: 1. MAVENCLAD [prescribing information]. Rockland, MA: EMD Serono, Inc; 2019. 2. Giovannoni G, Comi G, Cook S, et al; for the CLARITY Study Group. A placebo-controlled trial of oral cladribine for relapsing multiple sclerosis. N Engl J Med. 2010;362(5):416-426. 3. Data on file.

Merck KGaA, Darmstadt, Germany. ©2019 EMD Serono, Inc. All rights reserved.

EMD Serono, Inc., One Technology Place, Rockland, MA 02370 Printed in USA US/CLA/0219/0044 04/19

MAVENCLAD® (cladribine) tablets, for oral use Brief Summary of Full Prescribing Information WARNING: MALIGNANCIES AND RISK OF TERATOGENICITY Malignancies Treatment with MAVENCLAD may increase the risk of malignancy. MAVENCLAD is contraindicated in patients with current malignancy. In patients with prior malignancy or with increased risk of malignancy, evaluate the benefits and risks of the use of MAVENCLAD on an individual patient basis. Follow standard cancer screening guidelines in patients treated with MAVENCLAD [see Contraindications (4) and Warnings and Precautions (5.1)].

Risk of Teratogenicity MAVENCLAD is contraindicated for use in pregnant women and in women and men of reproductive potential who do not plan to use effective contraception because of the potential for fetal harm. Malformations and embryolethality occurred in animals. Exclude pregnancy before the start of treatment with MAVENCLAD in females of reproductive potential. Advise females and males of reproductive potential to use effective contraception during MAVENCLAD dosing and for 6 months after the last dose in each treatment course. Stop MAVENCLAD if the patient becomes pregnant [see Contraindications (4), Warnings and Precautions (5.2), and Use in Specific Populations (8.1, 8.3)] 1 INDICATIONS AND USAGE MAVENCLAD is indicated for the treatment of relapsing forms of multiple sclerosis (MS), to include relapsingremitting disease and active secondary progressive disease, in adults. Because of its safety profile, use of MAVENCLAD is generally recommended for patients who have had an inadequate response to, or are unable to tolerate, an alternate drug indicated for the treatment of MS. MAVENCLAD is not recommended for use in patients with clinically isolated syndrome (CIS) because of its safety profile.

4 CONTRAINDICATIONS MAVENCLAD is contraindicated: • in patients with current malignancy [see Warnings and Precautions (5.1)].

• in pregnant women and in women and men of reproductive potential who do not plan to use effective contraception during MAVENCLAD dosing and for 6 months after the last dose in each treatment course.

May cause fetal harm [see Warnings and Precautions (5.2) and Use in Specific Populations (8.1, 8.3)].

• in patients infected with the human immunodeficiency virus (HIV) [see Warnings and Precautions (5.4)].

• in patients with active chronic infections (e.g., hepatitis or tuberculosis) [see Warnings and Precautions (5.4)].

• in patients with a history of hypersensitivity to cladribine [see Warnings and Precautions (5.8)].

5 WARNINGS AND PRECAUTIONS 5.1 Malignancies Treatment with MAVENCLAD may increase the risk of malignancy. In controlled and extension clinical studies worldwide, malignancies occurred more frequently in MAVENCLAD-treated patients (10 events in 3,754 patient-years [0.27 events per 100 patient-years]), compared to placebo patients (3 events in 2,275 patientyears [0.13 events per 100 patient-years]). Malignancy cases in MAVENCLAD patients included metastatic pancreatic carcinoma, malignant melanoma (2 cases), ovarian cancer, compared to malignancy cases in placebo patients, all of which were curable by surgical resection (basal cell carcinoma, cervical carcinoma in situ [2 cases]). The incidence of malignancies in United States MAVENCLAD clinical study patients was higher than the rest of the world (4 events in 189 patient-years [2.21 events per 100 patient-years] compared to 0 events in United States placebo patients; however, the United States results were based on a limited amount of patient data. After the completion of 2 treatment courses, do not administer additional MAVENCLAD treatment during the next 2 years [see Dosage and Administration (2.2)]. In clinical studies, patients who received additional MAVENCLAD treatment within 2 years after the first 2 treatment courses had an increased incidence of malignancy (7 events in 790 patient-years [0.91 events per 100 patientyears] calculated from the start of cladribine treatment in Year 3). The risk of malignancy with reinitiating MAVENCLAD more than 2 years after the completion of 2 treatment courses has not been studied.

MAVENCLAD is contraindicated in patients with current malignancy. In patients with prior malignancy or with increased risk of malignancy, evaluate the benefits and risks of the use of MAVENCLAD on an individual patient basis. Follow standard cancer screening guidelines in patients treated with MAVENCLAD. 5.2 Risk of Teratogenicity MAVENCLAD may cause fetal harm when administered to pregnant women. Malformations and embryolethality occurred in animals [see Use in Specific Populations (8.1)]. Advise women of the potential risk to a fetus during MAVENCLAD dosing and for 6 months after the last dose in each treatment course.

In females of reproductive potential, pregnancy should be excluded before initiation of each treatment course of MAVENCLAD and prevented by the use of effective contraception during MAVENCLAD dosing and for at least 6 months after the last dose of each treatment course. Women who become pregnant during treatment with MAVENCLAD should discontinue treatment [see Use in Specific Populations (8.1, 8.3)]. MAVENCLAD is contraindicated for use in pregnant women and in women and men of reproductive potential who do not plan to use effective contraception.

5.3 Lymphopenia MAVENCLAD causes a dose-dependent reduction in lymphocyte count. In clinical studies, 87% of MAVENCLAD-treated patients experienced lymphopenia.

The lowest absolute lymphocyte counts occurred approximately 2 to 3 months after the start of each treatment course and were lower with each additional treatment course. In patients treated with a cumulative dose of MAVENCLAD 3.5 mg per kg over 2 courses as monotherapy, 26% and 1% had nadir absolute lymphocyte counts less than 500 and less than 200 cells per microliter, respectively. At the end of the second treatment course, 2% of clinical study patients had lymphocyte counts less than 500 cells per microliter; median time to recovery to at least 800 cells per microliter was approximately 28 weeks.

Additive hematological adverse reactions may be expected if MAVENCLAD is administered prior to or concomitantly with other drugs that affect the hematological profile [see Drug Interactions (7.3)].

The incidence of lymphopenia less than 500 cells per microliter was higher in patients who had used drugs to treat relapsing forms of MS prior to study entry (32.1%), compared to those with no prior use of these drugs (23.8%).

Obtain complete blood count (CBC) with differential including lymphocyte count prior to, during, and after treatment with MAVENCLAD. [see Dosage and Administration (2.1, 2.5) and Warnings and Precautions (5.4) for timing of CBC measurements and additional instructions based on the patient’s lymphocyte counts and clinical status (e.g., infections)].

5.4 Infections MAVENCLAD can reduce the body’s immune defense and may increase the likelihood of infections.

Infections occurred in 49% of MAVENCLAD-treated patients compared to 44% of placebo patients in clinical studies. The most frequent serious infections in MAVENCLAD-treated patients included herpes zoster and pyelonephritis [see Herpes Virus Infections]. Fungal infections were observed, including cases of coccidioidomycosis.

HIV infection, active tuberculosis, and active hepatitis must be excluded before initiation of each treatment course of MAVENCLAD [see Contraindications (4)].

Consider a delay in initiation of MAVENCLAD in patients with an acute infection until the infection is fully controlled.

Initiation of MAVENCLAD in patients currently receiving immunosuppressive or myelosuppressive therapy is not recommended [see Drug Interactions (7.1)].

Concomitant use of MAVENCLAD with these therapies could increase the risk of immunosuppression.

Tuberculosis Three of 1,976 (0.2%) cladribine-treated patients in the clinical program developed tuberculosis. All 3 cases occurred in regions where tuberculosis is endemic.

One case of tuberculosis was fatal, and 2 cases resolved with treatment.

Perform tuberculosis screening prior to initiation of the first and second treatment course of MAVENCLAD. Latent tuberculosis infections may be

activated with use of MAVENCLAD. In patients with tuberculosis infection, delay initiation of MAVENCLAD until the infection has been adequately treated.

Hepatitis One clinical study patient died from fulminant hepatitis B infection. Perform screening for hepatitis B and C prior to initiation of the first and second treatment course of MAVENCLAD. Latent hepatitis infections may be activated with use of MAVENCLAD. Patients who are carriers of hepatitis B or C virus may be at risk of irreversible liver damage caused by virus reactivation. In patients with hepatitis infection, delay initiation of MAVENCLAD until the infection has been adequately treated.

Herpes Virus Infections In controlled clinical studies, 6% of MAVENCLADtreated patients developed a herpes viral infection compared to 2% of placebo patients. The most frequent types of herpes viral infections were herpes zoster infections (2.0% vs. 0.2%) and oral herpes (2.6% vs. 1.2%). Serious herpes zoster infections occurred in 0.2% of MAVENCLAD-treated patients.

Vaccination of patients who are antibody-negative for varicella zoster virus is recommended prior to initiation of MAVENCLAD. Administer live-attenuated or live vaccines at least 4 to 6 weeks prior to starting MAVENCLAD. The incidence of herpes zoster was higher during the period of absolute lymphocyte count less than 500 cells per microliter, compared to the time when the patients were not experiencing this degree of lymphopenia. Administer anti-herpes prophylaxis in patients with lymphocyte counts less than 200 cells per microliter.

Patients with lymphocyte counts below 500 cells per microliter should be monitored for signs and symptoms suggestive of infections, including herpes infections.

If such signs and symptoms occur, initiate treatment as clinically indicated. Consider interruption or delay of MAVENCLAD until resolution of the infection.

Progressive Multifocal Leukoencephalopathy Progressive multifocal leukoencephalopathy (PML) is an opportunistic viral infection of the brain caused by the JC virus (JCV) that typically only occurs in patients who are immunocompromised, and that usually leads to death or severe disability. Typical symptoms associated with PML are diverse, progress over days to weeks, and include progressive weakness on one side of the body or clumsiness of limbs, disturbance of vision, and changes in thinking, memory, and orientation leading to confusion and personality changes.

No case of PML has been reported in clinical studies of cladribine in patients with multiple sclerosis. In patients treated with parenteral cladribine for oncologic indications, cases of PML have been reported in the postmarketing setting.

Obtain a baseline (within 3 months) magnetic resonance imaging (MRI) before initiating the first treatment course of MAVENCLAD. At the first sign or symptom suggestive of PML, withhold MAVENCLAD and perform an appropriate diagnostic evaluation.

MRI findings may be apparent before clinical signs or symptoms.

Vaccinations Administer all immunizations according to immunization guidelines prior to starting MAVENCLAD. Administer live-attenuated or live vaccines at least 4 to 6 weeks prior to starting MAVENCLAD, because of a risk of active vaccine infection [see Herpes Virus Infections]. Avoid vaccination with live-attenuated or live vaccines during and after MAVENCLAD treatment while the patient’s white blood cell counts are not within normal limits.

5.5 Hematologic Toxicity In addition to lymphopenia [see Warnings and Precautions (5.3)], decreases in other blood cells and hematological parameters have been reported with MAVENCLAD in clinical studies. Mild to moderate decreases in neutrophil counts (cell count between 1,000 cells per microliter and < lower limit of normal [LLN]) were observed in 27% of MAVENCLAD-treated patients, compared to 13% of placebo patients whereas severe decreases in neutrophil counts (cell count below 1,000 cells per microliter) were observed in 3.6% of MAVENCLAD-treated patients, compared to 2.8% of placebo patients. Decreases in hemoglobin levels, in general mild to moderate (hemoglobin

8.0 g per dL to < LLN), were observed in 26% of MAVENCLAD-treated patients, compared to 19% of placebo patients. Decreases in platelet counts were generally mild (cell count 75,000 cells per microliter to < LLN) and were observed in 11% of MAVENCLADtreated patients, compared to 4% of placebo patients.

In clinical studies at dosages similar to or higher than the approved MAVENCLAD dosage, serious cases of thrombocytopenia, neutropenia, and pancytopenia (some with documented bone marrow hypoplasia) requiring transfusion and granulocyte-colony stimulating factor treatment have been reported [see Warnings and Precautions (5.6) for information regarding graft-versus-host disease with blood transfusion].

Obtain complete blood count (CBC) with differential prior to, during, and after treatment with MAVENCLAD [see Dosage and Administration (2.1, 2.5)].

5.6 Graft-Versus-Host Disease With Blood Transfusion Transfusion-associated graft-versus-host disease has been observed rarely after transfusion of nonirradiated blood in patients treated with cladribine for non-MS treatment indications.

In patients who require blood transfusion, irradiation of cellular blood components is recommended prior to administration to decrease the risk of transfusionrelated graft-versus-host disease. Consultation with a hematologist is advised.

5.7 Liver Injury In clinical studies, 0.3% of MAVENCLAD-treated patients had liver injury (serious or causing treatment discontinuation) considered related to treatment, compared to 0 placebo patients. Onset has ranged from a few weeks to several months after initiation of treatment with MAVENCLAD. Signs and symptoms of liver injury, including elevation of serum aminotransferases to greater than 20-fold the upper limit of normal, have been observed.

These abnormalities resolved upon treatment discontinuation.

Obtain serum aminotransferase, alkaline phosphatase, and total bilirubin levels prior to the first and second treatment course [see Dosage and Administration (2.1)]. If a patient develops clinical signs, including unexplained liver enzyme elevations or symptoms suggestive of hepatic dysfunction (e.g., unexplained nausea, vomiting, abdominal pain, fatigue, anorexia, or jaundice and/or dark urine), promptly measure serum transaminases and total bilirubin and interrupt or discontinue treatment with MAVENCLAD, as appropriate.

5.8 Hypersensitivity In clinical studies, 11% of MAVENCLAD-treated patients had hypersensitivity reactions, compared to 7% of placebo patients. Hypersensitivity reactions that were serious and/or led to discontinuation of MAVENCLAD (e.g., dermatitis, pruritus) occurred in 0.5% of MAVENCLAD-treated patients, compared to 0.1% of placebo patients. One patient had a serious hypersensitivity reaction with rash, mucous membrane ulceration, throat swelling, vertigo, diplopia, and headache after the first dose of MAVENCLAD. If a hypersensitivity reaction is suspected, discontinue MAVENCLAD therapy. Do not use MAVENCLAD in patients with a history of hypersensitivity to cladribine [see Contraindications (4)].

5.9 Cardiac Failure In clinical studies, one MAVENCLAD-treated patient experienced life-threatening acute cardiac failure with myocarditis, which improved after approximately 1 week. Cases of cardiac failure have also been reported with parenteral cladribine used for treatment indications other than multiple sclerosis.

Instruct patients to seek medical advice if they experience symptoms of cardiac failure (e.g., shortness of breath, rapid or irregular heartbeat, swelling).

6 Adverse Reactions The following serious adverse reactions and potential risks are discussed, or discussed in greater detail, in other sections: Malignancies [see Warnings and Precautions (5.1)], Risk of Teratogenicity [see Warnings and Precautions (5.2)], Lymphopenia [see Warnings and Precautions (5.3)], Infections [see Warnings and Precautions (5.4)], Hematologic Toxicity [see Warnings and Precautions (5.5)], Graft-Versus-Host Disease With Blood Transfusion [see Warnings and Precautions (5.6)], Liver Injury [see Warnings and Precautions (5.7)], Hypersensitivity

[see Warnings and Precautions (5.8)], Cardiac Failure [see Warnings and Precautions (5.9)] 6.1 Clinical Trials Experience

Drug Interactions With MAVENCLAD (continued) 7.2 Interferon Beta

MAVENCLAD (N=440) %

Placebo (N=435) %

Clinical Impact

Upper respiratory tract infection

Concomitant use of MAVENCLAD with interferon beta did not change the exposure of cladribine to a clinically significant effect; however, lymphopenia risk may be increased [see Warnings and Precautions (5.3)].

38

32

Prevention or Management

Concomitant use is not recommended.

Headache

25

19

7.3 Hematotoxic Drugs

Lymphopenia

24

2

Nausea

10

9

Back pain

8

6

Arthralgia and arthritis

7

5

Insomnia

6

4

Bronchitis

5

3

Hypertension

5

3

Fever

5

3

Depression

5

3

Adverse Reactions in Study 1 With an Incidence of at Least 5% for MAVENCLAD and Higher Than Placebo

Hypersensitivity In clinical studies, 11% of MAVENCLAD patients had hypersensitivity adverse reactions, compared to 7% of placebo patients [see Warnings and Precautions (5.8)].

Alopecia Alopecia occurred in 3% of MAVENCLAD-treated patients compared to 1% of placebo patients.

Myelodysplastic Syndrome Cases of myelodysplastic syndrome have been reported in patients that had received parenteral cladribine at a higher dosage than that approved for MAVENCLAD. These cases occurred several years after treatment.

Herpes Meningoencephalitis Fatal herpes meningoencephalitis occurred in 1 MAVENCLAD-treated patient, at a higher dosage and longer duration of therapy than the approved MAVENCLAD dosage and in combination with interferon beta-1a treatment.

Stevens-Johnson Syndrome (SJS) and Toxic Epidermal Necrolysis (TEN) SJS and TEN are identified risks of parenteral cladribine for the treatment of oncologic indications.

Seizures In clinical studies, serious events of seizure occurred in 0.3% of MAVENCLAD-treated patients compared to 0 placebo patients. Serious events included generalized tonic-clonic seizures and status epilepticus. It is unknown whether these events were related to the effects of multiple sclerosis alone, to MAVENCLAD, or to a combination of both.

Clinical Impact

Concomitant use of MAVENCLAD with hematotoxic drugs may increase the risk of adverse reactions because of the additive hematological effects [see Warnings and Precautions (5.5)].

Prevention or Management

Monitor hematological parameters.

7.4 Antiviral and Antiretroviral Drugs

Clinical Impact

Compounds that require intracellular phosphorylation to become active (e.g., lamivudine, zalcitabine, ribavirin, stavudine, and zidovudine) could interfere with the intracellular phosphorylation and activity of cladribine.

Prevention or Management

Avoid concomitant use.

7.5 Potent ENT, CNT, and BCRP Transporter Inhibitors

Clinical Impact

Cladribine is a substrate of breast cancer resistance protein (BCRP), equilibrative nucleoside (ENT1), and concentrative nucleoside (CNT3) transport proteins. The bioavailability, intracellular distribution, and renal elimination of cladribine may be altered by potent ENT1, CNT3, and BCRP transporter inhibitors.

Prevention or Management

Avoid co-administration of potent ENT1, CNT3, or BCRP transporter inhibitors (e.g., ritonavir, eltrombopag, curcumin, cyclosporine, dilazep, nifedipine, nimodipine, cilostazol, sulindac, dipyridamole, or reserpine) during the 4- to 5-day MAVENCLAD treatment cycles. If this is not possible, consider selection of alternative concomitant drugs with no or minimal ENT1, CNT3, or BCRP transporter inhibiting properties. If this is not possible, dose reduction to the minimum mandatory dose of drugs containing these compounds, separation in the timing of administration, and careful patient monitoring is recommended.

Drug Interactions With MAVENCLAD 7.1 Immunomodulatory, Immunosuppressive, or Myelosuppressive Drugs

Clinical Impact

Prevention or Management

Concomitant use of MAVENCLAD with immunomodulatory, immunosuppressive, or myelosuppressive drugs may increase the risk of adverse reactions because of the additive effects on the immune system [see Warnings and Precautions (5.4)].

Concomitant use with myelosuppressive or other immunosuppressive drugs is not recommended. Acute short-term therapy with corticosteroids can be administered.

In patients who have previously been treated with immunomodulatory or immunosuppressive drugs, consider potential additive effect, the mode of action, and duration of effect of the other drugs prior to initiation of MAVENCLAD.

7.6 Potent BCRP and P-gp Transporter Inducers Clinical Impact

Possible decrease in cladribine exposure if potent BCRP or P-gp transporter inducers are co-administered.

Prevention or Management

Consider a possible decrease in cladribine efficacy if potent BCRP (e.g., corticosteroids) or P-gp (e.g., rifampicin, St. Johnâ&#x20AC;&#x2122;s Wort) transporter inducers are co-administered.

7.7 Hormonal Contraceptives Clinical Impact

It is currently unknown whether MAVENCLAD may reduce the effectiveness of systemically acting hormonal contraceptives.

Prevention or Management

Women using systemically acting hormonal contraceptives should add a barrier method during MAVENCLAD dosing and for at least 4 weeks after the last dose in each treatment course.

8 Use in Specific Populations 8.1 Pregnancy Risk Summary MAVENCLAD is contraindicated in pregnant women and in females and males of reproductive potential who do not plan to use effective contraception. There are no adequate data on the developmental risk associated with use of MAVENCLAD in pregnant women.

Cladribine was embryolethal when administered to pregnant mice and produced malformations in mice and rabbits [see Data]. The observed developmental effects are consistent with the effects of cladribine on DNA [see Contraindications (4) and Warnings and Precautions (5.2)].

Data Animal Data When cladribine was administered intravenously (0, 0.5, 1.5, or 3 mg/kg/day) to pregnant mice during the period of organogenesis, fetal growth retardation and malformations (including exencephaly and cleft palate) and embryofetal death were observed at the highest dose tested. An increase in skeletal variations was observed at all but the lowest dose tested. There was no evidence of maternal toxicity.

When cladribine was administered intravenously (0, 0.3, 1, and 3 mg/kg/day) to pregnant rabbits during the period of organogenesis, fetal growth retardation and a high incidence of craniofacial and limb malformations were observed at the highest dose tested, in the absence of maternal toxicity.

When cladribine was administered intravenously (0, 0.5, 1.5, or 3.0 mg/kg/day) to mice throughout pregnancy and lactation, skeletal anomalies and embryolethality were observed at all but the lowest dose tested.

8.2 Lactation MAVENCLAD is contraindicated in breastfeeding women because of the potential for serious adverse reactions in breastfed infants [see Contraindications (4) and Warnings and Precautions (5)]. Advise women not to breastfeed during dosing with MAVENCLAD and for 10 days after the last dose.

8.3 Females and Males of Reproductive Potential Pregnancy Testing In females of reproductive potential, pregnancy should be excluded before the initiation of each treatment course of MAVENCLAD [see Use in Specific Populations (8.1)].

Contraception Females Females of reproductive potential should prevent pregnancy by use of effective contraception during MAVENCLAD dosing and for at least 6 months after the last dose in each treatment course. It is unknown if MAVENCLAD may reduce the effectiveness of the systemically acting hormonal contraceptives. Women using systemically acting hormonal contraceptives should add a barrier method during MAVENCLAD dosing and for at least 4 weeks after the last dose in each treatment course. Women who become pregnant during MAVENCLAD therapy should discontinue treatment [see Warnings and Precautions (5.2) and Drug Interactions (7.7)].

Males As cladribine interferes with DNA synthesis, adverse effects on human gametogenesis could be expected.

Therefore, male patients of reproductive potential should take precautions to prevent pregnancy of their partner during MAVENCLAD dosing and for at least 6 months after the last dose in each treatment course [see Warnings and Precautions (5.2) and Nonclinical Toxicology (13.1)].

8.4 Pediatric Use The safety and effectiveness in pediatric patients (below 18 years of age) have not been established.

Use of MAVENCLAD is not recommended in pediatric patients because of the risk of malignancies [see Warnings and Precautions (5.1)].

8.5 Geriatric Use Clinical studies with MAVENCLAD did not include sufficient numbers of patients aged 65 or over to determine whether they respond differently from younger patients. Other reported clinical experience has not identified differences in responses between the

elderly and younger patients. Caution is recommended when MAVENCLAD is used in elderly patients, taking into account the potential greater frequency of decreased hepatic, renal, or cardiac function, concomitant diseases, and other drug therapy.

8.6 Patients With Renal Impairment The concentration of cladribine is predicted to increase in patients with renal impairment [see Clinical Pharmacology (12.3)]. No dosage adjustment is recommended in patients with mild renal impairment (creatinine clearance 60 to 89 mL per minute).

MAVENCLAD is not recommended in patients with moderate to severe renal impairment (creatinine clearance below 60 mL per minute) [see Clinical Pharmacology (12.3)].

8.7 Patients With Hepatic Impairment The effect of hepatic impairment on the pharmacokinetics of cladribine is unknown [see Clinical Pharmacology (12.3)]. No dosage adjustment is recommended in patients with mild hepatic impairment. MAVENCLAD is not recommended in patients with moderate to severe hepatic impairment (Child-Pugh score greater than 6) [see Clinical Pharmacology (12.3)].

17 PATIENT COUNSELING INFORMATION Advise the patient to read the FDA-approved patient labeling (Medication Guide).

Inform patients of the possible risk of malignancies, teratogenicity, lymphopenia, and other hematologic toxicity, infections, liver injury, hypersensitivity, and cardiac failure. Inform women that they cannot breastfeed on a MAVENCLAD treatment day and for 10 days after the last dose. Instruct patients that MAVENCLAD is a cytotoxic drug and to use care when handling MAVENCLAD tablets.

MAVENCLADŽ (cladribine) tablets, for oral use Distributed by: EMD SERONO, Inc. MAVENCLAD is a One Technology Place registered trademark of Rockland, MA 02370 Merck KGaA, Darmstadt, Germany US/CLA/0419/0220 04/19 Š2019 EMD Serono, Inc.

Policy & Guidelines

AAN Regulatory Advocacy Efforts Receive Award The AAN has won an advocacy award from the American Association of Medical Society Executives (AAMSE) in the large organization division.

The AAN was honored for its submission, Protecting Cognitive Care, detailing the Academy’s regulatory work on evaluation and management codes in 2018.

“This award recognizes the dogged determination of many Academy member advocates and staff who have pushed back on changes to E/M codes that would adversely affect neurologists,” said AAN President James C. Stevens, MD, FAAN. “We continue to strive to ensure fair compensation for our members and reducing onerous regulatory burdens that take away time that could be better spent with patients.” 

Stevens

Conferences & Community

Lively, Multicultural Toronto to Host 2020 Annual Meeting

Academic Year Members: It’s Time to Renew!

Toronto—known as one of the world’s most thriving multicultural cities— will welcome the AAN for its 72nd Annual Meeting April 25 to May 1, 2020.

For those AAN members on the academic year membership* cycle, now is the time to renew for 2019–2020. By renewing today, you can help ensure you go into the next school year with the essential training resources, education, and support you need to succeed, including:

With its wide range of languages, food, arts, entertainment, and more, Toronto’s motto aptly declares “Diversity Our Strength.” And there’s no better city in which to experience the excitement and diversity of the AAN Annual Meeting, with its seemingly endless choice of top-tier education in nearly every topic and specialty imaginable; all the valuable CME you need for knowledge, growth, and maintenance; the most cutting-edge science covering every specialty; and the opportunity to connect with friends—both old and new—from around the world. With its recent record-breaking attendance of more than 15,000 representing nearly 100 countries, the Annual Meeting’s diversity is also its strength.

Visit AAN.com/view/AM20Interest to sign up to be notified when registration goes live—see you in Toronto! 

Free access to Continuum® and Continuum® Audio Career guidance with job seeker tools including CV support, salary calculator, articles and webinars, and career coaching The latest scientific research and news affecting the neuroscience community Resources including online education and clinical practice guidelines Access to a network of more than 36,000 neurologists and neuroscience professionals worldwide View a full listing of benefits and renew at AAN.com/Dues. If your program pays for your AAN membership, please contact your program coordinator for assistance. *Student, Intern, and Junior memberships run on an academic year (July 1 through June 30), regardless of the join date. 

Education & Research

August Application Deadlines Approaching for Two Research Program Opportunities The August application deadlines are quickly approaching for two opportunities for 2020. Visit AAN.com/view/ResearchProgram for more information.

Clinician Scientist Development Award in Multiple Sclerosis Pre-application Deadline: August 14 Funded by the National Multiple Sclerosis Society and American Brain Foundation, this award supports three years of research training in an environment where talented young clinicians address problems in MS with the most current scientific tools.

Lawrence M. Brass Stroke Research Award Application Deadline: August 15 Funded by the American Heart Association/American Stroke Association and the American Brain Foundation, this award provides one or two years of financial support to enhance the integrated research and clinical training of postdoctoral applicants who are not yet independent. 

Wide Range of Movement Disorders Is Focus of August Continuum Readers will find “valuable information on the diagnosis and treatment of patients with a wide range of movement disorders,” according to Guest Editor Elan D. Louis, MD, MS, FAAN, in speaking of the August issue of Continuum: Lifelong Learning in Neurology®. Indeed, those seeking the latest updates on Parkinson’s disease, progressive supranuclear palsy, corticobasal degeneration and multiple system atrophy, tics and Tourette syndrome, tremor, the dystonias, chorea,

AAN members pay only $349 per year for a subscription to Continuum® and Continuum® Audio. Subscribe now by contacting Wolters Kluwer at (800) 3610633, (301) 223-2300 (international); or visit Shop.LWW.com/continuum. AAN Junior members who are transitioning to neurologist memberships can receive a 50-percent discount on the already low member rate for the Continuum and Continuum Audio subscription. 

ataxia, myoclonus, tardive syndromes, movement disorders in children, and psychogenic movement disorders will discover something to improve their knowledge, skills, and care.

The issue also includes a chapter on medicolegal issues entitled “Liability and Failure to Warn a Patient,” as well as a postreading self-assessment and test with the opportunity to earn up to 20 AMA PRA Category 1™ SA-CME.

UCNS Accredits New Fellowship Training Program in Neurocritical Care The UCNS has accredited the Neurocritical Care program at AdventHealth in Orlando, FL, making this the 201st program to receive accreditation in UCNS-recognized neurologic subspecialties.

Programs attaining UCNS accreditation status offer the core curriculum established by the subspecialty and meet required quality standards established by the UCNS. Accreditation is a voluntary process of evaluation and peer review based on UCNS accreditation standards. Fellows who complete a UCNSaccredited program meet the training eligibility requirements to apply for certification in the subspecialty. 

Next Accreditation Application Deadline Is December 1 Applications are now being accepted until December 1, 2019, from programs seeking accreditation in any of the UCNS-recognized neurologic subspecialty areas. New applications received by the December 1 deadline will be reviewed for approval in the spring of 2020. Learn more at UCNS.org. 

AANnews • August 2019 21

AAN.com/careers

Visit the AAN’s Neurology Career Center to view hundreds of additional jobs and sign up for customized, confidential notifications when positions of interest are added.

Cognitive/Behavioral Neurologist. Inova Neuroscience and Spine Institute is part of the Inova Health System and a regional leader in the diagnosis, treatment and research of complex neurological conditions involving the brain, spine and nervous system. From its hub at Inova Fairfax Hospital, the Institute also encompasses specialized programs at Inova Alexandria Hospital, Inova Fair Oaks Hospital, Inova Loudoun Hospital and Inova Mount Vernon Hospital.

With a network of five hospitals and more than 14,000 neuroscience patients treated annually, Inova Neuroscience and Spine Institute is the largest program of its kind in Northern Virginia and one of the most comprehensive within the mid-Atlantic region. Led by highly trained, nationally recognized physicians, the Institute diagnoses and treats adult and pediatric patients with neurotrauma, concussions, stroke and cerebrovascular disease, memory disorders, spine conditions, brain and spinal tumors. Its comprehensive sub-specialty offerings, multidisciplinary approach and seamless interactions within the health system ensure that every patient receives the appropriate level of leading-edge care in the most convenient and appropriate setting. Inova Neuroscience and Spine Institute includes experts from multiple disciplines including emergency medicine, radiology, neurology, pharmacy, critical care, nursing and rehabilitation working closely together to give each patient the best chance at recovery.

We offer sophisticated, minimally invasive technology and advanced imaging by interventional neuroradiologists, and cerebrovascular and endovascular surgeons. Our comprehensive research program is committed to the advancement of treatment protocols. We are seeking an experienced Cognitive/Behavioral Neurologist to serve as Medical Director of the new Inova Brain Health and Performance Enhancement Center in Northern Virginia.

Partnering with the established Center for Brain Health at the University of Texas at Dallas, the Inova Brain Health and Performance Enhancement Center will offer a variety of specialized services for individuals with disease and recovering from surgery, as well as healthy adults and adolescents wanting to improve their overall brain performance. In addition to administrative responsibilities, the successful candidate will provide outpatient services as a member of Inova Medical Group—Neurology. IMG provides patients with the highest level of care relating to diagnostic, treatment and research services for neurological and related disorders. Our physicians are board certified in neurology, clinical neurophysiology, sleep medicine, internal medicine, electroencephalography, vascular neurology and electrodiagnostic medicine. Our practice also offers in-office testing for a wide range of neurological and sleep disorders. Inova is a not-for-profit healthcare system based in Northern Virginia that serves more than 2 million people each year from throughout the Washington, DC, metro area and beyond. Inova is a comprehensive network of hospitals, outpatient services and facilities, primary and specialty care practices, and health and wellness initiatives. Full time position with compensation package that includes medical, dental, vision and life insurance, paid time off, CME reimbursement, as well as defined contribution retirement plans. Job Requirements: The ideal candidate will have a minimum of five years of relevant experience.

Must be able to obtain a Virginia state medical license and obtain the required privileges with Inova. To apply for this position, contact Allison Spindle at allison.spindle@ inova.org or (703) 205-2324. https://jobs.brassring.com/ TGnewUI/Search/home/ BE/BC Neurologists in the beautiful Philadelphia suburbs at Paoli Hospital. Main Line HealthCare has opportunities for BE/BC Neurologists at Paoli Hospital which is located in the beautiful Philadelphia suburbs. Due to future retirements of our neurologists, we are seeking to recruit general neurologists, as well as neurologists with fellowship training. These physicians will practice general neurology and be able to build a practice in their area of special interest. They will enjoy high patient volumes and an existing patient base plus room for growth. Opportunities: Combination of outpatient and inpatient consults. Enjoy the benefits of working in a well-established, employed practice.

Enjoy the support of respected and top-level primary care,

22

AANnews • August 2019

hospitalists and other specialists within Main Line Health community. Diverse neurologic patient mix. Open to all sub-specialties except sleep medicine. Cognitive, headache and movement disorder subspecialists a plus. Reasonable call schedules. Part-time neuro-hospitalists will also be considered. Benefits and Lifestyle: High income potential with competitive base compensation and production incentives. Excellent benefits package. Financial security with working for a top ranked, financially secure hospital system. Area is well known for the top ranked public and private schools. Less than an hour drive to historic Philadelphia. Wonderful cultural opportunities. Short drive to beaches, mountains, New York City and Washington, DC. Contact Information: Rose Caione, Main Line Health, Physician Recruiter, (484) 580-4146, caioner@mlhs.org.

Neurologist Needed with a Sign-on Bonus. If you want to join a team focused on clinical quality and experience a great family lifestyle at the same time, this is without a doubt the unique place for you. Earn in excess of $500,000 (salary plus production and performance bonuses). Sign-on bonus/Relocation assistance. Student Loan Assistance.

Generous CME Allowance. Malpractice coverage, including tail coverage. Outstanding Medical, Dental, Vision, Disability, Life Insurance & Retirement Benefits. Paid Time Off up to 6 weeks (including CME). A team atmosphere where good clinicians and staff thrive. Board Certified or Board Eligible required. Job Requirements: Outpatient Neurologist with call. To apply for this position, contact Krisann Dikes at Krisann.Dikes@mysrhs.com, Phone: (228) 818-4024 and Fax: (228) 818-4014.

Neurologist—Outpatient. Central Vermont Medical Center (CVMC), a partner in The University of Vermont Health Network is recruiting for a Neurologist to join our practice. Located in the heart of the Green Mountain state, CVMC has a reputation for clinical excellence with a staff deeply rooted in our community. We have attracted and retained a very talented staff due to our focus on lifestyle and professional growth. Our Neurology practice provides general neurology services including, epilepsy/ seizure disorders, stroke, chronic headaches/ migraines, multiple sclerosis, Parkinson’s and Alzheimer disease, as well as movement and neuromuscular disorders.

This position is primarily an outpatient position with very reasonable inpatient call responsibilities. We are looking for a physician who wants to work in an area where you can have a long, sustainable career and enjoy the special lifestyle that comes with living in Vermont. The financial package includes a market based, competitive salary plus quality and productivity bonuses. Full benefit package includes moving expenses and assistance with student loans. Job Requirements: BC/BE Neurologist. To apply for this position, contact Sarah Child at sarah.child@cvmc. org, phone: (802) 225-1739, http://cvmc.org.

West Virginia Pediatric Neurology Opening. Join one of the best health care providers and teaching hospital in the state. Pediatric Neurology. Employed Position. Competitive salary with full benefit package. $50K sign-on bonus. More than 30 specialties are represented. Procedures performed: Advanced MS infusion therapies, Electromyography (EMG), Electroencephalogram (EEG), Evoked potentials studies, Lumbar puncture, Nerve conduction studies, Therapeutic injections for migraine and Epilepsy Monitoring Unit for long-term monitoring. Neurology department specializes in the following conditions Autism, Cerebral palsy, Dementia, Epilepsy, Multiple sclerosis (MS), Neuropathy, Stroke, Seizures, Migraine, Nerve and muscle disorders and Tremors. “Hip, Historic and Almost Heaven”—Tourism Board. The cultural, recreational, and business capital of the Appalachian Mountains. Excellent Public and Private Schools. NCAA Division I Intercollegiate Sports Teams.

Driving distance for skiing, water sports, hiking, etc. Bike friendly community with a network of trails. Art walks, downtown street festivals and brown bag concert series.

Come play—multiple family friendly venues and activities.

Mention Code 180802—CHN. Minimum Requirements: MD or DO Medical Degree. Eligible to be state licensed in the United States. United States Residency and / or Fellowship training. To apply for this position, contact Timothy Stanley

at tstanleyweb@phg.com, Phone: (404) 591-4224 or Fax: (404) 816-7853. Cell/Text: (770) 265-2001.

West Virginia Neurophysiology Opening. Medical school affiliated Academic Medical Center. Neurophysiology.

Opportunity to join growing Neurology department of 8 Neurologists. Faculty members including General, Pediatric, Neuromuscular, Movement and Vascular. New Neurology Residency Program. Accredited Neurophysiology Center on site. Multidisciplinary team includes Radiologists, Pharmacists, Nursing, Dietitians and Physical, Occupational and Speech Therapists. Excellent Salary plus Full Benefits and Academic Appointment. An outdoor enthusiast´s haven. Enjoy the scenic shores of an historic river. Take in the four season views while mountain hiking. The region´s best skiing at your doorstep. Year-round family fun. A down-to-earth place to live combined with amazing cultural sensations. NCAA Division One Intercollegiate Sports Teams. Excellent Public and Private Schools.

Short Distance to 4 Major Metro Areas. Grand prize winner America´s Best Communities Competition. Mention Code 180316—CN. Minimum Requirements: MD or DO Medical Degree. Eligible to be state licensed in the United States.

United States Residency and / or Fellowship training. To apply for this position, contact Rob Rector at rrectorweb@ phg.com, Phone: (404) 591-4218, Fax: (404)816-7853.

Neurologist Multiple Sclerosis Specialist. You will love the Northwest. Why not love your career, too? The Everett Clinic is looking for a full-time, BC/BE neurologist with expertise in treating patients with multiple sclerosis, to join our exceptional neurology staff. Our neurology department has a supportive and collegial team of 9 providers with diverse training (Cleveland clinic, UW, Rush, Vanderbilt, U of M, OHSU and Columbia). Our specialist will practice primarily in the north Seattle area. The clinic’s neurology department is one of the largest in the metropolitan Seattle area, and we already have neuromuscular, movement, dementia, sleep, neuro-ophthalmology, vascular, epilepsy and autonomic subspecialty representation. Also, we have no emergency department or hospital call. We are part of a large and growing multispecialty clinic with a primary referral base. The clinic also has a pain clinic and a robust behavioral health department. Why did our highly skilled provider team choose The Everett Clinic. Progressive care model offering personalized care coordination for our patients. Physician leadership pathway programs.

Phenomenal support staff. Prioritization of work/life balance.

Flexible scheduling. Highly competitive compensation, signing bonus, and benefits. The Everett Clinic is a longstanding and thriving physician-led practice centered north of Seattle in a naturally beautiful region. We focus on health for our patients and our team and encourage a healthy work-life balance. Our low physician turnover rates and high physician satisfaction scores make The Everett Clinic one of the Northwest’s most sought-after organizations. If you value quality, go above-and beyond in making patients a priority and want to help cultivate a fun, team-centered environment, we want to talk to you.

To apply for this job, contact Spencer Vaden at svaden@ everettclinic.com or (425) 339-5475, https://everettclinic. com/provider-opportunities/provider-opportunities.

AANnews® Classified Advertising

he AAN offers a complete package of print, online, T and in-person recruitment advertising opportunities.

Visit careers.AAN.com for all AAN options, rates, and deadlines. d copy for the October 2019 print edition of AANnews A must be submitted by September 1, 2019 The same deadline applies to changes/cancellations. he American Academy of Neurology reserves the T right to decline, withdraw, or edit advertisements at its discretion. Every care is taken to avoid mistakes, but the responsibility for clerical or printer errors does not exceed the cost of the ad.

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AUGUST 13

Webinar: Increasing Revenue in Your Practice: Care Models, Ancillary Services, and Other Strategies Register by August 12 AAN.com/view/pmw19

AUGUST 15

Deadline: Fall Conference Early Registration AAN.com/view/19FC

SEPTEMBER 12

Deadline: Fall Conference Advance Registration and Hotel Deadline AAN.com/view/19FC

OCTOBER 1

Webinar: Using Technology for Better Practice Management of Stroke Register by September 30 AAN.com/view/pmw19

OCTOBER 1

Application Deadline: 2020 Research Program AAN.com/view/ResearchProgram

OCTOBER 17

Pre-conference for Advanced Practice Providers AAN.com/view/APPConference

OCTOBER 18–20 EduScience: 19 Fall Conference Ad—Half Page Horizontal> AN Placed in AANnews 8.25 x 5.25 +0.125 bleed, 4C

2019 Fall Conference AAN.com/view/19FC

REGISTER NOW! OCTOBER 18–20

THE COSMOPOLITAN OF LAS VEGAS Join us for the hottest topics in the field of neurology, real-world issues in practice management, and innovative science—plus valuable end-of-year CME.

Featuring an October 17 Pre-conference for Advanced Practice Providers (APPs) Bundle with the full Fall Conference registration to save!

Save $200 when you register by August 15.

AAN.com/view/Fall

A COMMUNITY DRIVEN TO FIND A CURE

Jennifer Vermilion, MD Recipient of Clinical Research Training Scholarship in Tourette Syndrome I am excited to advance our understanding of anxiety symptoms in youth with tic disorders and to better understand how to approach treatment of these patients.

Zoe Diagnosed with Tourette Syndrome at Age Seven I had to figure out at a young age how my emotions affect my tics, from good to awful ways. It has been frustrating to figure out on my own and learn to deal with. This was the first moment in my life where my parents couldn’t fix something for me.

Young people like Zoe will benefit from innovative research projects like Dr. Vermilion’s—and you can help. Explore the world’s first neuroscience crowdfunding website and learn about research that can help Zoe at AmericanBrainFoundation.org/Zoe.