Hospitalist trends...are you in the know?

From the Washington Post article:

Most hospitalists are internists; 11 percent are pediatricians. By 2010, SHM projects 30,000 hospitalists will be practicing. Medical students may soon choose which side of the hospital divide they want to work on: inpatient or outpatient. For now, it's your physician's choice whether to refer you to a hospitalist or to follow your inpatient care. If you have no primary care physician, a hospitalist will probably manage your hospital stay.

Although patients are often confused about the role of hospitalists, hospitals embrace the new model, nationally subsidizing $50,000 to $60,000 of the average hospitalist's $169,000 salary. Managed-care organizations, such as Kaiser, have established their own hospitalist practices. There is financial incentive to do so: Studies show hospitalists manage care more efficiently and reduce hospital stays. Hospitalists say they think that's because they order tests and procedures more promptly.

Shortening hospital stays is to the patient's advantage as well, said Frederick Finelli, chairman of the D.C. Board of Medicine.

Click here to access the article.

Sharp rise in adverse drug reactions

From the Wall Street Journal article:

The number of serious drug side effects and deaths reported to the U.S. Food and Drug Administration more than doubled over an eight-year period, according to an analysis of adverse-drug events reported to the agency.

As part of the agency's so-called MedWatch reporting system, drug companies, health-care professionals and the public can file reports when they think a drug is connected to a side-effect or fatality. Drug companies are required to file such reports while they are voluntary for health-care professionals.

A study, published in Monday's Archives of Internal Medicine, looked at reports that are considered serious from 1998 to 2005. The study was conducted by researchers at the Institute for Safe Medication Practices in Huntingdon Valley, Pa., and Wake-Forest University School of Medicine in Winston-Salem, N.C.

Click here to access (subscription required).

Federal law for disclosure of gifts/payments to physicians?

From the New York Times article:

Makers of drugs and medical devices would be required to report publicly nearly all payments and gifts to doctors under legislation introduced Thursday in the Senate.

“Right now, the public has no way to know whether a doctor’s been given money that might affect prescribing habits,” said Senator Charles E. Grassley of Iowa, the ranking Republican on the Senate Finance Committee and one of the bill’s authors.

Senator Herb Kohl, Democrat of Wisconsin, said drug and medical device makers had long defended their payments and gifts to doctors as appropriate.

“If that is the case, full disclosure will only serve to prove them right,” Mr. Kohl said.

Ken Johnson, senior vice president at the Pharmaceutical Research and Manufacturers of America, said, “A new law is not necessary when pharmaceutical marketing is already heavily regulated by the Food and Drug Administration.”

The F.D.A. does not regulate the gifts or consulting arrangements drug and device makers routinely provide doctors, and it reviews only a fraction of the scripted marketing talks doctors make on companies’ behalf.

Click here to read the entire article.

Interesting stuff over at the Carlat Psychiatry Blog!

Click here to read the 9/04/07 entry. Be certain to read the comment posted by James M. La Rossa Jr.

Need for CME on Biostats?

From the Science Daily article:

Donna M. Windish, M.D., M.P.H., of the Yale University School of Medicine, New Haven, Conn., and colleagues conducted a multiprogram assessment of residents' biostatistics knowledge and interpretation of research results. The study consisted of a cross-sectional survey of 277 internal medicine residents in 11 residency programs. The survey included a biostatistics/study design multiple-choice knowledge test.

...

"If physicians cannot detect appropriate statistical analyses and accurately understand their results, the risk of incorrect interpretation may lead to erroneous applications of clinical research. Educators should re-evaluate how this information is taught and reinforced in order to adequately prepare trainees for lifelong learning, and further research should examine the effectiveness of specific educational interventions."

Click here to access the article.

Teen smoking

From the Archives of Pediatric & Adolescent Medicine:

Exposure to Smoking Depictions in Movies

Its Association With Established Adolescent Smoking

James D. Sargent, MD; Mike Stoolmiller, PhD; Keilah A. Worth, PhD; Sonya Dal Cin, PhD; Thomas A. Wills, PhD; Frederick X. Gibbons, PhD; Meg Gerrard, PhD; Susanne Tanski, MD

Arch Pediatr Adolesc Med. 2007;161:849-856.

Objective To assess the association between exposure to movie smoking and established adolescent smoking.
...
Conclusion In this national US adolescent sample, exposure to smoking in movies predicted risk of becoming an established smoker, an outcome linked with adult dependent smoking and its associated morbidity and mortality.

Click here to read the entire abstract.

JAMA Medical Education Theme Issue

There are a number of interesting articles in the latest issue of JAMA. Click here to access.

A parachute story

Please read today's entry on Medinnovation.blog: "Know Who is Packing Your Parachute"

The "Swiss cheese effect"

From the HeraldTribune.com article:

Two major advances that have improved health care -- abundant, specialized medications and powerful new technology -- also create new possibility for errors.

"The likelihood of error goes up with the more steps there are," said Frances Griffin, a director of the Institute for Healthcare Improvement.

The nonprofit group, known as IHI, won acclaim for its "100,000 Lives Campaign" in 2005 to reduce medical errors.

To all that, add in that doctors are susceptible to the same "classic human factors," Griffin said: "If we have to rely on memory for something, if we're distracted by something, if we have to do several things at once."

She and Krumholz both cited the "Swiss cheese effect."

The concept arose from studying aviation errors, and in recent years has been applied to health care. The thinking goes: A block of Swiss cheese has a lot of holes. But only rarely do they line up so you can see all the way through. When they do, a mistake makes its way through to the patient.

This article also discusses one physician who is very transparent about a surgical error that he made. Click here to check it out.

What about physician privacy?

From the recent press release:

Consumers’ CHECKBOOK/Center for the Study of Services, a nonprofit consumer research and information organization, has won a Freedom of Information Act lawsuit that will require the U.S. Department of Health and Human Services to release data on every physician claim paid by Medicare. The data to be released will identify physicians but will not make possible identification of patients.

“Consumers, physicians, and the Medicare program itself will benefit greatly when these data are used in measures of physician experience, quality, and efficiency,” said Robert Krughoff, president of CHECKBOOK/CSS.

As a first use of the data, the consumer organization will create a resource, free to the public, on its www.checkbook.org website, that will report the number of various types of major procedures performed by each physician and reimbursed by Medicare, “so a consumer selecting a physician for a knee replacement or prostate surgery or other major procedure will be able easily to check that a physician has an appropriate level of experience,” said Krughoff.
CHECKBOOK/CSS

Might this not result in physicians "cherry picking" their Medicare cases so that they will build good stats?? Click here to access the full press release.

U.S. News & World Report ranks best hospitals

From the most recent issue:

In July, America's Best Hospitals turned 18. From the very first, U.S. News has ranked hospitals in pediatrics, identifying medical centers that excel at helping the sickest young patients. We've heard reassuringly few complaints through the years that one or another of the ranked hospitals might not merit such distinction.

Still, improving the usefulness and relevance of the rankings in this important specialty has been a long-standing goal. Mortality data and other information factored into various adult specialty rankings cannot be obtained for children's hospitals. In pediatrics, therefore, the rankings have always relied solely on a facility's reputation among an annual sampling of board-certified physicians in various pediatric specialties. We've long wanted to move beyond reputation.

Click here to read the entire article.

ACCME issues policy updates

Click here to access.

Washington state's "decade of pain"

From the Healthdecisions.org article:

Ten years ago, the state of Washington began a major push to make sure doctors weren't undertreating pain. The change was revolutionary for people dealing with chronic pain, but it was also a boon for drug dealers and those with addiction problems.

Between 1997 and 2005, the percentage of people using five major painkillers rose 96 percent in Washington state, according to an Associated Press analysis of statistics from the Drug Enforcement Administration.

Oxycodone, commonly known as Oxy Contin, is responsible for most of the increase in this state. Use of oxycodone increased by 500 percent between 1997 and 2005. Use of morphine and hydrocodon, commonly known as Vicodin, also have increased dramatically: morphine by 223 percent and hydrocodon by 166 percent.

I can personally understand the good intentions of this major effort in the state of Washington for adequate treatment of pain. A few years back I was suspected of seeking pain medication (that was before the x-rays came back). Click here to access the article.

Real Age

According to the Real Age test, I'm 13 years younger than my "calendar" age and I'll live to be 90. I know nothing about the scientific accuracy of this test, so you should probably think of it as entertainment. That said, it might get you thinking about your lifestyle choices. Click here to access.

Gist artistry in silver and gold

Okay, this is the last Friday for a while on Gist artists (don't worry, we're growing up some more of them). This week I'm highlighting the artistry of my cousin, Gary, and his sons over at Gist Silversmiths:

Click here to access their website.

On-site ACCME monitors?

Well, it hit the WSJ's Health Blog:

In a recent conversation with the Health Blog, Kopelow said ACCME will likely start sending auditors to CME lectures. “We could have trained monitors observing CME presentations and reporting their findings to us,” to see whether the presentations are straying from the rules, he said. The group hasn’t yet decided whether the monitors would work undercover.

CME providers that step out of line might find themselves facing sanction more quickly and more often. Providers now have several years to clean up their act, and only one provider or so a year loses its accreditation. “The Senate and others have said we don’t … have as heavy a hand as we could. The ACCME is going to talk about that,” Kopelow said.

The way money passes from drug and device companies to CME providers could also change, Kopelow said. Now, a provider applies to a company for funding, and the company decides whether to grant the request.

Click here to access.

New study from the Center for Studying Health System Change

From the news release:

The proportion of physicians in solo and two-physician practices decreased significantly from 40.7 percent in 1996-97 to 32.5 percent in 2004-05, according to a new national study released today by the Center for Studying Health System Change (HSC).

Changes in physician practice setting and organization have important implications for the practice of medicine and the care patients receive. Some experts believe that large, multispecialty practices, which combine primary care physicians and a range of specialists in the same practice, are the organizational structure with the greatest potential to provide consistently high-quality care.

Despite the shift away from the smallest practices, physicians are not moving to multispecialty practices, the study found. The proportion of physicians in multispecialty practices decreased from 30.9 percent to 27.5 percent between 1998-99 and 2004-05.

While growth of multispecialty practices stalled, other significant changes in physician practice settings and organization took place over the last decade—more physicians moved to larger practices and more physicians gave up an ownership stake in their practices. Physicians increasingly are practicing in mid-sized, single-specialty groups of six to 50 physicians (17.6 % of physicians in 2004-05 vs. 13.1 % in 1996-97). At the same time, the proportion of physicians with an ownership stake in their practice declined from 61.6 percent in 1996-97 to 54.4 percent in 2004-05.

Perspective?

It's Friday and you should be looking forward to the weekend! The artist?...my nephew, Erik Gist. You can access Erik's website by clicking here. Be forewarned, it's not for the faint of heart!

Breast implants and higher suicide rate

From the Los Angeles Times article:

The report in the August issue of the Annals of Plastic Surgery was the most recent to detect a higher suicide rate among women who had their breasts enlarged, providing a gloomy counterpoint to other studies that showed women felt better about themselves after getting implants.

While the study did not look at the reasons behind the suicides, senior author Joseph McLaughlin, a professor of medicine at the Vanderbilt University School of Medicine, said he believed that many of the women had psychological problems before getting breast implants and that their condition did not improve afterward.

Duh. Click here to access the article.

ACCME Responds to Senate Committee on Finance Report

Click here to access.

"New Prescriptions for Neglected Diseases"

That's the title of a new article just published in Open Medicine. From the article:

Consider that, between 1975 and 1999, only nine medicines of the 1393 that were developed targeted the most neglected diseases. (This figure rises to 16 if one considers tuberculosis and malaria.3) Of the remaining 1377 medicines developed, only two made the World Health Organization’s Model List of Essential Medicines. All 16 new medicines for neglected diseases did. In the ensuing five years, an additional 163 drugs were brought to market, of which four were for the treatment of malaria and one targeted a neglected disease—the drug miltefosine for treatment of leishmaniasis.

Click here to read the entire article.

Bibliotherapy

From the Wall Street Journal article:

A growing number of therapists are recommending something surprising for depressed and anxious patients: Read a book.

The treatment is called bibliotherapy, and it is gaining force from a spate of research showing that some self-help books can measurably improve mental health. In May alone, the journal Behaviour Research and Therapy published two studies demonstrating the effectiveness of bibliotherapy in patients with depression or other mood disorders. The national health system in Britain this year is prescribing self-help books for tens of thousands of people seeking medical attention for mood disorders.

Decades after the emergence of the self-help book, it remains one of publishing's hottest categories. This year, U.S. revenue for the category will exceed $600 million, a single-digit jump from 2006, says Simba Information, a market research firm in Stamford, Conn.

Click here to access the article (sub. req.).

Meadow Gist, Artist

Check out a painting by Meadow Gist:


Click here to access Meadow's website!

Alcohol and drugs

Came across an interesting website with an online newsletter. Looks like it is the result of a collaboration between Boston University, the National Institute on Alcohol Abuse and Alcoholism, and the National Institute on Drug Abuse. Check it out if you are looking for needs assessment data on alcohol and drug use/abuse. Physicians could probably also use it for self-directed learning! Some articles in the most recent newsletter:

• Unhealthy Alcohol Use and the Preventive Paradox
• Drug Use Disorders: Onset, Mental Health Impairment, and Comorbidity
• Why Don't Primary Care Clinicians Screen Teens for Substance Abuse?
• Coordinated Treatment for Hepatitis C in Injection Drug Users

There are also slide presentations available! Click here to access.

Low health literacy and mortality

From the Archives of Internal Medicine article "Health Literacy and Mortality Among Elderly Persons":

Conclusions Inadequate health literacy, as measured by reading fluency, independently predicts all-cause mortality and cardiovascular death among community-dwelling elderly persons. Reading fluency is a more powerful variable than education for examining the association between socioeconomic status and health.

Click here to access the journal abstract. Click here to access a lay article on this study.

Minnesota hospital suspends patient privacy violators

From the StarTribune.com article:

More than 100 Park Nicollet Clinic employees have been suspended this year for violating federal laws on patient privacy -- mostly by tapping into electronic records of relatives or friends, according to clinic officials.

This week, the clinic notified its 8,300 employees about the suspensions as a reminder of what it calls its "zero tolerance policy" on confidentiality. Already, twice as many employees have been disciplined for privacy violations in 2007 than in all of 2006, officials say. They were suspended without pay for three days.

Click here to access the article.

Physician shortage

From the New York Times article:

The government estimates that more than 35 million Americans live in underserved areas, and it would take 16,000 doctors to immediately fill that need, according to the American Medical Association. And the gap is expected to widen dramatically over the next several years, reaching 24,000 in 2020 by one government estimate. A 2005 study in the journal Health Affairs said it could hit an astonishing 200,000 by then, based on a rising population and an aging work force.

Click here to access the article (reg. req.).

Prescription for change?

Check out this Boston Globe article "Tests of ER trainees find signs of race bias in care"; from the article:

In the new study, trainee doctors in Boston and Atlanta took a 20-minute computer survey designed to detect overt and implicit prejudice. They were also presented with the hypothetical case of a 50-year-old man stricken with sharp chest pain; in some scenarios the man was white, while in others he was black.

"We found that as doctors' unconscious biases against blacks increased, their likelihood of giving [clot-busting] treatment decreased," said the lead author of the study, Dr. Alexander R. Green of Massachusetts General Hospital. "It's not a matter of you being a racist. It's really a matter of the way your brain processes information is influenced by things you've seen, things you've experienced, the way media has presented things."

Specialists predict that the novel study, appearing on the website of the Journal of General Internal Medicine, will result in considerable soul-searching in the medical profession, rethinking of medical school curriculum, and refresher courses for veteran doctors.

Click here to access the article.

A bad bug

From the Archives of Surgery:

Main Outcome Measures The prevalence, case fatality, total mortality rate, and colectomy rate of C difficile colitis.

Results We found that the prevalence, case fatality, total mortality rate, and colectomy rate of C difficile colitis increased from 1993 through 2003. In our regression analysis, the year of diagnosis predicted an increase in prevalence, case fatality, total mortality rate, and colectomy rate after adjusting for potential confounders.

Conclusions The prevalence, case fatality, total mortality rate, and colectomy rate of C difficile colitis significantly increased from 1993 to 2003. These findings provide compelling evidence of the changing epidemiological features of C difficile colitis.

Click here to access the Archives of Surgery (subscription required for full article). Click here to read a Boston Globe article on this bad bug.

Physician impairment?

From the Miami Herald article:

Doctors' problems are usually closely held secrets in the healthcare industry and can persist for years before becoming public with any disciplinary action.

Click here to read more.

Disabilityblog.info

Check out the work of my fellow blogger, Rudy, over at disabilityblog.info. This site is a great news feed on a wide variety of disability topics. Per Rudy, it is:

...intended both for people with disabilities and those who wish to learn about disability issues. The main goal of this web site is to raise disability awareness and understanding. It's a place where people can do research on disability issues. I also wanted it to be a place where people can share experiences and help each other.

CME Providers, bookmark it! Click here to access Rudy's blog. Blessings!

Gap in clot risk knowledge?

From the United Press International:

One out of three U.S. hospital patients is at risk for dangerous blood clots, but far fewer actually receive treatments to prevent the potentially life-threatening condition, according to a study released this week.

"Blood clots are the most common preventable cause of death in hospital patients. It is profound and puzzling: Why is there a preventable issue that people are dying from?" Frederick Anderson, a research professor in the Department of Surgery at the University of Massachusetts Medical School and director of the Center for Outcomes Research, told United Press International.

Deep venous thromboembolism, a blood clot in the deep vein of a leg or arm, can occur when people are immobilized for two or three days, such as after surgery. The condition is treatable but if ignored, may become deadly if the blood clot travels to the lung.

It is estimated that 5 percent to 10 percent of hospital deaths are due to blood clots that travel to the lungs, also called a pulmonary embolism.

Click here to access the article.

The patient's perspective

From the Boston Globe article:

When the ambulance arrived, the self-assured nurse was suddenly on the other side of her profession, depending on hulking EMTs to pound life back into her. She suffered a massive heart attack and it took 12 shocks of a defibrillator to stabilize her.

Eaton recently told her story to a rapt audience of doctors and nurses in a crowded conference room at Winchester Hospital. Over coffee and buzzing beepers, the point was to use Eaton's experience to review "best practices" and how to cope with trauma from a patient's point of view.

Click here to access the article.

Triskaidekaphobia

Say what!? Yep, it means fear of the number 13.

ACCME Annual Report 2006 available

Total hours of instruction:

2006: 712,163
2005: 678,528

Total commercial support:

2006: $1,199,405,519
2005: $1,115,597,071

Exhibit income:

2006: $244,913,684
2005: $235,721,224

Click here to access the report.

Proceduralists

From the Wall Street Journal article:

With a steady decline in the number of doctors trained to perform such skills-intensive medical procedures in recent years, Cedars and other large academic medical centers are looking for ways to fill the gap. They are creating special procedure services and new procedure-training programs for medical residents. Teams of doctors known as proceduralists are now available at some centers with special expertise in tunneling a catheter into a vein, slicing an incision in the neck for an airway, or plunging a needle into a patient's back for a spinal tap.

While not a medical specialty in its own right, procedural medicine is emerging as an important new role for physicians with the manual dexterity and steady nerves to perform risky procedures. And hospitals say they see reduced complication rates when services are performed by physicians who are very well-versed in the procedures.

Click here to read the article (subscription required).

Thirteen horses and diphtheria

I love medical history; from the New York Times article, "Long Ago Against Diphtheria, the Heroes Were Horses":

The Claremont Riding Academy, on the Upper West Side of Manhattan, shut its doors for good a few months ago. As the oldest continuously operated stable in New York City, it reached back to an era when horses were as common as taxis are today, and it prompted thoughts of some of New York’s most heroic horses: the 13 beasts of burden used in 1894 to produce the miracle drug of their day, diphtheria antitoxin.

The horses and their successors were stabled for nearly two decades at the New York College of Veterinary Surgeons, on East 57th Street and Third Avenue. Initially joined by a few sheep, goats and dogs, the horses prevailed because they were larger and better antitoxin factories: when systematically injected with diphtheria toxin, their immune systems were prompted to develop neutralizing antibodies against the germ’s poison. (Most survived the injections with nothing more than a fever and loss of appetite, but over the years quite a few horses succumbed to even tiny doses of toxin.)

Click here to read the entire article.

University of Pittsburgh Medical Center and gifts from indusry

From the www.post-gazette.com article:

The University of Pittsburgh Medical Center has drafted a get-tough policy that would prohibit its physicians and other employees from accepting almost all freebies -- from sample medications to pens and notepads -- from drug and medical device companies.

Industry influence can result in "unacceptable conflicts of interest," the draft says, adding that financial support or gifts, even in modest amounts, "can exert a subtle but measurable impact on recipients' behavior."

Click here to access the article.

Palliative Care

I encourage every CME professional to read the Washington Post article "A New Focus on Easing the Pain"; an excerpt:

A 12-year-old boy, struggling to understand why dialysis could no longer keep his father alive, reflected on how fast he outgrew his sneakers. "I'm the size of a man -- size 11. I don't want my feet to grow any more," he said, unaware, perhaps, of how well his imagery called up his preparation to step into his father's shoes as the man of the family.

Click here to access.

Health Data Tools and Statistics

Have you ever wished there was one place on the web where you could access health statistics and public health data? Where there is, you'll find it at Partners in Information Access for the Public Health Workforce which is the result of a collaboration of U.S. government agencies, public health organizations and health sciences libraries. Click here to access; there's even an online tutorial and training manual.

A blow to DTC advertising?

From LegalNewsline.com:

Drug companies cannot escape liability for harmful prescriptions in West Virginia by laying all responsibility on doctors, the West Virginia Supreme Court of Appeals ruled Wednesday.

Three of five Justices denied a writ that would have kept Marshall Circuit Judge Mark Karl from holding trial against Janssen Pharmaceutica.

They upheld Karl's rejection of a doctrine that would define a doctor as a "learned intermediary" between a drug maker and a patient.

Chief Justice Robin Davis treated the doctrine as a useless 82-year-old relic.

"When the learned intermediary doctrine was developed, direct to consumer advertising of prescription drugs was utterly unknown," she wrote. "Pharmaceutical manufacturers never advertised their products to patients, but rather directed all sales efforts at physicians."

She wrote that the law created an exception to the duty of a manufacturer to warn consumers directly of risks.

"For good or ill, that has all changed," Davis wrote. "... we now hold that, under West Virginia products liability law, manufacturers of prescription drugs are subject to the same duty to warn consumers about the risks of their products as other manufacturers."

Click here to read the entire article.

Gift registry?

From the New York Times article:

In the midst of a Senate hearing about the money and gifts that drug makers routinely provide to doctors, Senator Claire McCaskill mentioned that she had a brother who runs a restaurant.

“And he said that the most lucrative part of his business was the private room that is used mostly by drug companies” to entertain doctors, said Ms. McCaskill, Democrat of Missouri. “He said that you wouldn’t believe how much expensive wine these guys buy.” The tab often totals thousands of dollars, she said later.

Marjorie Powell, senior assistant general counsel for the Pharmaceutical Research and Manufacturers of America, assured Ms. McCaskill that major drug makers no longer offer doctors expensive dinners. The industry’s code of ethics mandates that free meals be modest — pizza, for instance, Ms. Powell said.

Click here to access the article.

G'day mate?

From the Sydney Morning Herald article:

The pharmaceutical industry was dealt a bitter blow this week when a three-member panel headed by Justice Robert French ruled that Medicines Australia, the industry body covering more than 90 per cent of drug companies in Australia, could only continue to self-regulate its code of conduct if all drug companies twice a year forwarded complete information on hospitality: the venues, the number and types of professionals invited, the total cost of food, travel, accommodation and entertainment. This information would be published on a freely accessible internet database.

Click here to access the article; interesting reading.

And now, the Senate Special Committee on Aging

From the Washington Post article:

For doctors, though, drug company funding "makes it very difficult to know what research to believe," said J. Gregory Rosenthal, an Ohio retinal surgeon and a founder of Physicians for Clinical Responsibility, a group pushing for tighter controls on conflicts of interest in medicine. "Even at the [specialty] academy level, you can't go onto a Web site without being confronted by sponsorship logos."

Rosenthal will testify today in a hearing before the Senate Special Committee on Aging, which is looking into physician links with the drug industry. Sen. Herb Kohl (D-Wis.), the chairman, said the commercial sponsorship of courses creates a conflict of interest.

"It appears that everyone profits from this pervasive system of gifts and payments, except the consumer," Kohl said.

The hearing marks the second time this year that the Senate has examined the independence of industry-sponsored continuing education. In April, a Senate Finance Committee study found that the Accreditation Council for Continuing Medical Education, the main accrediting body for education providers, does not scrutinize course materials for accuracy or evidence of bias toward sponsors' products. At times, sponsors have been able to select topics, and presenters have discussed off-label uses for drugs, the report found.

The article goes on to quote Murray Kopelow, ACCME CEO. Click here to access the article.

Injuries and surgeons in training

From the New York Times article:

Nearly all surgeons accidentally stick themselves with needles and sharp instruments while in training. But most fail to report the injuries, risking their health and that of their families and patients to the threat of diseases including AIDS, hepatitis and many other blood-borne illnesses, according to a survey being published today.

Their being rushed was the chief reason the surgical residents cited for the injuries, which were mostly self-inflicted. Among the reasons they cited for not reporting the potentially fatal injuries was that doing so would take too much time, could jeopardize career opportunities and might cause a loss of face among peers.

In addition, there was a false belief that getting even timely medical attention would not prevent infection. In fact, immediate treatment with antiviral drugs can prevent infection among those stuck with needles while caring for patients with the viruses that cause AIDS and hepatitis B. Immediate treatment can also prevent chronic infection among those infected with hepatitis C virus.

Click here to access the article. Click here to access the New England Journal of Medicine source article.

Shrinks and pharma dollars

From the New York Times article:

As states begin to require that drug companies disclose their payments to doctors for lectures and other services, a pattern has emerged: psychiatrists earn more money from drug makers than doctors in any other specialty.

How this money may be influencing psychiatrists and other doctors has become one of the most contentious issues in health care. For instance, the more psychiatrists have earned from drug makers, the more they have prescribed a new class of powerful medicines known as atypical antipsychotics to children, for whom the drugs are especially risky and mostly unapproved.

Vermont officials disclosed Tuesday that drug company payments to psychiatrists in the state more than doubled last year, to an average of $45,692 each from $20,835 in 2005. Antipsychotic medicines are among the largest expenses for the state’s Medicaid program.

Click here to read the entire article.

Teletrauma

From an interesting article in the Arizona Daily Star:

A new live two-way video link between University Medical Center and the city's 17 paramedic units is expected to put Tucson at the cutting edge of medical technology when it goes online in August.
The system allows real-time videoconferencing over the city's public safety and public works wireless Internet system — a wireless mesh that links the city's traffic signals and other public safety wireless functions.
Dr. Rifat Latifi, interim medical director of UMC's Level 1 trauma center, said the video link will be the first of its kind in the country and the world.
"We think it's an incredible thing," Latifi said. "Wherever a patient is, we're there."

Click here to access the article.

The Joint Commission 2008 National Patient Safety Goals

From the Joint Commission's press release:

Major changes in this sixth annual issuance of National Patient Safety Goals include a new Requirement to take specific actions to reduce the risks of patient harm associated with the use of anticoagulant therapy, and a new Goal and Requirement that address the recognition of, and response to unexpected deterioration in a patient’s condition. The new anticoagulant therapy Requirement addresses a widely-acknowledged patient safety problem and becomes a key element of the Goal: Improve the safety of using medications. It is applicable to hospitals, critical access hospitals, ambulatory care and office-based surgery settings, and home care and long term care organizations. The new Goal and Requirement respecting the deteriorating patient will ask hospitals and critical access hospitals to select a suitable method for enabling care-givers to directly request and obtain assistance from a specially-trained individual(s) if and when a patient’s condition worsens. Each of the foregoing new Requirements has a one-year phase-in period that includes defined milestones. Full implementation is targeted for January 2009.

Click here to read the press release; click here to access the 2008 National Patient Safety Goals.

A squirt of hope

Why should we care about the environment and all those species of flora and fauna upon the earth? Well, one reason is that one of them might save your life someday. From a science blog:

A toxin derived from a humble sea squirt, Ecteinascidia turbinata (pictured, right), shows great promise as an anti-cancer drug. This toxin, known as trabectedin (ecteinascidinin-743), shrinks and even completely removes cancerous tumors in more than half of the patients treated with it, according to a new study. The patients treated with this drug suffered from a specific type of liposarcoma cancer, which is associated with chromosomal mutations. Liposarcomas are a rare but malignant tumor that grow in the fat cells in deep soft tissue, such as inside the thigh or within the abdominal cavity.

Dr Federica Grosso, from the Sarcoma Unit of the Instituto Nazionale Tumori in Milan, Italy, and her colleagues from sarcoma centers in Boston, London, Lyon and Paris, conducted this study. Out of 51 patients with myxoid liposarcomas that were treated only with trabectedin, they found that two had their tumors disappear completely (complete response) while another 24 experienced at least a 30% shrinkage of their tumor (partial response), representing an overall response rate of 51%.

Click here to read the blog entry. This study will be published in the July issue of The Lancet Oncology.

Six innovations

Check out Doctor Richard L. Reece's essay "Six Innovations to Increase Productivity, Cut Costs and Extend Coverage." Briefly, they are:

1. Facilitating patient-physician information exchange as a key of productivity.
2. Introducing new, more focused and more productive medical specialties.
3. Lessons from retailers: Hidden in plain sight and DIG (Demand-First Innovation and Growth).
4. Demand for transparency with bundled services and bundled billing arrangements.
5. Chief innovation officers will become common.
6. Tax deductible insurance for everyone to extend coverage--with strings attached.

Click here to read more about these innovations; I especially like the Chief Innovation Officer concept (CIO has a nice ring to it).
:)

AHRQ State Snapshots

From the AHRQ website:

The State Snapshots provide State-specific health care quality information including strengths, weaknesses, and opportunities for improvement. The goal is to help State officials and their public- and private-sector partners better understand health care quality and disparities in their State.

State-level information used to create the State Snapshots is based on data collected for the National Healthcare Quality Report (NHQR).

Pretty interesting stuff! Look up your state and see how it's doing. Thanks to the SACME listserve for this information. Click here to access State Snapshots.

ACGME work rules

Yale-New Haven Hospital researchers studied the impact of the new work rules on length of stay, 30-day readmission rates and medication errors at their hospital. What did they find? An excerpt from the New York Times article:

The teaching services saw a decrease in transfers to the intensive care unit, a decrease in medication errors and an increase in discharges to home or rehabilitation. After adjusting for other variables, there was also a significant decrease in deaths. While drug interaction errors increased, they also increased on the nonteaching service, probably because of the addition of new interaction rules to the database.

Click here to read the NYT article. Click here to access the Annals of Internal Medicine abstract.

$1.3 TRILLION in pharma sales?

That's what PricewaterhouseCoopers predicts in worldwide prescription drug sales by the year 2020. But it looks like Big Pharma might need to change how they do business. From the San Francisco Chronicle article:

Pharmaceutical giants that stick with that blockbuster model will be edged out by nimble, innovative companies that tailor their drugs to specific patient populations and advance the standard of care, the report says.

If the current global drug market of $520 billion more than doubles by 2020, the rise will not necessarily make health costs unaffordable, Farino said. New drugs could be cost-effective if they work better, help patients avoid more expensive treatments or hospitalization, and save health insurance payers money in the long term, Farino said.

In the United States, prescription products accounted for 10.1 percent of the nearly $2 trillion spent on health care in 2005. Hospital spending claimed 33 percent of all expenditures, according to government figures cited by PricewaterhouseCoopers.

Do your CME activities routinely address pharmacoeconomics? Click here to read the entire article.

Army Medical Action Plan

From the U.S. Army's press release:

"As we've said before, the Army takes Soldier inpatient and outpatient care very seriously," said Army Chief of Staff Gen. George W. Casey Jr., "and remains firmly committed to returning our Soldiers to productive careers and lives. We have made improvements, but realize there is still work to be done - including work with the complex Medical Evaluation Board and Physical Evaluation Board processes. By no means is everything 'fixed' - but we are aggressively acting on what we can fix now."

Click here to access the press release (ten examples of immediate improvements are delineated).

Batter up?

The folks over the Commonwealth Fund have published a report on states relative to their health system performance ("access, quality, avoidable hospital use and costs, equity, and healthy lives"). From the Executive Summary of The State Scorecard:

The rich geographical diversity of the United States is part of its appeal. The diverse performance of the health care system across the U.S., however, is not. People in the United States, regardless of where they live, deserve the best of American health care. The State Scorecard is intended to assist states in identifying opportunities to better meet their residents current and future health needs and enable them to live long and healthy lives. With rising health costs squeezing the budgets of businesses, families, and public programs, there is a pressing need to improve performance and reap greater value from the health system.

The State Scorecard offers a framework through which policymakers and other stakeholders can gauge efforts to ensure affordable access to high quality, efficient, and equitable care. With a goal of focusing on opportunities to improve, the analysis assesses performance relative to what is achievable, based on benchmarks drawn from the range of state health system performance.

Click here to access the report.

Black and white?

Startling statistics from a study just published in JAMA; an excerpt from the www.cnn.com article:

Black people were 22 percent less likely to be transferred from a hospital that did not do such procedures to one that did, it found. And when they were, black people were 23 percent less likely to get these operations than white people, the researchers said.

In the first month after a heart attack, black people were 9 percent less likely to die than white people, the researchers said, perhaps because whites were more likely to undergo specialized procedures that sometimes can be fatal.

But in the period from a month to a year after the heart attack, blacks were up to 26 percent more likely to die than whites, the study found.

"I wished we knew what's going on," lead researcher Dr. Ioana Popescu of the University of Iowa Carver College of Medicine and the VA Medical Center in Iowa City said in a telephone interview.

The study was not designed to find the reasons for the disparities.

Click here to access the article.

The Carlat Report

Daniel Carlat, a professor at Tufts Medical School and the editor in chief of The Carlat Psychiatry Report sounds off in the New York Times:

The revelation that the diabetes drug Avandia can potentially cause heart disease is the latest in a string of pharmaceutical disappointments. Vioxx was pulled from the market in 2004 because it doubled the risks for heart attacks and strokes. Eli Lilly recently paid $750 million to settle lawsuits alleging that Zyprexa causes diabetes. Many have criticized the Food and Drug Administration as being too lax about monitoring drug safety.

While those criticisms have merit, there is another culprit: the transformation of continuing medical education into an enterprise for drug marketing. The chore of teaching doctors how to practice medicine has been handed to the pharmaceutical industry. As a result, dangerous side effects are rarely on the curriculum.

Always important to know what is being published in the lay press. Click here to access the article.

A new villain in healthcare?

The Pacific Research Institute (PRI), a think tank in San Francisco, conducted a study on health care regulation. An excerpt from the San Francisco Examiner article:

In other PRI examples: A group of surgeons is ready to invest in a clinic where they will perform only operations they specialize in, but the local acute-care hospital invokes state regulations blocking the competition. A privately insured individual wants to buy a low-premium catastrophic coverage policy while also starting a tax-exempt health savings account, but this option is unavailable under state insurance rules.

Click here to access the article.

Cap malpractice lawsuit awards and they will come

According to an article in the San Antonio Express-News, physicians are flocking to Texas:

The lower cost of being a doctor in Texas has helped trigger a stampede of applications for physician licenses, with the waiting line now up to 12 months.

Rates have fallen an average of 21.3 percent, and up to 41 percent at one insurance company, says former state Rep. Joe Nixon, a Houston trial lawyer who helped sponsor passage of Proposition 12.

An internal medicine doctor in Houston paid $18,507 for malpractice insurance in 2003 but only $13,272 in 2007, or $10,403 with a 20 percent renewal dividend, according to figures given to Nixon by the state's largest insurer, Texas Medical Liability Trust.

Apparently insurance companies are also moving to Texas since they can now "...put a numeric value on the risk of doing business in Texas, something that was not possible when the sky was the limit for juries." Click here to read this article.

New Chief Learning Officer at the American College of Cardiology

Congratulations to Joe Green, my mentor and colleague!! From the American College of Cardiology's website:

The ACC has selected Joseph S. Green, Ph.D., to serve as its chief learning officer. As the ACC’s newest vice president, Dr. Green will be responsible for shaping the College’s continuing medical education (CME) curriculum and directing the implementation of the ACC’s educational mission. Dr. Green was most recently founder and president of Professional Resource Network, Inc., a CME consulting firm. He has over 34 years of experience in medical education. He served as the associate dean of CME and associate clinical professor in the Duke University School of Medicine, and he was director of CME and vice president of educational affairs for Sharp HealthCare, an integrated health care system in San Diego. Dr. Green will begin his tenure at the ACC on Sept. 17.

"Just living is not enough... One must have sunshine, freedom, and a little flower."

So said Hans Christian Anderson. Click here to see some lovely photographs (I have no financial interest in these products and do not know this photographer, just sharing).

Health Care Report Card Compendium

From the press release:

With rising interest in information about the quality of care delivered by health care providers, HHS' Agency for Healthcare Research and Quality has developed a new Web tool demonstrating a variety of approaches for health quality report cards.

The new Health Care Report Card Compendium is a searchable directory of over 200 samples of report cards produced by a variety of organizations. The samples show formats and approaches for providing comparative information on the quality of health plans, hospitals, medical groups, individual physicians, nursing homes, and other providers of care. The Health Care Report Card Compendium can be found at http://www.talkingquality.gov/compendium/.

"Consumers and providers alike need better information if we're to get the highest quality and value from our health care system," said HHS Secretary Mike Leavitt. "We're still learning how to gather and present that information in the best ways, and we can learn from one another. The new AHRQ Web site will help with that learning."

Click here to access the press release.

DTC advertising

Check out the latest issue of the New England Journal of Medicine for the free full-text article "Drug Risks and Free Speech — Can Congress Ban Consumer Drug Ads?" From the article:

Spending on direct-to-consumer advertising increased by 296.4% from 1997 to 2005, during which time spending on promotion to physicians increased by 86.0% and spending on pharmaceutical research and development increased by 103.3%. Data are from the Government Accountability Office (report no. GAO-07-54, December 14, 2006).

Click here to read the article (registration required).

"Musings of a Dinosaur"

I came across this entertaining blog written by a family physician in solo practice ("dinosaur")! An excerpt from the physician's "Laws of the Dinosaur":

First Law: The Art of Medicine consists of amusing the patient while nature takes its course.

Second Law: It is impossible to make an asymptomatic patient feel better.

Third Law: The urgency of the test is inversely proportional to the IQ of the insurance company preauthorization clerk.

Fourth Law: No good deed goes unpunished.

I especially like the 12th Law:

Twelfth Law: A bad idea held by many people for a long time is still a bad idea.

Click here to access this blog.

Continuing Education Alliance Wins Award from California Medical Association

From the press release:

After only three years as a continuing medical educational (CME) non-profit, Continuing Education Alliance has received the California Medical Association’s first Cultural and Linguistic Competency Award for Excellence in a CME Activity. The award was presented at the annual CME provider conference in San Francisco on Friday, May 11, attended by over 260 accredited providers from throughout California.
Continuing Education Alliance received this award for the original concept and development of a CME activity, “Cross Cultural Considerations at End of Life” presented by Dr. Stephen Oppenheim, medical director of San Diego Hospice. This CME is an interactive discussion of multiple case studies showing effective end-of-life treatment, pain management, and communication strategies for patients of diverse religious, linguistic and/or cultural backgrounds.

Following the initial presentation of this activity at Continuing Education Alliance’s monthly meeting in September 2006, the course was offered to area hospitals. Two hospitals in San Diego, Scripps Memorial Hospital La Jolla and Sharp Grossmont Hospital, presented this activity to their staff physicians in 2006 and other hospitals in San Diego have asked for more information about including “Cross Cultural Considerations in End of Life Care” in their 2007 schedule.

Kudos to CEA! Jenell Hollett, President of CEA, is a collaborator extraordinaire; CME Providers interested in learning more about this CME activity or CEA can contact her at:

Continuing Education Alliance
4403 Manchester Ave, Ste 103
Encinitas CA 92024
Telephone# 760.633.4160

Disclosure: I have provided consulting services to CEA on accreditation issues.

Malpractice insurance price gouging?

According to a new report issued by the American Association for Justice the answer is "yes": from the press release:

Written by former Missouri Insurance Commissioner Jay Angoff, the study is based on recent annual reports from the top 15 medical malpractice insurers as rated by A.M. Best. The report shows that these insurers artificially raised doctors’ premiums and misled the public about the nature of malpractice claims – asserting that a so-called “malpractice crisis” exists. The report puts the lie to that claim.

According to the study:

The medical malpractice insurers saw losses and projected losses plummet by 48% over the period 2003-2006.
These incurred losses have declined every year for the past five years. These insurers’ 2006 surplus is 43% greater than their surplus in 2003 – five times the state-minimum surplus for insurer stability.
Only three of the 15 leading insurers issued dividends to doctors in 2006.

“Medical malpractice insurance companies have been price-gouging doctors, padding their pockets with excessive premiums and driving up the cost of healthcare,” said Jon Haber, AAJ Chief Executive Officer. “Cynically, these same insurance companies have been blaming high premiums on a so-called ‘malpractice crisis’ that doesn’t exist. We have an insurance crisis, not a medical malpractice crisis.”

Click here to read the entire press release. Click here to access the AAJ report (that graph on page 3 says it all).

hospitalcompare.hhs.gov

As reported in the USA Today article, beginning in June, "the Centers for Medicare and Medicaid Services (CMS) plans to post the first broad comparison of the death rates for heart attack and heart failure on its website, Hospital Compare." From the article:

The federal initiative marks a bold departure for an agency that has long been the repository of private information on Medicare patients. More than a dozen top hospitals provided USA TODAY with an exclusive look at the government's initiative by sharing their confidential Medicare death-rate report cards. The reports are drawn from death rates of heart attack and heart failure patients who died between July 2005 and June 2006, of any cause, within a month of entering the hospital.

The analysis reveals just 17 of 4,477 hospitals had heart attack death rates that were better than the national rate. Thirty-eight of 4,804 hospitals had heart failure death rates that were better than the national rate.

There was cause for alarm, too. The analysis reveals 42 hospitals where patients are more likely to die from heart attacks and heart failure than patients who go elsewhere, including at least one whose 24% heart attack death rate topped the national rate by nearly 10 percentage points.

Click here to read the entire article.

Data sources on health facts

Ever wonder how many U.S. states have firearm laws designed to protect children? Then check out statehealthfacts.org.

Did you know that, globally, in 2005 there were 8,810,805 new cases of TB? Do you know which three countries led the world in new cases of TB? Check out globalhealthfacts.org.

AMA Therapeutic Insights released (eCME activity)

From the PRNewswire press release:

The AMA is collaborating with recognized disease experts, national data providers and medical specialty groups to incorporate unique drug therapy information, disease prevalence and practice guidelines into an educational delivery format. The prescribing data included in AMA Therapeutic Insights are provided by IMS Health. The data are fully compliant with federal privacy standards and do not contain any patient identifiable information.

Physicians interested in continuing medical education can access AMA Therapeutic Insights to earn AMA PRA Category 1 Credit(TM) that can be applied toward the Physician Recognition Award (PRA).

Click here to read the press release. Click here to access AMA Therapeutic Insights.

Loose lips...

From the theheart.org article:

The American College of Cardiology (ACC) is formally penalizing Dr Martin Leon (Columbia University, New York, NY) for remarks about the COURAGE trial, made openly at an industry-sponsored symposium, that the organization says were in violation of an embargo on public disclosure of the trial's outcomes. The sanctions will include public censure and restrictions on his participation in the group's scientific sessions next year, the ACC announced today.

Click here to read the entire article (registration required).

The Nissen "Net" that caught Avandia

That'd be Cleveland Clinic's cardiology chief, Dr. Steven Nissen, who is also the immediate past president of the American College of Cardiology. From the Houston Chronicle article:

...review of dozens of studies showed the drug, taken by millions of diabetics, significantly raises the risk of heart attack. Six days later, he submitted the paper to the New England Journal of Medicine, which moved "at lightning speed" to get it out on Monday.

"I felt I had an ethical and a moral obligation to work as fast as I could," Nissen said.

He previously warned of heart risks from the painkiller Vioxx, which was pulled off the market in 2004, and three other drugs that nearly won approval: the diabetes drug Pargluva, the anticoagulant Exanta and the blood pressure drug Vanlev. He was the only FDA adviser to vote against Natrecor, a heart failure drug that some research has tied to a risk of death.

"I didn't really ask for this role," Nissen said. "I would rather spend my time doing studies that develop medications. But what happened was the FDA seems to have lost its way, and seems to be incapable of monitoring drug safety adequately. So it's fallen upon individuals to do independent analyses. I would love for that to change."

Click here to read the entire article.

Let's all take a deep breath...

From the Wall Street Journal article on Avandia "What Diabetes Patients Need to Know":

In a joint statement, the American Heart Association, American College of Cardiology and American Diabetes Association said the study "deserves serious thought and follow up" though the overall level of risk associated with the drug "appears to be small." The groups said patients should not stop taking any prescribed drugs without talking with their health-care providers.

Dr. Kirkman of the American Diabetes Association noted that diabetics are at a high risk for cardiovascular problems. However, she said, "We don't feel that this is an emergency or a panic situation, and we certainly don't advise that people go off medication without talking to their health-care provider about alternatives," she says.

Richard Hellman, president of the American Association of Clinical Endocrinologists, said Dr. Nissen's study raises the possibility that certain patients, such as those who have heart disease, may be at especially high risk. He said, the association isn't recommending that doctors stop prescribing Avandia altogether.

Click here to access the WSJ article (subscription required).

Too much, too soon?

Looks like states are backing away from making the cervical cancer vaccination mandatory. From the courant.com article:

Combine national wariness with a vaccine that costs more than any other in U.S. history; skimpy or non-existent insurance payments to doctors; and concern from social conservatives that a vaccine to prevent a sexually transmitted disease might promote promiscuity, and efforts to mandate the HPV vaccine ended up on the legislative back burner.

On top of all that, while cervical cancer remains a serious disease, it is not a public health crisis in the United States.

However, the article makes an important point:

Last week, a newly published study linked the HPV virus to certain types of throat cancer among people infected through oral sex. The incidence of oral cancer has not dropped in the United States, despite a decline in the major risk factor, smoking, leading researchers to suspect that HPV might be a culprit.

Given the reported popularity of oral sex among teens (Centers for Disease Control), there may be a public health crisis brewing; I offer that research on the etiology of these types of throat cancer is needed quickly. Click here to read the courant.com article.

Good health for SiCKO?

Michael Moore's new film, SiCKO, was shown at the Cannes Film Festival over the weekend; from a review:

Pic's tone alternates between comedy, poignancy and outrage as it compares the U.S system of care to other countries. Given Moore's celebrity and fan base, plus heightened awareness of the pic resulting from the heated battle that's already begun between left and right, returns look to be extremely healthy.

Pic should also play well internationally, providing an eye-opening lesson for foreigners who may be inclined (like Moore's Canadian cousins) to take out insurance from their homeland before visiting the States.

Chief criticism of the film is that it paints too rosy a picture of the national health care of the countries he compares America to, including Canada, England, France -- and Cuba.

Click here to read the entire review.

Another reasonable voice

Scott Lassman, senior assistant general counsel for the Pharmaceutical Research and Manufacturers of America, sounded off in the Boston Globe this past Friday:

The information exchange also goes both ways. Doctors learn firsthand the trends in medicine safety before anyone else in the medical community. It's the kind of experiential knowledge that can't be taught in the university or even learned in a lab, and they share their experiences with a given medicine with these representatives.

This debate is really about trust. The industry values the relationship its representatives have built with the nation's healthcare professionals, and it is critical to the mission of helping patients that these interactions be maintained at the highest ethical standards. Just as patients trust their physician, it is equally important that physicians trust their pharmaceutical representatives.

Click here to read the entire article.

A reasonable voice

This essay didn't make it into one of the big newspapers; however, it deserves a wider forum, from the Daily News Tribune:

Current medical journals and the popular press carry numerous articles about the relationships between the drug manufacturing industry and physicians. Newspapers and computer screens roar with disturbing headlines: ``Doctors reap millions for anemia drugs;'' ``Pills for Patients, Payday for Docs;'' ``Posing as pals, drug reps sway doctors' choices.''

The perception of physicians created by these stories raises many questions. It often appears that physicians and pharmaceutical companies are engaged in an unholy alliance where greed and money rule. Some reports would have you believe most doctors are checking patients with one hand and looking for a hand-out with the other.

It's true some physicians (as well as drug company representatives) may lose their ethical compass from time to time. Thankfully, the overwhelming percentage of my profession is populated with good, honest, decent and wonderfully caring people.

Click here to read this essay written by Leonard J. Morse, M.D.

Advances in medical technology

On the theme of new medical technology and its associated monetary costs, here are a couple of other news items y'all might want to check out:

The Baltimore Sun article "Medical Scans Zapping Insurers":

The upshot: Imaging has nudged out drugs as the fastest growing component of rising medical costs, increasing as much as 20 percent a year.

The overall cost of diagnostic imaging is estimated at well over $100 billion annually in the United States. That's about a nickel of each health spending dollar.

That's gotten the attention of insurers, who have put up more hurdles and imposed more controls, creating hassles for doctors and patients alike. Sometimes they refuse to pay at all.

The courant.com article "Doctors Balk At Small Fee For Injecting Costly Vaccine":

Doctors report a brisk demand for the vaccine, which blocks strains of the ubiquitous human papillomavirus (HPV) that cause 70 percent of cervical cancers.

But some doctors, especially pediatricians and gynecologists, who are most likely to be asked for the vaccine, are refusing to buy it or restricting who receives the shots.

Discontent over the price of the vaccine - the most expensive ever - highlights a long-simmering dispute over reimbursement for immunizations, traditionally regarded as bedrock medicine. It is a dispute, experts say, with significant public health implications that has accelerated as the number of costly new vaccines has proliferated.

No doctor in the OR!

From the Tennessean.com article:

Imagine going to the hospital for surgery, but there's no doctor in the operating room.

Instead, there's a robot, controlled by a doctor in some other city.

The breakthrough that makes that possible is among the technology on display at the 12th annual meeting of the American Telemedicine Association. The meet, which began Sunday, ends today at the Gaylord Opryland Resort & Convention Center.

The event drew about 120 exhibitors, including the makers of a robot that lets doctors interact with patients from miles away, and of machines that can be used to check on patients in their homes and record their blood pressure and other vital signs.

The article points out that insurance (lack of reimbursement) can be a barrier to telemedicine. Click here to read the entire article.

"Engaging" sales reps result in more scripts

From the PRNewswire press release:

The puzzle of why physicians make different prescribing decisions is a complex one. Many companies invest solely in research that assesses sales representative performance from the physician perspective. Such research often examines only the functional aspects of the detail process. PeopleMetrics research finds that the engagement level of the representative and their passion for the company is an overlooked but critical piece to this puzzle. Pharmaceutical companies that measure and improve sales representative engagement thereby position their sales force to build stronger relationships with physicians.

Gosh, what a surprise! Click here to read the entire press release.

Walkin' and workin'...

This is so cool! A physician at the Mayo Clinic just finished a small study (n=15) in which obese folks worked on a special computer-treadmill station:

Levine didn't measure actual weight loss. This is a theoretical study, but he calculates that burning an extra 100 or more calories an hour for two or three hours each working day would cause many obese people to lose between 20 and 30 kilograms a year.

The "walk and work" device is no ordinary treadmill.

It's built on a steel frame with four wheels, so that workers can steer it around the office.

There's room for a computer, books, pens, a phone, a flower vase, coffee cup and paper tray. The whole thing slides over a standard treadmill, or slides away when the user wants to stand on a solid floor.

It can also slide over to a chair so that the user doesn't have to stand for the entire day. Mr. Levine says it costs about $1,600 US, not including the treadmill - a bargain, he suggests, since obesity costs the U.S. $100-billion to $200-billion a year in health costs and lost productivity.

Click here to read the entire article.

Dietary supplements...what residents don't know

Interesting study just published in the Archives of Internal Medicine on physician knowledge of dietary supplements and FDA regulation (or lack thereof):

Baseline knowledge of dietary supplement regulatory issues was poor. The total average pretest score was only 59% (986/1675). The average score rose to 91% (1526/1675) after completion of the curriculum (P<.001). With regard to specific content areas, about one third of physicians were unaware that dietary supplements did not require FDA approval or submission of safety and efficacy data before being marketed. Similar percentages believed that there are regulations in place to ensure supplement quality. Most physicians were unaware that serious adverse events due to the use of supplements should be reported through the FDA MedWatch system.

Click here to access the abstract.

New TIA diagnostic protocol

From the ACEP News Release:

A new emergency department diagnostic protocol shows potential for saving money and time, as well as for dramatically reducing the number of hospital admissions for patients diagnosed with transient ischemic attack (TIA), or stroke. The study appears online in the Annals of Emergency Medicine ("An emergency department diagnostic protocol for patients with transient ischemic attack: a randomized controlled trial").

"Because TIAs tend to be so predictive of future, more serious strokes, many within a couple of days, emergency physicians hospitalize most TIA patients," said lead study author Michael A. Ross, MD, of William Beaumont Hospital in Royal Oak, Michigan. "By managing TIA patients using an accelerated diagnostic protocol in the emergency department, we were able to cut most patients' length of stays and costs in half without compromising their 90-day clinical outcomes. Besides freeing up inpatient beds, this should lead to greater patient satisfaction."

Click here to read the entire news release.

Atypical psychiatrists?

From the New York Times article:

The psychiatrist receiving the most from drug companies was Dr. Annette M. Smick, who lives outside Rochester, Minn., and was paid more than $689,000 by drug makers from 1998 to 2004. At one point Dr. Smick was doing so many sponsored talks that “it was hard for me to find time to see patients in my clinical practice,” she said.

Dr. Steven S. Sharfstein, immediate past president of the American Psychiatric Association, said psychiatrists have become too cozy with drug makers. One example of this, he said, involves Lexapro, made by Forest Laboratories, which is now the most widely used antidepressant in the country even though there are cheaper alternatives, including generic versions of Prozac.

Click here to read the entire article.

Purdue pain

From the New York Times article:

The company that makes the narcotic painkiller OxyContin and three current and former executives pleaded guilty today in federal court here to criminal charges that they misled regulators, doctors and patients about the drug’s risk of addiction and its potential to be abused.

To resolve criminal and civil charges related to the drug’s “misbranding”, the parent of Purdue Pharma, the company that markets OxyContin, agreed to pay more than $600 million in fines. That is the third-highest amount ever paid by a drug company in such a case.

Also, in a rare move, three executives of Purdue Pharma, including its president and it top lawyer, pleaded guilty today as individuals to misbranding charges, a criminal violation. They agreed to pay a total of $34.5 million in fines.

Click here to read the entire article.

More on anemia drugs

From the Wall Street Journal:

A Food and Drug Administration advisory committee said that cancer patients' use of popular anemia drugs made by Amgen Inc. and Johnson & Johnson should be limited further, and the companies should be required to complete studies to answer lingering safety questions.

The votes were a blow to the class of medications that the FDA calls erythropoiesis-stimulating agents, sometimes known as ESAs or EPO drugs, which are sold as Epogen and Aranesp by Amgen and Procrit by J&J. The medications are prescribed for anemia, which is a deficiency of red blood cells that can occur as a side effect of cancer chemotherapy and kidney disease.

Click here to read the WSJ article (subscription required).

Earlier in the week, the New York Times published an article on rebates to oncologists on these anemia drugs:

Two of the world’s largest drug companies are paying hundreds of millions of dollars to doctors every year in return for giving their patients anemia medicines, which regulators now say may be unsafe at commonly used doses.

The payments are legal, but very few people outside of the doctors who receive them are aware of their size. Critics, including prominent cancer and kidney doctors, say the payments give physicians an incentive to prescribe the medicines at levels that might increase patients’ risks of heart attacks or strokes.
...
Federal laws bar drug companies from paying doctors to prescribe medicines that are given in pill form and purchased by patients from pharmacies. But companies can rebate part of the price that doctors pay for drugs, like the anemia medicines, which they dispense in their offices as part of treatment.

Click here to read the NYT article.

Gender gap in health care

Make a note, ladies, now we not only make less than men for doing the same job but we don't receive the same level of health care. That's the finding according to a study done by the Health and Human Services' Agency for Healthcare Research and Quality (using 2004 data). From the United Press International article:

Women were 47 percent more likely than men to be hospitalized for high blood pressure, an event that can usually be avoided with good primary care, the study said, and 50 percent of women receive recommended colorectal cancer screening, compared to 54 percent of men.

Click here to read this short article (and don't be shocked by that photo of Imus; methinks someone has a sense of humor).

More power to the FDA?

If the bill reauthorizing FDA user fees passes Congress, as expected, then it most likely will bring "sidecar" regulations for Pharma. From the Wall Street Journal:

If it becomes law, the Senate bill, called the Food and Drug Administration Revitalization Act, could shift the balance of power between regulators and the pharmaceutical industry. It requires the FDA to monitor drugs after they go on the market and provides new funding for that job. The bill would also require companies to make public the results from many of their studies.

The measure would grant the FDA authority to take major actions, including requiring new studies, limiting distribution or ordering label changes if the agency thought they were necessary. Currently, the FDA's authority in that area isn't clearly delineated, so the agency often has to negotiate with companies, using its leverage before it grants approval for a new drug or the indirect threat of its bully-pulpit power to get the concessions it seeks.

Click here to access the article (subscription required).

"150 consecutive daily entries on innovation"

Be certain to check out Doctor Reece's blog on medical innovations! Wednesday, May 9, 2007 marks 150 entries -- maybe you will read something you will want to put into practice. Click here to access his blog.

Influenza-Associated Pediatric Mortality and the Increase of Staphylococcus aureus co-infection

Click here to read this CDC Health Advisory.

Just say "no" to cancer prevention?

I have to admit that when I think of the issue of HPV vaccination from a public health perspective, it's a slam dunk! However, if I had a young daughter, would I race her into the doctor's office to be vaccinated? Professor R. Alta Charo discusses the issues surrounding HPV vaccination in the latest issue of the New England Journal of Medicine:

Cancer prevention has fallen victim to the culture wars. Throughout the United States, state legislatures are scrambling to respond to the availability of Merck's human papillomavirus (HPV) vaccine, Gardasil, and to the likely introduction of GlaxoSmithKline's not-yet-approved HPV vaccine, Cervarix, which have been shown to be effective in preventing infection with HPV strains that cause about 70% of cases of cervical cancer. At the Centers for Disease Control and Prevention (CDC), the Advisory Committee on Immunization Practices (ACIP) has voted unanimously to recommend that girls 11 and 12 years of age receive the vaccine, and the CDC has added Gardasil to its Vaccines for Children Program, which provides free immunizations to impoverished or underserved children.

Yet despite this federal imprimatur, access to these vaccines has already become more a political than a public health question. Though the more important focus might be on the high cost of the vaccines — a cost that poses a genuine obstacle to patients, physicians, and insurers — concern has focused instead on a purported interference in family life and sexual mores.

Click here to read the entire full free-text article (registration required).

The hip joint's connected to the pocketbook?

From The Star Ledger article:

For two years, federal prosecutors in New Jersey have been building a case that the nation's largest makers of artificial hips and knees defrauded the government and taxpayers by paying surgeons to use and promote their products, according to sources close to the probe.

The evidence includes statements from prominent doctors around the country who allegedly accepted lavish vacations, gifts and "consulting fees" as high as $200,000 a year from the implant makers for little or no work, said four attorneys who have been briefed on aspects of the case.

There is no allegation that the practice jeopardized patients or subjected them to substandard products or treatment. But the sources say prosecutors contend that the money had a sole purpose -- to buy surgeons' loyalty to specific products -- and that doctors often failed to reveal such a conflict to their patients. If true, such payments would violate the federal anti-kickback statutes that govern hospitals and health professionals who participate in Medicare.

Click here to read the entire article.

Chronic Obstructive Pulmonary Disease

From the Wall Street Journal article:

Former smokers may believe they are out of the woods because they quit, but nearly half of COPD patients are former smokers rather than current smokers, according to Amy Pianalto, project director of the NHBLI's "Learn More, Breathe Better" awareness campaign (www.learnaboutCOPD.org), which is sponsoring radio and print ads and offers materials for both doctors and patients.

Second-hand smoke, air pollution and workplace exposure to pollutants like chemicals, dust and fumes can also trigger the disease. An estimated 100,000 Americans also have a genetic disorder known as alpha-1 antitrypsin, or AAT, deficiency that makes them susceptible even without any kind of exposure.

"There are 12 million people in this country who are coughing and can't breathe who don't know they have COPD," says Molly McGuire, administrator of the nonprofit COPD Foundation (COPDFoundation.org). "It has been a slow process getting everyone connected to resources."

Click here to read the article (subscription required). Speaker resources on this topic are available here.

ACCME post re: Senate Finance Committee letter

From the ACCME's website:

The Senate Committee on Finance has provided the ACCME and the CME system with many face- and content-valid observations where enhancements could be implemented that would make the independence of CME from commercial interests more distinct. Since the development of the first version of the ACCME Standards for Commercial Support in the late 1980s, the ACCME has taken seriously its roles and responsibilities to set expectations about this independence of CME and to measure CME providers’ compliance with those expectations, especially in the presence of funds from commercial interests.

In this same spirit, the ACCME will reflect on the Senate Committee on Finance’s observations. The timing and process for this consideration matches well with the ACCME’s current process of review and assessment of the implementation of the 2004 ACCME Standards for Commercial Support: Standards to Ensure Independence. As these updated Standards are now in place across the CME system, the ACCME looks forward to determining where and how improvements to the accreditation policies and processes might strengthen the validity and independence of CME.

Click here to access.

FDA Proposes New Warnings About Suicidal Thinking, Behavior in Young Adults Who Take Antidepressant Medications

Click here to read the FDA's statement.

Lilly lifting the veil

Eli Lilly & Co. announced that it will be publicly disclosing which organizations receive grant funding from the company. From the Wall Street Journal article:

Lilly's decision to disclose its grants was prompted in part by an investigation into drug company donations by the Senate Finance Committee. The committee's report last week said while there is separation between grants and sales and marketing, potential for abuse remains. Some Eli Lilly executives had worried revealing the company's grants could expose recipients to criticism and bring more scrutiny. But ultimately, Lilly decided to disclose the details after an internal analysis showed the marketing department wasn't influencing the grant office's decisions, says Michael Bigelow, Lilly's assistant general counsel. Lilly shouldn't have to feel "apologetic" about the grants, he adds.

Click here to read the article (subscription required).

Fasten your seatbelts

The Senate Finance Committe just sent a letter to the ACCME urging "greater oversight by the council" per the press release. An excerpt from the letter:

Based on our analysis of the information you provided, we find it interesting that, even though ACCME's reaccreditation process relies almost exclusively on information supplied by the CME providers under review, ACCME still detects a significant number of incidences of noncompliance. It also appears that compliance with ACCME standards still allows CME providers to accommodate the business interests of their commercial sponsors and affords drug companies the ability to target their grant funding at programs likely to support sales of their products. The full extent to which drug companies influence the content of putatively independent CME programs cannot be estimated from the information we currently have.

Click here to read the press release and letter. And don't forget to participate in the Medical Meetings magazine survey on this topic -- click here to access.

Free prescription drug samples - good idea or bad idea?

From today's New York Times article:

The crackdown on free samples comes amid growing concern about the close ties between physicians and drug companies. Critics like Dr. Rothman say physicians don’t realize the extent to which their medical judgment is influenced by their acceptance of the samples. They point to studies like a 2002 paper in the journal Annals of Family Medicine finding that the number of doctors who treated high blood pressure with the “first line” drugs recommended by national guidelines was low, but increased sharply when free samples were removed.

So far, the University of Michigan Health System has banned free samples altogether, and the University of Pennsylvania and Stanford University medical schools have prohibited staff members from accepting them (though samples can be given to Stanford’s pharmacy for use in free clinics).
...
But there’s an upside to the samples. Using samples, a doctor can see if a patient can tolerate a new medication before the patient goes out and buys a 30-day supply. Physicians who treat poor people like to have samples on hand for them, and for uninsured patients.

Click here to read the entire article.

NH prescription data law interrupted...

A U.S. District Court judge on Monday overturned a New Hampshire law that was the first in the nation to ban the commercial use of information on what drugs physicians prescribe.

Judge Paul Barbadoro of the U.S. District Court in Concord ruled in favor of IMS Health Inc. (RX.N: Quote, Profile, Research and Verispan, two companies that collect prescription data from pharmacies and sell it to drug makers, researchers and investment firms.

Click here to read the Reuters news article.