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Cardiac medication errors common after hospitalization
SAN FRANCISCO – Clinically important medication errors occurred in 51% of patients within 3 months of discharge from hospitalization for acute coronary syndrome and/or decompensated heart failure, a study of 851 patients showed.
In addition, the randomized controlled trial found no benefit from a predischarge pharmacist intervention and counseling incorporating tools designed for patients with low health literacy levels, compared with usual care in which the treating health care provider reconciled medications with the help of support software before patient discharge.
Although the trial focused on comparing the pharmacist intervention with usual care, "the biggest take-home message is that medication errors are very common" in these patients after hospitalization, Dr. Cecelia N. Theobald said at the annual meeting of the American College of Physicians.
Patients came from Vanderbilt University Medical Center in Nashville, Tenn., and from Brigham and Women’s Hospital in Boston. The study randomized 423 patients to the intervention and 428 to usual care.
In the intervention group, pharmacists reconciled medications and provided in-depth patient counseling before discharge, including a review of potential drug side effects. The pharmacists had specialized aids to help low-literacy patients adhere to their medication regimens, and they provided tailored follow-up to patients via postdischarge phone calls. In the usual-care group, the treating provider reconciled medications and pharmacist consultation was available on request. The usual-care group did not use the low-literacy aids or phone follow-up.
To assess outcomes, two clinicians reviewed patient records and patients were interviewed by phone 30 days after discharge.
Thirty percent of patients had one or more adverse drug events that were considered to be preventable or ameliorable. Another 30% of patients had at least one potential adverse drug event, she said. Adverse drug events occurred in 47% of patients on cardiovascular agents other than diuretics, 21% of patients on diuretics, and 5% of patients on opioids. Potential adverse drug events were seen in 43% of patients on cardiovascular agents other than diuretics, and in 12% of patients on diuretics (Ann. Intern. Med. 2012;157:1-10).
On a per-patient basis, 0.87 clinically important medication errors occurred in the intervention group, compared with 0.95 events per patient in the usual-care group, a difference that was not statistically significant, reported Dr. Theobald of Vanderbilt University and her associates.
These events included adverse drug events (0.43 per patient in the intervention group and 0.40 per patient in the control group) and potential adverse drug events (0.44 per patient in the intervention group and 0.55 in the control group), rates of which did not differ significantly between groups.
"If we can’t figure out a way to talk to our patients immediately after discharge, these problems will continue," one physician in the audience said during the discussion session after the presentation.
Dr. Theobald noted that the Vanderbilt University system still has pharmacists available to counsel patients before discharge, but only at the request of clinicians, not routinely.
At the start of the study, 41% in the intervention group and 42% in the control group were female, and 61% in both groups had acute coronary syndrome. Congestive heart failure was diagnosed in 32% of the intervention group and 31% of the control group, and both diagnoses were present in 7% of the intervention group and 8% of the control group. Before admission, patients in the intervention group were on a median of eight medications, and those in the control group were taking a median of seven medications.
Health literacy levels were considered marginal in 9% of each group, and inadequate in 12% of the intervention group and 9% of the control group. Twelve percent of patients in the intervention group and 11% of patients in the control group had cognitive impairment.
There were suggestions of benefit from the intervention, compared with usual care, in three prespecified subgroups, but these did not reach statistical significance. With the intervention, clinically important medication errors were 32% less likely in patients with inadequate health literacy, 38% less likely in cognitively impaired patients, and 17% less likely in patients treated at Vanderbilt.
Further work would be needed to determine if high-risk subgroups should be targeted for this kind of intervention, Dr. Theobald said.
In general, 13%-17% of patients develop clinically important medication errors after hospitalization, according to previous studies. An estimated 50%-75% of those errors are preventable or ameliorable, other data suggest. Some studies report that postdischarge medication errors may be more common in patients who are older, are on complex regimens of multiple medications, are cognitively impaired, or have low health literacy. Previous trials of interventions to reduce posthospitalization medication errors have produced mixed results.
The National Heart, Lung, and Blood Institute and the Department of Veterans Affairs funded the study. Dr. Theobald reported having no financial disclosures.
On Twitter @sherryboschert
According to the Institute of Medicine,
gaps in medication information collected at interfaces in care may represent
the most common source of preventable health care error. Studies have shown
that unintentional prescribing discrepancies are common and occur in 60%-90% of
hospital admissions (Arch. Intern. Med.
 |
| Dr. Blake Lesselroth |
While systematized processes intended to reconcile
medications have been shown to reduce discrepancies by up to 70% and
potentially reduce downstream adverse drug events, most US hospitals
have not yet fully implemented standardized reconciliation practices (BMJ Qual. Saf.
Hospitalists have a particularly critical role to play
in the development and diffusion of reconciliation practices for multiple
reasons (J. Hosp. Med. 2010;5:477-85).
First, patients on hospitalist services tend to be
medically complex and have the most to gain from a structured medication
review. Second, hospitalists are well positioned to recognize problems across a
breadth of specialty domains and marshal resources to triage and manage
potential medication errors. Third, hospitalists have assumed a central role in
the quality improvement movement and possess the skills to lead multi-modal
interventions designed to detect and manage high risk discrepancies. Despite
these disciplinary strengths and opportunities, an alarmingly high proportion
of hospitalists are unconvinced that their time is well spent on reconciliation
efforts or that interventions can improve outcomes (J.
Hosp. Med. 2011;6:329-3; J. Hosp. Med. 2008;3:465-72).
Multidisciplinary approaches that are patient centered,
leverage the unique skills of nurses, pharmacists, and physicians, and
capitalize upon information technologies are most likely to be successful.
Dr. Blake J.
Lesselroth, is a hospitalist-informatician at the Portland Veterans Affairs
Medical Center
in Oregon.
According to the Institute of Medicine,
gaps in medication information collected at interfaces in care may represent
the most common source of preventable health care error. Studies have shown
that unintentional prescribing discrepancies are common and occur in 60%-90% of
hospital admissions (Arch. Intern. Med.
|
| Dr. Blake Lesselroth |
While systematized processes intended to reconcile
medications have been shown to reduce discrepancies by up to 70% and
potentially reduce downstream adverse drug events, most US hospitals
have not yet fully implemented standardized reconciliation practices (BMJ Qual. Saf.
Hospitalists have a particularly critical role to play
in the development and diffusion of reconciliation practices for multiple
reasons (J. Hosp. Med. 2010;5:477-85).
First, patients on hospitalist services tend to be
medically complex and have the most to gain from a structured medication
review. Second, hospitalists are well positioned to recognize problems across a
breadth of specialty domains and marshal resources to triage and manage
potential medication errors. Third, hospitalists have assumed a central role in
the quality improvement movement and possess the skills to lead multi-modal
interventions designed to detect and manage high risk discrepancies. Despite
these disciplinary strengths and opportunities, an alarmingly high proportion
of hospitalists are unconvinced that their time is well spent on reconciliation
efforts or that interventions can improve outcomes (J.
Hosp. Med. 2011;6:329-3; J. Hosp. Med. 2008;3:465-72).
Multidisciplinary approaches that are patient centered,
leverage the unique skills of nurses, pharmacists, and physicians, and
capitalize upon information technologies are most likely to be successful.
Dr. Blake J.
Lesselroth, is a hospitalist-informatician at the Portland Veterans Affairs
Medical Center
in Oregon.
According to the Institute of Medicine,
gaps in medication information collected at interfaces in care may represent
the most common source of preventable health care error. Studies have shown
that unintentional prescribing discrepancies are common and occur in 60%-90% of
hospital admissions (Arch. Intern. Med.
|
| Dr. Blake Lesselroth |
While systematized processes intended to reconcile
medications have been shown to reduce discrepancies by up to 70% and
potentially reduce downstream adverse drug events, most US hospitals
have not yet fully implemented standardized reconciliation practices (BMJ Qual. Saf.
Hospitalists have a particularly critical role to play
in the development and diffusion of reconciliation practices for multiple
reasons (J. Hosp. Med. 2010;5:477-85).
First, patients on hospitalist services tend to be
medically complex and have the most to gain from a structured medication
review. Second, hospitalists are well positioned to recognize problems across a
breadth of specialty domains and marshal resources to triage and manage
potential medication errors. Third, hospitalists have assumed a central role in
the quality improvement movement and possess the skills to lead multi-modal
interventions designed to detect and manage high risk discrepancies. Despite
these disciplinary strengths and opportunities, an alarmingly high proportion
of hospitalists are unconvinced that their time is well spent on reconciliation
efforts or that interventions can improve outcomes (J.
Hosp. Med. 2011;6:329-3; J. Hosp. Med. 2008;3:465-72).
Multidisciplinary approaches that are patient centered,
leverage the unique skills of nurses, pharmacists, and physicians, and
capitalize upon information technologies are most likely to be successful.
Dr. Blake J.
Lesselroth, is a hospitalist-informatician at the Portland Veterans Affairs
Medical Center
in Oregon.
SAN FRANCISCO – Clinically important medication errors occurred in 51% of patients within 3 months of discharge from hospitalization for acute coronary syndrome and/or decompensated heart failure, a study of 851 patients showed.
In addition, the randomized controlled trial found no benefit from a predischarge pharmacist intervention and counseling incorporating tools designed for patients with low health literacy levels, compared with usual care in which the treating health care provider reconciled medications with the help of support software before patient discharge.
Although the trial focused on comparing the pharmacist intervention with usual care, "the biggest take-home message is that medication errors are very common" in these patients after hospitalization, Dr. Cecelia N. Theobald said at the annual meeting of the American College of Physicians.
Patients came from Vanderbilt University Medical Center in Nashville, Tenn., and from Brigham and Women’s Hospital in Boston. The study randomized 423 patients to the intervention and 428 to usual care.
In the intervention group, pharmacists reconciled medications and provided in-depth patient counseling before discharge, including a review of potential drug side effects. The pharmacists had specialized aids to help low-literacy patients adhere to their medication regimens, and they provided tailored follow-up to patients via postdischarge phone calls. In the usual-care group, the treating provider reconciled medications and pharmacist consultation was available on request. The usual-care group did not use the low-literacy aids or phone follow-up.
To assess outcomes, two clinicians reviewed patient records and patients were interviewed by phone 30 days after discharge.
Thirty percent of patients had one or more adverse drug events that were considered to be preventable or ameliorable. Another 30% of patients had at least one potential adverse drug event, she said. Adverse drug events occurred in 47% of patients on cardiovascular agents other than diuretics, 21% of patients on diuretics, and 5% of patients on opioids. Potential adverse drug events were seen in 43% of patients on cardiovascular agents other than diuretics, and in 12% of patients on diuretics (Ann. Intern. Med. 2012;157:1-10).
On a per-patient basis, 0.87 clinically important medication errors occurred in the intervention group, compared with 0.95 events per patient in the usual-care group, a difference that was not statistically significant, reported Dr. Theobald of Vanderbilt University and her associates.
These events included adverse drug events (0.43 per patient in the intervention group and 0.40 per patient in the control group) and potential adverse drug events (0.44 per patient in the intervention group and 0.55 in the control group), rates of which did not differ significantly between groups.
"If we can’t figure out a way to talk to our patients immediately after discharge, these problems will continue," one physician in the audience said during the discussion session after the presentation.
Dr. Theobald noted that the Vanderbilt University system still has pharmacists available to counsel patients before discharge, but only at the request of clinicians, not routinely.
At the start of the study, 41% in the intervention group and 42% in the control group were female, and 61% in both groups had acute coronary syndrome. Congestive heart failure was diagnosed in 32% of the intervention group and 31% of the control group, and both diagnoses were present in 7% of the intervention group and 8% of the control group. Before admission, patients in the intervention group were on a median of eight medications, and those in the control group were taking a median of seven medications.
Health literacy levels were considered marginal in 9% of each group, and inadequate in 12% of the intervention group and 9% of the control group. Twelve percent of patients in the intervention group and 11% of patients in the control group had cognitive impairment.
There were suggestions of benefit from the intervention, compared with usual care, in three prespecified subgroups, but these did not reach statistical significance. With the intervention, clinically important medication errors were 32% less likely in patients with inadequate health literacy, 38% less likely in cognitively impaired patients, and 17% less likely in patients treated at Vanderbilt.
Further work would be needed to determine if high-risk subgroups should be targeted for this kind of intervention, Dr. Theobald said.
In general, 13%-17% of patients develop clinically important medication errors after hospitalization, according to previous studies. An estimated 50%-75% of those errors are preventable or ameliorable, other data suggest. Some studies report that postdischarge medication errors may be more common in patients who are older, are on complex regimens of multiple medications, are cognitively impaired, or have low health literacy. Previous trials of interventions to reduce posthospitalization medication errors have produced mixed results.
The National Heart, Lung, and Blood Institute and the Department of Veterans Affairs funded the study. Dr. Theobald reported having no financial disclosures.
On Twitter @sherryboschert
SAN FRANCISCO – Clinically important medication errors occurred in 51% of patients within 3 months of discharge from hospitalization for acute coronary syndrome and/or decompensated heart failure, a study of 851 patients showed.
In addition, the randomized controlled trial found no benefit from a predischarge pharmacist intervention and counseling incorporating tools designed for patients with low health literacy levels, compared with usual care in which the treating health care provider reconciled medications with the help of support software before patient discharge.
Although the trial focused on comparing the pharmacist intervention with usual care, "the biggest take-home message is that medication errors are very common" in these patients after hospitalization, Dr. Cecelia N. Theobald said at the annual meeting of the American College of Physicians.
Patients came from Vanderbilt University Medical Center in Nashville, Tenn., and from Brigham and Women’s Hospital in Boston. The study randomized 423 patients to the intervention and 428 to usual care.
In the intervention group, pharmacists reconciled medications and provided in-depth patient counseling before discharge, including a review of potential drug side effects. The pharmacists had specialized aids to help low-literacy patients adhere to their medication regimens, and they provided tailored follow-up to patients via postdischarge phone calls. In the usual-care group, the treating provider reconciled medications and pharmacist consultation was available on request. The usual-care group did not use the low-literacy aids or phone follow-up.
To assess outcomes, two clinicians reviewed patient records and patients were interviewed by phone 30 days after discharge.
Thirty percent of patients had one or more adverse drug events that were considered to be preventable or ameliorable. Another 30% of patients had at least one potential adverse drug event, she said. Adverse drug events occurred in 47% of patients on cardiovascular agents other than diuretics, 21% of patients on diuretics, and 5% of patients on opioids. Potential adverse drug events were seen in 43% of patients on cardiovascular agents other than diuretics, and in 12% of patients on diuretics (Ann. Intern. Med. 2012;157:1-10).
On a per-patient basis, 0.87 clinically important medication errors occurred in the intervention group, compared with 0.95 events per patient in the usual-care group, a difference that was not statistically significant, reported Dr. Theobald of Vanderbilt University and her associates.
These events included adverse drug events (0.43 per patient in the intervention group and 0.40 per patient in the control group) and potential adverse drug events (0.44 per patient in the intervention group and 0.55 in the control group), rates of which did not differ significantly between groups.
"If we can’t figure out a way to talk to our patients immediately after discharge, these problems will continue," one physician in the audience said during the discussion session after the presentation.
Dr. Theobald noted that the Vanderbilt University system still has pharmacists available to counsel patients before discharge, but only at the request of clinicians, not routinely.
At the start of the study, 41% in the intervention group and 42% in the control group were female, and 61% in both groups had acute coronary syndrome. Congestive heart failure was diagnosed in 32% of the intervention group and 31% of the control group, and both diagnoses were present in 7% of the intervention group and 8% of the control group. Before admission, patients in the intervention group were on a median of eight medications, and those in the control group were taking a median of seven medications.
Health literacy levels were considered marginal in 9% of each group, and inadequate in 12% of the intervention group and 9% of the control group. Twelve percent of patients in the intervention group and 11% of patients in the control group had cognitive impairment.
There were suggestions of benefit from the intervention, compared with usual care, in three prespecified subgroups, but these did not reach statistical significance. With the intervention, clinically important medication errors were 32% less likely in patients with inadequate health literacy, 38% less likely in cognitively impaired patients, and 17% less likely in patients treated at Vanderbilt.
Further work would be needed to determine if high-risk subgroups should be targeted for this kind of intervention, Dr. Theobald said.
In general, 13%-17% of patients develop clinically important medication errors after hospitalization, according to previous studies. An estimated 50%-75% of those errors are preventable or ameliorable, other data suggest. Some studies report that postdischarge medication errors may be more common in patients who are older, are on complex regimens of multiple medications, are cognitively impaired, or have low health literacy. Previous trials of interventions to reduce posthospitalization medication errors have produced mixed results.
The National Heart, Lung, and Blood Institute and the Department of Veterans Affairs funded the study. Dr. Theobald reported having no financial disclosures.
On Twitter @sherryboschert
AT ACP INTERNAL MEDICINE 2013
Major finding: After discharge, 0.87 clinically important medication errors occurred per patient in the intervention group, compared with 0.95 events per patient in the usual-care group.
Data source: Randomized controlled trial of a health literacy–sensitive pharmacist intervention in 851 patients at two institutions.
Disclosures: The National Heart, Lung, and Blood Institute and the Veterans Administration funded the study. Dr. Theobald reported having no financial disclosures.
When HbA1c Won't Do, Look to Fructosamine Test
NEW ORLEANS – Suspect a problem with the hemoglobin A1c whenever it’s discordant with blood sugar–monitoring data.
This happens surprisingly often. The HbA1c level is a measure of glycolated hemoglobin, so any condition that affects hemoglobin, either qualitatively or quantitatively, can seriously distort the HbA1c value, Dr. Thomas L. O’Connell explained at the annual meeting of the American College of Physicians.
Examples include patients on hemodialysis, or who have recently been transfused, are anemic, or who have a hemoglobinopathy, noted Dr. O’Connell, an endocrinologist at Duke University, Durham, N.C.
"Don’t even bother measuring [HbA1c] in a patient who has recently been transfused. This happens all the time in the hospital: a transfused patient’s blood sugar level on finger-stick testing is 300 mg/dL, but the [HbA1c] is 5.5%," he observed.
Hemoglobinopathies can result in either a false-high or false-low HbA1c value. More than 700 hemoglobinopathies or abnormal hemoglobin variants have been described and many of these are asymptomatic. The most common hemoglobinopathy in the United States is sickle cell trait, affecting 2 million people.
"There are a lot of people out there with hemoglobinopathies," the endocrinologist stressed.
When the HbA1c results seem sketchy, an excellent alternative is the fructosamine test. Not nearly as well known as the HbA1c, the fructosamine test measures glycolated protein in the blood rather than glycolated hemoglobin, so it is unaffected by hemoglobinopathies.
If blood glucose measurement by fingerstick provides a snapshot of a patient’s diabetic control and the HbA1c is more like a feature-length movie reflecting metabolic control over the past 3 months, then the fructosamine test is akin to a short film providing a view of a patient’s average blood glucose concentration during the previous 2-3 weeks.
Dr. O’Connell reported that he serves as a consultant to Sanofi-Aventis and Amylin.
NEW ORLEANS – Suspect a problem with the hemoglobin A1c whenever it’s discordant with blood sugar–monitoring data.
This happens surprisingly often. The HbA1c level is a measure of glycolated hemoglobin, so any condition that affects hemoglobin, either qualitatively or quantitatively, can seriously distort the HbA1c value, Dr. Thomas L. O’Connell explained at the annual meeting of the American College of Physicians.
Examples include patients on hemodialysis, or who have recently been transfused, are anemic, or who have a hemoglobinopathy, noted Dr. O’Connell, an endocrinologist at Duke University, Durham, N.C.
"Don’t even bother measuring [HbA1c] in a patient who has recently been transfused. This happens all the time in the hospital: a transfused patient’s blood sugar level on finger-stick testing is 300 mg/dL, but the [HbA1c] is 5.5%," he observed.
Hemoglobinopathies can result in either a false-high or false-low HbA1c value. More than 700 hemoglobinopathies or abnormal hemoglobin variants have been described and many of these are asymptomatic. The most common hemoglobinopathy in the United States is sickle cell trait, affecting 2 million people.
"There are a lot of people out there with hemoglobinopathies," the endocrinologist stressed.
When the HbA1c results seem sketchy, an excellent alternative is the fructosamine test. Not nearly as well known as the HbA1c, the fructosamine test measures glycolated protein in the blood rather than glycolated hemoglobin, so it is unaffected by hemoglobinopathies.
If blood glucose measurement by fingerstick provides a snapshot of a patient’s diabetic control and the HbA1c is more like a feature-length movie reflecting metabolic control over the past 3 months, then the fructosamine test is akin to a short film providing a view of a patient’s average blood glucose concentration during the previous 2-3 weeks.
Dr. O’Connell reported that he serves as a consultant to Sanofi-Aventis and Amylin.
NEW ORLEANS – Suspect a problem with the hemoglobin A1c whenever it’s discordant with blood sugar–monitoring data.
This happens surprisingly often. The HbA1c level is a measure of glycolated hemoglobin, so any condition that affects hemoglobin, either qualitatively or quantitatively, can seriously distort the HbA1c value, Dr. Thomas L. O’Connell explained at the annual meeting of the American College of Physicians.
Examples include patients on hemodialysis, or who have recently been transfused, are anemic, or who have a hemoglobinopathy, noted Dr. O’Connell, an endocrinologist at Duke University, Durham, N.C.
"Don’t even bother measuring [HbA1c] in a patient who has recently been transfused. This happens all the time in the hospital: a transfused patient’s blood sugar level on finger-stick testing is 300 mg/dL, but the [HbA1c] is 5.5%," he observed.
Hemoglobinopathies can result in either a false-high or false-low HbA1c value. More than 700 hemoglobinopathies or abnormal hemoglobin variants have been described and many of these are asymptomatic. The most common hemoglobinopathy in the United States is sickle cell trait, affecting 2 million people.
"There are a lot of people out there with hemoglobinopathies," the endocrinologist stressed.
When the HbA1c results seem sketchy, an excellent alternative is the fructosamine test. Not nearly as well known as the HbA1c, the fructosamine test measures glycolated protein in the blood rather than glycolated hemoglobin, so it is unaffected by hemoglobinopathies.
If blood glucose measurement by fingerstick provides a snapshot of a patient’s diabetic control and the HbA1c is more like a feature-length movie reflecting metabolic control over the past 3 months, then the fructosamine test is akin to a short film providing a view of a patient’s average blood glucose concentration during the previous 2-3 weeks.
Dr. O’Connell reported that he serves as a consultant to Sanofi-Aventis and Amylin.
EXPERT ANALYSIS FROM THE ANNUAL MEETING OF AMERICAN COLLEGE OF PHYSICIANS
Roughly 14 Million Americans Have Undiagnosed COPD
NEW ORLEANS – The most likely place to look for missed cases of chronic obstructive pulmonary disease – and they exist in abundance – is among women younger than age 65.
Chronic obstructive pulmonary disease, the fourth leading cause of death in the United States, is far and away the most widely underdiagnosed serious illness. The best available prevalence data on COPD come from the NHANES III (National Health and Nutrition Examination Survey III), which included spirometric testing in a proportionate sample of the U.S. population.
Extrapolating from those data, roughly 12 million Americans carry the diagnosis of COPD, and another 12 million have evidence of impaired lung function consistent with COPD but remain undiagnosed. Of those 12 million undiagnosed individuals, NHANES III data indicate that roughly a third have clinically relevant COPD warranting application of treatment guidelines, according to Dr. Fernando J. Martinez, professor of internal medicine and director of pulmonary diagnostic services at the University of Michigan, Ann Arbor.
He added that the latest data from NHANES IV, now under review, bump those estimates up to roughly 14 million patients with diagnosed COPD, and an equal number with undiagnosed COPD.
The NHANES III data showed that 70% of individuals with undiagnosed COPD are younger than age 65. Other studies point to a marked sex discrepancy in misdiagnosis. In one landmark study, investigators presented American and Canadian primary care physicians with a classic clinical scenario for COPD (that is, a patient with a strong smoking history, progressive shortness of breath, and chronic cough with morning sputum production). Half the time, investigators identified this hypothetical patient as male, the other half female. Physicians diagnosed COPD 58% of the time when the patient was male, but in only 42% of cases when the otherwise identical hypothetical patient was female (Chest 2001;119:1691-5).
This sex discrepancy in COPD diagnosis has been replicated in similar studies conducted in Spain and Israel, Dr. Martinez added.
Interestingly, the first diagnostic test most participating primary care physicians indicated they would order for this hypothetical patient was a chest x-ray, which Dr. Martinez dismissed as a "terrible" tool for diagnosing COPD. Spirometry, which is in fact the diagnostic test for COPD, would have been ordered initially by only 22% of the physicians.
The pulmonologist stressed that even though spirometry is the diagnostic test for airflow obstruction, three major sets of guidelines released within the past year uniformly emphasize that its use should be restricted to patients with respiratory symptoms. Using spirometry alone as a screening test results in substantial overdiagnosis.
The recent guidelines he referred to are the latest update from the Global Initiative for Chronic Obstructive Lung Disease, which Dr. Martinez coauthored; the joint American College of Physicians/American College of Chest Physicians/American Thoracic Society/European Respiratory Society guidelines (Ann. Intern. Med. 2011;155:179-91); and the U.K. National Institute for Health and Clinical Excellence guideline.
Spirometry continues to be greatly underutilized in primary care medicine, perhaps in part because some insurers are unwilling to pay for the test in the office setting, insisting instead that it be performed in a specialized pulmonary clinic. That policy is destined for the scrap heap, Dr. Martinez predicted. In the meantime, primary care physicians need to realize that spirometry "is remarkably easy – you only need to know two numbers to be able to do it and interpret it properly," he said.
In the study that identified sex bias in COPD diagnosis, classic COPD symptoms in women were misdiagnosed most frequently as asthma. That’s a crucial mistake, because the first-choice treatments for these two common respiratory diseases are "diametrically opposite," Dr. Martinez observed.
"In asthma, you use inhaled corticosteroids up front as first-line therapy. That’s not the case in COPD. In COPD you use a LABA [long-acting beta agonist] up front, and you add an inhaled corticosteroid to reduce the exacerbation rate in people at increased risk based on a history of two or more exacerbations in the past year," he explained.
All of the latest guidelines emphasize exacerbation reduction as a key component of COPD management. Exacerbations accelerate disease progression by worsening lung function and symptoms, and they drive up costs as well.
The National Heart, Lung, and Blood Institute is interested in developing a novel, practical means of screening the general population for COPD in primary care physicians’ offices. Toward that end, the institute recently awarded a large research grant to a team of investigators that includes Dr. Martinez. He said that while he and his coworkers are still in the brainstorming stage, they are drawn to a staged approach involving a very brief questionnaire, in-office measurement of peak expiratory flow via a pocket spirometer, followed by diagnostic-quality spirometry when indicated.
Polls of busy general internists and family physicians indicate that if this screening questionnaire is more than four questions long, they won’t use it. So, hypothetically, Dr. Martinez said, a three-item questionnaire might consist of something along these lines: How old are you? (Epidemiologic data indicate COPD risk rises at about age 40.) How much do you smoke? (COPD risk begins climbing with a lifetime history of just 100 cigarettes, a mere five packs.) And, do you have symptoms?
Dr. Martinez would like to incorporate in-office peak expiratory flow measurement using a pocket spirometer into the screening tool in light of the findings of a recent study in which he was a principal investigator.
This study of 5,761 patients demonstrated that it’s rare to find severe airflow obstruction in an individual whose FEV1 is at least 60% of the predicted value (Chest 2011 Dec. 22 [Epub ahead of print; PMID 22194590]).
"A peak flow measurement has very good negative predictive value. That could be a useful part of a screening instrument that’s going to need to be very practical," he observed.
Dr. Martinez reported that he serves as a consultant to Actelion, Almirall, AstraZeneca, Bayer, Forest, GlaxoSmithKline, Ikaria, MedImmune, Merck, Novartis, Nycomed, Pearl, and Pfizer.
NEW ORLEANS – The most likely place to look for missed cases of chronic obstructive pulmonary disease – and they exist in abundance – is among women younger than age 65.
Chronic obstructive pulmonary disease, the fourth leading cause of death in the United States, is far and away the most widely underdiagnosed serious illness. The best available prevalence data on COPD come from the NHANES III (National Health and Nutrition Examination Survey III), which included spirometric testing in a proportionate sample of the U.S. population.
Extrapolating from those data, roughly 12 million Americans carry the diagnosis of COPD, and another 12 million have evidence of impaired lung function consistent with COPD but remain undiagnosed. Of those 12 million undiagnosed individuals, NHANES III data indicate that roughly a third have clinically relevant COPD warranting application of treatment guidelines, according to Dr. Fernando J. Martinez, professor of internal medicine and director of pulmonary diagnostic services at the University of Michigan, Ann Arbor.
He added that the latest data from NHANES IV, now under review, bump those estimates up to roughly 14 million patients with diagnosed COPD, and an equal number with undiagnosed COPD.
The NHANES III data showed that 70% of individuals with undiagnosed COPD are younger than age 65. Other studies point to a marked sex discrepancy in misdiagnosis. In one landmark study, investigators presented American and Canadian primary care physicians with a classic clinical scenario for COPD (that is, a patient with a strong smoking history, progressive shortness of breath, and chronic cough with morning sputum production). Half the time, investigators identified this hypothetical patient as male, the other half female. Physicians diagnosed COPD 58% of the time when the patient was male, but in only 42% of cases when the otherwise identical hypothetical patient was female (Chest 2001;119:1691-5).
This sex discrepancy in COPD diagnosis has been replicated in similar studies conducted in Spain and Israel, Dr. Martinez added.
Interestingly, the first diagnostic test most participating primary care physicians indicated they would order for this hypothetical patient was a chest x-ray, which Dr. Martinez dismissed as a "terrible" tool for diagnosing COPD. Spirometry, which is in fact the diagnostic test for COPD, would have been ordered initially by only 22% of the physicians.
The pulmonologist stressed that even though spirometry is the diagnostic test for airflow obstruction, three major sets of guidelines released within the past year uniformly emphasize that its use should be restricted to patients with respiratory symptoms. Using spirometry alone as a screening test results in substantial overdiagnosis.
The recent guidelines he referred to are the latest update from the Global Initiative for Chronic Obstructive Lung Disease, which Dr. Martinez coauthored; the joint American College of Physicians/American College of Chest Physicians/American Thoracic Society/European Respiratory Society guidelines (Ann. Intern. Med. 2011;155:179-91); and the U.K. National Institute for Health and Clinical Excellence guideline.
Spirometry continues to be greatly underutilized in primary care medicine, perhaps in part because some insurers are unwilling to pay for the test in the office setting, insisting instead that it be performed in a specialized pulmonary clinic. That policy is destined for the scrap heap, Dr. Martinez predicted. In the meantime, primary care physicians need to realize that spirometry "is remarkably easy – you only need to know two numbers to be able to do it and interpret it properly," he said.
In the study that identified sex bias in COPD diagnosis, classic COPD symptoms in women were misdiagnosed most frequently as asthma. That’s a crucial mistake, because the first-choice treatments for these two common respiratory diseases are "diametrically opposite," Dr. Martinez observed.
"In asthma, you use inhaled corticosteroids up front as first-line therapy. That’s not the case in COPD. In COPD you use a LABA [long-acting beta agonist] up front, and you add an inhaled corticosteroid to reduce the exacerbation rate in people at increased risk based on a history of two or more exacerbations in the past year," he explained.
All of the latest guidelines emphasize exacerbation reduction as a key component of COPD management. Exacerbations accelerate disease progression by worsening lung function and symptoms, and they drive up costs as well.
The National Heart, Lung, and Blood Institute is interested in developing a novel, practical means of screening the general population for COPD in primary care physicians’ offices. Toward that end, the institute recently awarded a large research grant to a team of investigators that includes Dr. Martinez. He said that while he and his coworkers are still in the brainstorming stage, they are drawn to a staged approach involving a very brief questionnaire, in-office measurement of peak expiratory flow via a pocket spirometer, followed by diagnostic-quality spirometry when indicated.
Polls of busy general internists and family physicians indicate that if this screening questionnaire is more than four questions long, they won’t use it. So, hypothetically, Dr. Martinez said, a three-item questionnaire might consist of something along these lines: How old are you? (Epidemiologic data indicate COPD risk rises at about age 40.) How much do you smoke? (COPD risk begins climbing with a lifetime history of just 100 cigarettes, a mere five packs.) And, do you have symptoms?
Dr. Martinez would like to incorporate in-office peak expiratory flow measurement using a pocket spirometer into the screening tool in light of the findings of a recent study in which he was a principal investigator.
This study of 5,761 patients demonstrated that it’s rare to find severe airflow obstruction in an individual whose FEV1 is at least 60% of the predicted value (Chest 2011 Dec. 22 [Epub ahead of print; PMID 22194590]).
"A peak flow measurement has very good negative predictive value. That could be a useful part of a screening instrument that’s going to need to be very practical," he observed.
Dr. Martinez reported that he serves as a consultant to Actelion, Almirall, AstraZeneca, Bayer, Forest, GlaxoSmithKline, Ikaria, MedImmune, Merck, Novartis, Nycomed, Pearl, and Pfizer.
NEW ORLEANS – The most likely place to look for missed cases of chronic obstructive pulmonary disease – and they exist in abundance – is among women younger than age 65.
Chronic obstructive pulmonary disease, the fourth leading cause of death in the United States, is far and away the most widely underdiagnosed serious illness. The best available prevalence data on COPD come from the NHANES III (National Health and Nutrition Examination Survey III), which included spirometric testing in a proportionate sample of the U.S. population.
Extrapolating from those data, roughly 12 million Americans carry the diagnosis of COPD, and another 12 million have evidence of impaired lung function consistent with COPD but remain undiagnosed. Of those 12 million undiagnosed individuals, NHANES III data indicate that roughly a third have clinically relevant COPD warranting application of treatment guidelines, according to Dr. Fernando J. Martinez, professor of internal medicine and director of pulmonary diagnostic services at the University of Michigan, Ann Arbor.
He added that the latest data from NHANES IV, now under review, bump those estimates up to roughly 14 million patients with diagnosed COPD, and an equal number with undiagnosed COPD.
The NHANES III data showed that 70% of individuals with undiagnosed COPD are younger than age 65. Other studies point to a marked sex discrepancy in misdiagnosis. In one landmark study, investigators presented American and Canadian primary care physicians with a classic clinical scenario for COPD (that is, a patient with a strong smoking history, progressive shortness of breath, and chronic cough with morning sputum production). Half the time, investigators identified this hypothetical patient as male, the other half female. Physicians diagnosed COPD 58% of the time when the patient was male, but in only 42% of cases when the otherwise identical hypothetical patient was female (Chest 2001;119:1691-5).
This sex discrepancy in COPD diagnosis has been replicated in similar studies conducted in Spain and Israel, Dr. Martinez added.
Interestingly, the first diagnostic test most participating primary care physicians indicated they would order for this hypothetical patient was a chest x-ray, which Dr. Martinez dismissed as a "terrible" tool for diagnosing COPD. Spirometry, which is in fact the diagnostic test for COPD, would have been ordered initially by only 22% of the physicians.
The pulmonologist stressed that even though spirometry is the diagnostic test for airflow obstruction, three major sets of guidelines released within the past year uniformly emphasize that its use should be restricted to patients with respiratory symptoms. Using spirometry alone as a screening test results in substantial overdiagnosis.
The recent guidelines he referred to are the latest update from the Global Initiative for Chronic Obstructive Lung Disease, which Dr. Martinez coauthored; the joint American College of Physicians/American College of Chest Physicians/American Thoracic Society/European Respiratory Society guidelines (Ann. Intern. Med. 2011;155:179-91); and the U.K. National Institute for Health and Clinical Excellence guideline.
Spirometry continues to be greatly underutilized in primary care medicine, perhaps in part because some insurers are unwilling to pay for the test in the office setting, insisting instead that it be performed in a specialized pulmonary clinic. That policy is destined for the scrap heap, Dr. Martinez predicted. In the meantime, primary care physicians need to realize that spirometry "is remarkably easy – you only need to know two numbers to be able to do it and interpret it properly," he said.
In the study that identified sex bias in COPD diagnosis, classic COPD symptoms in women were misdiagnosed most frequently as asthma. That’s a crucial mistake, because the first-choice treatments for these two common respiratory diseases are "diametrically opposite," Dr. Martinez observed.
"In asthma, you use inhaled corticosteroids up front as first-line therapy. That’s not the case in COPD. In COPD you use a LABA [long-acting beta agonist] up front, and you add an inhaled corticosteroid to reduce the exacerbation rate in people at increased risk based on a history of two or more exacerbations in the past year," he explained.
All of the latest guidelines emphasize exacerbation reduction as a key component of COPD management. Exacerbations accelerate disease progression by worsening lung function and symptoms, and they drive up costs as well.
The National Heart, Lung, and Blood Institute is interested in developing a novel, practical means of screening the general population for COPD in primary care physicians’ offices. Toward that end, the institute recently awarded a large research grant to a team of investigators that includes Dr. Martinez. He said that while he and his coworkers are still in the brainstorming stage, they are drawn to a staged approach involving a very brief questionnaire, in-office measurement of peak expiratory flow via a pocket spirometer, followed by diagnostic-quality spirometry when indicated.
Polls of busy general internists and family physicians indicate that if this screening questionnaire is more than four questions long, they won’t use it. So, hypothetically, Dr. Martinez said, a three-item questionnaire might consist of something along these lines: How old are you? (Epidemiologic data indicate COPD risk rises at about age 40.) How much do you smoke? (COPD risk begins climbing with a lifetime history of just 100 cigarettes, a mere five packs.) And, do you have symptoms?
Dr. Martinez would like to incorporate in-office peak expiratory flow measurement using a pocket spirometer into the screening tool in light of the findings of a recent study in which he was a principal investigator.
This study of 5,761 patients demonstrated that it’s rare to find severe airflow obstruction in an individual whose FEV1 is at least 60% of the predicted value (Chest 2011 Dec. 22 [Epub ahead of print; PMID 22194590]).
"A peak flow measurement has very good negative predictive value. That could be a useful part of a screening instrument that’s going to need to be very practical," he observed.
Dr. Martinez reported that he serves as a consultant to Actelion, Almirall, AstraZeneca, Bayer, Forest, GlaxoSmithKline, Ikaria, MedImmune, Merck, Novartis, Nycomed, Pearl, and Pfizer.
EXPERT ANALYSIS FROM THE ANNUAL MEETING OF THE AMERICAN COLLEGE OF PHYSICIANS
Quickly Assess Driving Safety in the Elderly
NEW ORLEANS – Informing an elderly patient that it’s time to stop driving because of health-related safety concerns is one of the toughest, most tension-racked aspects of primary care practice, according to Dr. Hollis D. Day.
"The driving conversation with the elderly patient and family is probably the least favorite conversation that I have with anyone. And the fact that my colleagues send their patients to me to have that conversation tells me they don’t like it either," Dr. Day, a general internist at the University of Pittsburgh, said at the meeting.
"The reason is we’re actually afraid that it’s going to impair our future relationship with our patient. We’ve been with these patients for years, and now we’re telling them to stop doing something that is absolutely critical and vital to them. It makes us look like the bad guy. But it doesn’t have to be that way," she stressed.
She shared experience-based tips on how to make that discussion go as well as possible. She also explained how to efficiently conduct a driving safety assessment within the confines of a 10-minute office visit.
The first thing to understand about driver safety assessment is that there are no validated criteria for determining risk. While a classic study of Alzheimer’s disease outpatients showed they were overall less likely than nondemented controls to successfully complete a driving simulator test, many of the patients with mild Alzheimer’s disease did pass the test. And no cut point on the Mini-Mental Status Examination could be identified below which it was unsafe to drive (J. Am. Board Fam. Med. 1998;11:264-71).
"There were people who were apparently safely driving with MMSE scores of 21 and 20. So there is no hard and fast cut point at this time. This is important because there are legal considerations," Dr. Day said.
Public safety dictates that physicians have a duty to recommend limitation or cessation of driving if a patient’s health impairs driving ability. Only 10 states have a mandatory requirement for physician reporting to the department of motor vehicles, but another 22 encourage reporting if the physician thinks there’s a problem. State requirements change frequently. The best place to go to learn your current state laws is the Insurance Institute for Highway Safety website, which is updated every 6 months.
In Dr. Day’s home state of Pennsylvania, any health care provider has a legal duty to report a patient to the Department of Motor Vehicles within 10 days of diagnosing a qualifying condition. Such conditions specifically include visual impairment that’s uncorrectable, such as macular degeneration or diminished depth perception, as well as Parkinson’s disease, Alzheimer’s disease, and any other cardiovascular, cerebrovascular, convulsive, or other health conditions that may impair driving ability.
She sends off a standardized reporting form to the DMV. What happens next varies widely and seemingly arbitrarily. Some patients will get a letter from the DMV stating they need to come in for testing – either a written test, a road test, or a driving simulator. Others get a cease-and-desist order.
"That’s when I get the angry phone calls. I tell them in advance that I have to report them, but if they’re cognitively impaired, they may not remember having this conversation," Dr. Day said.
She’ll often use the annual wellness visit as an opportunity to talk about driving safety. But she also can carry out a driving evaluation during a 10-minute office visit. The key elements are to check the heart and lungs and perform a 10-second Get-Up-and-Go mobility test; a cognitive screening test; a musculoskeletal exam addressing the cervical spine, knees, and hips; and vision testing, which she has her medical assistant do.
The Get-Up-and-Go test entails having the patient rise out of a chair without the use of arms, walk three paces, turn around, and sit back down in the chair – all as fast as possible. It should take less than 10 seconds.
"That’s less than 10 seconds in your office to determine whether someone has got problems – potentially an arthritis problem or something else that could affect their driving ability. I defy you to give me any other screening test that takes less than 10 seconds," she said.
The fastest cognitive screening test is the Mini-Cog, which consists of clock drawing plus a three-word recall. It provides an indication as to whether additional neuropsychological testing is necessary. Dr. Day said she also uses the Trail Making B test "all the time" because there is some evidence that it’s a fairly good indicator of driving ability. It’s best to get someone on the office staff to become comfortable administering it. The test instructions allow grossly impaired patients up to 5 minutes to connect the letters to the numbers, which is too much of a physician’s time during a 10-minute visit.
Red flags in the history include a myocardial infarction, a stroke, traumatic brain injury due to a fall, seizures, the use of medications known to impair driving, and delirium.
"Development of delirium during a hospitalization is a sign that there’s actually some underlying cognitive impairment that hasn’t been recognized yet," according to Dr. Day.
Her preliminary screen for driving safety routinely includes the "10 Questions to Ask the Patient" described in the American Medical Association’s very useful "Physician's Guide to Assessing and Counseling Older Drivers." Among the 10 questions are, for example, " ‘Have you received any traffic citations for speeding, going too slow, improper turns, failure to stop, etc.?’ " and " ‘Have others criticized your driving or refused to drive with you?’ " she said. Patients can fill out the answers on a clipboard while in the waiting room.
Many patients will quickly see where these questions are headed and won’t answer honestly. That’s why the AMA also has come up with "10 Questions to Ask the Family." Among them are " ‘Does the patient need a copilot to alert them of potentially hazardous events or conditions?’ " and " ‘Do you feel uncomfortable in any way driving with the patient?’ " Dr. Day said.
"That’s a great question to ask the children because if they’re not letting the grandchildren drive with grandma or grandpa, there’s a problem," she said.
Driver rehabilitation options include occupational therapy to address mobility limitations, instruction by a member of the Association for Driver Rehabilitation Specialists, local driving schools, and training courses offered by the American Association of Retired Persons, the American Automobile Association, and the National Safety Council.
But when it really is time to stop driving altogether, Dr. Day said she speaks to the patient of "driving retirement," akin to the familiar milestone experience of retirement from work. She also plays the public safety card, asking, " ‘Would you want to hit someone’s child?’ " And since she is in Pennsylvania, a mandatory reporting state, she mentions her own responsibility.
"I work that," she admitted. "I say, ‘Look, my license is on the line. I have to report you.’ "
One audience member, noting that driving cessation conversations are "often very tense," likes to lighten things up a bit in the following way: "I tell patients there are three categories of recommendations for driving: One is you can drive. Two is you cannot drive. And the third is you can drive, but not in my neighborhood."
Dr. Day said an important part of preparing for the aftermath of not driving involves alerting patients to local resources that will help them get around without driving. Eldercare Locator is a U.S. Administration on Aging clearinghouse for local van services for the elderly and numerous other resources. The National Association of Area Agencies on Aging is another helpful organization. ITN America is a growing nonprofit volunteer organization of screened drivers available around the clock to drive patients.
She stressed that it’s crucial to monitor for depression at the next office visit after a patient stops driving. Giving up the car keys is often a big blow to self-esteem, and it can reduce opportunities to engage in social activities.
Dr. Day reported having no relevant financial conflicts.
NEW ORLEANS – Informing an elderly patient that it’s time to stop driving because of health-related safety concerns is one of the toughest, most tension-racked aspects of primary care practice, according to Dr. Hollis D. Day.
"The driving conversation with the elderly patient and family is probably the least favorite conversation that I have with anyone. And the fact that my colleagues send their patients to me to have that conversation tells me they don’t like it either," Dr. Day, a general internist at the University of Pittsburgh, said at the meeting.
"The reason is we’re actually afraid that it’s going to impair our future relationship with our patient. We’ve been with these patients for years, and now we’re telling them to stop doing something that is absolutely critical and vital to them. It makes us look like the bad guy. But it doesn’t have to be that way," she stressed.
She shared experience-based tips on how to make that discussion go as well as possible. She also explained how to efficiently conduct a driving safety assessment within the confines of a 10-minute office visit.
The first thing to understand about driver safety assessment is that there are no validated criteria for determining risk. While a classic study of Alzheimer’s disease outpatients showed they were overall less likely than nondemented controls to successfully complete a driving simulator test, many of the patients with mild Alzheimer’s disease did pass the test. And no cut point on the Mini-Mental Status Examination could be identified below which it was unsafe to drive (J. Am. Board Fam. Med. 1998;11:264-71).
"There were people who were apparently safely driving with MMSE scores of 21 and 20. So there is no hard and fast cut point at this time. This is important because there are legal considerations," Dr. Day said.
Public safety dictates that physicians have a duty to recommend limitation or cessation of driving if a patient’s health impairs driving ability. Only 10 states have a mandatory requirement for physician reporting to the department of motor vehicles, but another 22 encourage reporting if the physician thinks there’s a problem. State requirements change frequently. The best place to go to learn your current state laws is the Insurance Institute for Highway Safety website, which is updated every 6 months.
In Dr. Day’s home state of Pennsylvania, any health care provider has a legal duty to report a patient to the Department of Motor Vehicles within 10 days of diagnosing a qualifying condition. Such conditions specifically include visual impairment that’s uncorrectable, such as macular degeneration or diminished depth perception, as well as Parkinson’s disease, Alzheimer’s disease, and any other cardiovascular, cerebrovascular, convulsive, or other health conditions that may impair driving ability.
She sends off a standardized reporting form to the DMV. What happens next varies widely and seemingly arbitrarily. Some patients will get a letter from the DMV stating they need to come in for testing – either a written test, a road test, or a driving simulator. Others get a cease-and-desist order.
"That’s when I get the angry phone calls. I tell them in advance that I have to report them, but if they’re cognitively impaired, they may not remember having this conversation," Dr. Day said.
She’ll often use the annual wellness visit as an opportunity to talk about driving safety. But she also can carry out a driving evaluation during a 10-minute office visit. The key elements are to check the heart and lungs and perform a 10-second Get-Up-and-Go mobility test; a cognitive screening test; a musculoskeletal exam addressing the cervical spine, knees, and hips; and vision testing, which she has her medical assistant do.
The Get-Up-and-Go test entails having the patient rise out of a chair without the use of arms, walk three paces, turn around, and sit back down in the chair – all as fast as possible. It should take less than 10 seconds.
"That’s less than 10 seconds in your office to determine whether someone has got problems – potentially an arthritis problem or something else that could affect their driving ability. I defy you to give me any other screening test that takes less than 10 seconds," she said.
The fastest cognitive screening test is the Mini-Cog, which consists of clock drawing plus a three-word recall. It provides an indication as to whether additional neuropsychological testing is necessary. Dr. Day said she also uses the Trail Making B test "all the time" because there is some evidence that it’s a fairly good indicator of driving ability. It’s best to get someone on the office staff to become comfortable administering it. The test instructions allow grossly impaired patients up to 5 minutes to connect the letters to the numbers, which is too much of a physician’s time during a 10-minute visit.
Red flags in the history include a myocardial infarction, a stroke, traumatic brain injury due to a fall, seizures, the use of medications known to impair driving, and delirium.
"Development of delirium during a hospitalization is a sign that there’s actually some underlying cognitive impairment that hasn’t been recognized yet," according to Dr. Day.
Her preliminary screen for driving safety routinely includes the "10 Questions to Ask the Patient" described in the American Medical Association’s very useful "Physician's Guide to Assessing and Counseling Older Drivers." Among the 10 questions are, for example, " ‘Have you received any traffic citations for speeding, going too slow, improper turns, failure to stop, etc.?’ " and " ‘Have others criticized your driving or refused to drive with you?’ " she said. Patients can fill out the answers on a clipboard while in the waiting room.
Many patients will quickly see where these questions are headed and won’t answer honestly. That’s why the AMA also has come up with "10 Questions to Ask the Family." Among them are " ‘Does the patient need a copilot to alert them of potentially hazardous events or conditions?’ " and " ‘Do you feel uncomfortable in any way driving with the patient?’ " Dr. Day said.
"That’s a great question to ask the children because if they’re not letting the grandchildren drive with grandma or grandpa, there’s a problem," she said.
Driver rehabilitation options include occupational therapy to address mobility limitations, instruction by a member of the Association for Driver Rehabilitation Specialists, local driving schools, and training courses offered by the American Association of Retired Persons, the American Automobile Association, and the National Safety Council.
But when it really is time to stop driving altogether, Dr. Day said she speaks to the patient of "driving retirement," akin to the familiar milestone experience of retirement from work. She also plays the public safety card, asking, " ‘Would you want to hit someone’s child?’ " And since she is in Pennsylvania, a mandatory reporting state, she mentions her own responsibility.
"I work that," she admitted. "I say, ‘Look, my license is on the line. I have to report you.’ "
One audience member, noting that driving cessation conversations are "often very tense," likes to lighten things up a bit in the following way: "I tell patients there are three categories of recommendations for driving: One is you can drive. Two is you cannot drive. And the third is you can drive, but not in my neighborhood."
Dr. Day said an important part of preparing for the aftermath of not driving involves alerting patients to local resources that will help them get around without driving. Eldercare Locator is a U.S. Administration on Aging clearinghouse for local van services for the elderly and numerous other resources. The National Association of Area Agencies on Aging is another helpful organization. ITN America is a growing nonprofit volunteer organization of screened drivers available around the clock to drive patients.
She stressed that it’s crucial to monitor for depression at the next office visit after a patient stops driving. Giving up the car keys is often a big blow to self-esteem, and it can reduce opportunities to engage in social activities.
Dr. Day reported having no relevant financial conflicts.
NEW ORLEANS – Informing an elderly patient that it’s time to stop driving because of health-related safety concerns is one of the toughest, most tension-racked aspects of primary care practice, according to Dr. Hollis D. Day.
"The driving conversation with the elderly patient and family is probably the least favorite conversation that I have with anyone. And the fact that my colleagues send their patients to me to have that conversation tells me they don’t like it either," Dr. Day, a general internist at the University of Pittsburgh, said at the meeting.
"The reason is we’re actually afraid that it’s going to impair our future relationship with our patient. We’ve been with these patients for years, and now we’re telling them to stop doing something that is absolutely critical and vital to them. It makes us look like the bad guy. But it doesn’t have to be that way," she stressed.
She shared experience-based tips on how to make that discussion go as well as possible. She also explained how to efficiently conduct a driving safety assessment within the confines of a 10-minute office visit.
The first thing to understand about driver safety assessment is that there are no validated criteria for determining risk. While a classic study of Alzheimer’s disease outpatients showed they were overall less likely than nondemented controls to successfully complete a driving simulator test, many of the patients with mild Alzheimer’s disease did pass the test. And no cut point on the Mini-Mental Status Examination could be identified below which it was unsafe to drive (J. Am. Board Fam. Med. 1998;11:264-71).
"There were people who were apparently safely driving with MMSE scores of 21 and 20. So there is no hard and fast cut point at this time. This is important because there are legal considerations," Dr. Day said.
Public safety dictates that physicians have a duty to recommend limitation or cessation of driving if a patient’s health impairs driving ability. Only 10 states have a mandatory requirement for physician reporting to the department of motor vehicles, but another 22 encourage reporting if the physician thinks there’s a problem. State requirements change frequently. The best place to go to learn your current state laws is the Insurance Institute for Highway Safety website, which is updated every 6 months.
In Dr. Day’s home state of Pennsylvania, any health care provider has a legal duty to report a patient to the Department of Motor Vehicles within 10 days of diagnosing a qualifying condition. Such conditions specifically include visual impairment that’s uncorrectable, such as macular degeneration or diminished depth perception, as well as Parkinson’s disease, Alzheimer’s disease, and any other cardiovascular, cerebrovascular, convulsive, or other health conditions that may impair driving ability.
She sends off a standardized reporting form to the DMV. What happens next varies widely and seemingly arbitrarily. Some patients will get a letter from the DMV stating they need to come in for testing – either a written test, a road test, or a driving simulator. Others get a cease-and-desist order.
"That’s when I get the angry phone calls. I tell them in advance that I have to report them, but if they’re cognitively impaired, they may not remember having this conversation," Dr. Day said.
She’ll often use the annual wellness visit as an opportunity to talk about driving safety. But she also can carry out a driving evaluation during a 10-minute office visit. The key elements are to check the heart and lungs and perform a 10-second Get-Up-and-Go mobility test; a cognitive screening test; a musculoskeletal exam addressing the cervical spine, knees, and hips; and vision testing, which she has her medical assistant do.
The Get-Up-and-Go test entails having the patient rise out of a chair without the use of arms, walk three paces, turn around, and sit back down in the chair – all as fast as possible. It should take less than 10 seconds.
"That’s less than 10 seconds in your office to determine whether someone has got problems – potentially an arthritis problem or something else that could affect their driving ability. I defy you to give me any other screening test that takes less than 10 seconds," she said.
The fastest cognitive screening test is the Mini-Cog, which consists of clock drawing plus a three-word recall. It provides an indication as to whether additional neuropsychological testing is necessary. Dr. Day said she also uses the Trail Making B test "all the time" because there is some evidence that it’s a fairly good indicator of driving ability. It’s best to get someone on the office staff to become comfortable administering it. The test instructions allow grossly impaired patients up to 5 minutes to connect the letters to the numbers, which is too much of a physician’s time during a 10-minute visit.
Red flags in the history include a myocardial infarction, a stroke, traumatic brain injury due to a fall, seizures, the use of medications known to impair driving, and delirium.
"Development of delirium during a hospitalization is a sign that there’s actually some underlying cognitive impairment that hasn’t been recognized yet," according to Dr. Day.
Her preliminary screen for driving safety routinely includes the "10 Questions to Ask the Patient" described in the American Medical Association’s very useful "Physician's Guide to Assessing and Counseling Older Drivers." Among the 10 questions are, for example, " ‘Have you received any traffic citations for speeding, going too slow, improper turns, failure to stop, etc.?’ " and " ‘Have others criticized your driving or refused to drive with you?’ " she said. Patients can fill out the answers on a clipboard while in the waiting room.
Many patients will quickly see where these questions are headed and won’t answer honestly. That’s why the AMA also has come up with "10 Questions to Ask the Family." Among them are " ‘Does the patient need a copilot to alert them of potentially hazardous events or conditions?’ " and " ‘Do you feel uncomfortable in any way driving with the patient?’ " Dr. Day said.
"That’s a great question to ask the children because if they’re not letting the grandchildren drive with grandma or grandpa, there’s a problem," she said.
Driver rehabilitation options include occupational therapy to address mobility limitations, instruction by a member of the Association for Driver Rehabilitation Specialists, local driving schools, and training courses offered by the American Association of Retired Persons, the American Automobile Association, and the National Safety Council.
But when it really is time to stop driving altogether, Dr. Day said she speaks to the patient of "driving retirement," akin to the familiar milestone experience of retirement from work. She also plays the public safety card, asking, " ‘Would you want to hit someone’s child?’ " And since she is in Pennsylvania, a mandatory reporting state, she mentions her own responsibility.
"I work that," she admitted. "I say, ‘Look, my license is on the line. I have to report you.’ "
One audience member, noting that driving cessation conversations are "often very tense," likes to lighten things up a bit in the following way: "I tell patients there are three categories of recommendations for driving: One is you can drive. Two is you cannot drive. And the third is you can drive, but not in my neighborhood."
Dr. Day said an important part of preparing for the aftermath of not driving involves alerting patients to local resources that will help them get around without driving. Eldercare Locator is a U.S. Administration on Aging clearinghouse for local van services for the elderly and numerous other resources. The National Association of Area Agencies on Aging is another helpful organization. ITN America is a growing nonprofit volunteer organization of screened drivers available around the clock to drive patients.
She stressed that it’s crucial to monitor for depression at the next office visit after a patient stops driving. Giving up the car keys is often a big blow to self-esteem, and it can reduce opportunities to engage in social activities.
Dr. Day reported having no relevant financial conflicts.
FROM THE ANNUAL MEETING OF THE AMERICAN COLLEGE OF PHYSICIANS
Did the IOM Get Vitamin D Targets Wrong?
NEW ORLEANS – When the Institute of Medicine released updated recommendations on calcium and vitamin D intake in late 2010, the report became the backbone for clinical guidance. But since then, they have been hotly debated among those who say that the recommendations were too weak, and others who say that it has been inappropriately used to herald vitamin D as the next wonder substance, with little scientific evidence backing that claim.
The IOM guidelines "fail the smell test," said Dr. Neil Binkley, a geriatrician and research scientist at the University of Wisconsin–Madison. The recommended intake for a 1-year-old (600 IU/day) is the same as for a 70-year-old. That would make the recommended dietary allowance for vitamin D one of the few RDAs that do not adjust for age, he said at the annual meeting of the American College of Physicians.
In addition, the recommendations were formulated from a public health standpoint. That makes them less useful for determining the best recommended dietary allowance for an individual patient. Knowing an individual’s particular risk factors and variables in his or her life are crucial for determining an appropriate intake, he said.
Vitamin D deficiency is likely a growing issue, not just in the United States, but worldwide. Vitamin D is not commonly found in food, but is easily synthesized from sunlight. Centuries ago, humans wore less clothing and did not wear sunscreen. Now, of course, avoidance of sun exposure is common practice and has likely contributed to lower serum vitamin D levels in modern humans, he said.
For instance, a recent study showed that two traditional sub-Saharan tribes – the Maasai and the Hadzabe – who wear little clothing, do not use sunscreen, and have darkly pigmented skin (putting them at greater risk for vitamin D deficiency) – had a mean serum 25-hydroxyvitamin D concentration of 46 ng/mL (or 115 nmol/L), according to a study (Br. J. Nutr. 2012 Jan. 23 [doi:10.1017/S0007114511007161]).
This serum concentration is much greater than the IOM’s target of "sufficient" levels (defined as greater than 30 nmol/L). Levels between 20 and 30 nmol/L are considered insufficient, and less than 12 is considered deficient. According to these IOM figures, some 80% of whites have sufficient levels, whereas 71% of African Americans and 46% of Mexican Americans have low levels of serum vitamin D. Dr. Binkley said that he considers the IOM cut-offs to be conservative, but even according to those numbers, as much as a third of the U.S. population may be deficient.
Guidelines subsequently issued by the Endocrine Society called for higher RDAs than that recommended by the IOM, underscoring the lack of consensus around what constitutes a sufficient vitamin D intake, said Dr. Binkley.
There’s also lack of consensus around who should be screened for serum vitamin D levels. The Endocrine Society has called for screening of those "at risk," but then categorizes so many people as being at risk that it’s essentially equivalent to total population screening, said Dr. Binkley. He supports screening, in particular of older adults with a history of falls, and of others with a history of nontraumatic fractures. But he does not advocate total population screening.
What should physicians do? First, recognize that not all patients are the same and that a serum concentration of 20 ng/L may not be sufficient for every individual. Also, just urging sun exposure may not be enough for some patients, either. Multiple studies in the literature have shown that serum concentrations can vary widely among individuals, even when they have had equivalent levels of sun exposure, said Dr. Binkley.
Lab tests for serum vitamin D levels have improved over the years, but they are far from perfect.
So what are adequate levels? According to several studies in sun-exposed individuals, 20 ng/mL seems low and levels in the mid-30s seem reasonable, said Dr. Binkley. "I think we need to be above 30," he said, noting that, for many patients, that means a daily intake of 1,000-2,000 IU of vitamin D daily.
That advice jibes with a statement the American Association of Clinical Endocrinologists issued shortly after the IOM report. AACE recommended that an optimal range for most patients should be 30-50 ng/mL. To achieve that, it would be necessary to take 1,000-2,000 IU of vitamin D daily. The group also said that physicians should use the IOM recommendations "in conjunction with clinical judgment to determine the proper vitamin D requirement for any given patient."
The evidence seems to support that higher serum levels (greater than 30 ng/mL) are associated with reduced fracture and fall risk, but that at super-high levels, vitamin D actually increases falls and fractures, said Dr. Binkley. It’s not clear why that is. In the study, women were given a megadose of 500,000 IU of vitamin D once a year; findings suggested that a big blast of the vitamin is not helpful, he said (JAMA 2010:303:1815-22).
The data show that for each additional 1,000 IU daily, the serum level goes up by about 6 ng/mL. Increases will be greater for patients who start with lower serum levels. To determine what’s optimal, it’s probably necessary to measure serum levels periodically, Dr. Binkley said.
If you write a prescription, you’re likely to get the less optimal form of vitamin D, that is, vitamin D2. Humans make vitamin D3 when they are exposed to sunlight, but only D2 is available in prescription form. Dr. Binkley said that he prefers patients to take D3, which is available over the counter. But if he’s going for a big repletion – say a typical 50,000 IU dose – he has to use the D2 form.
It is possible to have vitamin D intoxication. Most studies have never documented anyone with serum levels greater than 70 ng/mL. Patients who have levels above 70 are probably getting too much vitamin D, he said.
Equally intoxicating is the hype surrounding vitamin D, which recently has been touted as a veritable fountain of youth. Almost every tissue in the body has a vitamin D receptor and it is produced locally by many tissues. But the evidence does not support the notion that low levels are responsible for a laundry list of diseases, Dr. Binkley said. It is plausible that low vitamin D contributes to impaired immune function, diabetes, vascular disease, and a higher risk for bone loss and fractures, among other conditions. Sufficient vitamin D may also reduce cancer risk.
But so far, too many studies show association, and not causation. "We need to stay tuned," said Dr. Binkley, noting that there need to be more randomized, prospective studies and no more meta-analyses.
The IOM report "is too weak," but trying to get patients to serum vitamin D levels greater than 40 ng/mL is not responsible, Dr. Binkley stressed.
Dr. Binkley has consulting arrangements with Eli Lilly and Merck, and grants from those companies as well as Amgen and Tarsa, but none relate to vitamin D.
NEW ORLEANS – When the Institute of Medicine released updated recommendations on calcium and vitamin D intake in late 2010, the report became the backbone for clinical guidance. But since then, they have been hotly debated among those who say that the recommendations were too weak, and others who say that it has been inappropriately used to herald vitamin D as the next wonder substance, with little scientific evidence backing that claim.
The IOM guidelines "fail the smell test," said Dr. Neil Binkley, a geriatrician and research scientist at the University of Wisconsin–Madison. The recommended intake for a 1-year-old (600 IU/day) is the same as for a 70-year-old. That would make the recommended dietary allowance for vitamin D one of the few RDAs that do not adjust for age, he said at the annual meeting of the American College of Physicians.
In addition, the recommendations were formulated from a public health standpoint. That makes them less useful for determining the best recommended dietary allowance for an individual patient. Knowing an individual’s particular risk factors and variables in his or her life are crucial for determining an appropriate intake, he said.
Vitamin D deficiency is likely a growing issue, not just in the United States, but worldwide. Vitamin D is not commonly found in food, but is easily synthesized from sunlight. Centuries ago, humans wore less clothing and did not wear sunscreen. Now, of course, avoidance of sun exposure is common practice and has likely contributed to lower serum vitamin D levels in modern humans, he said.
For instance, a recent study showed that two traditional sub-Saharan tribes – the Maasai and the Hadzabe – who wear little clothing, do not use sunscreen, and have darkly pigmented skin (putting them at greater risk for vitamin D deficiency) – had a mean serum 25-hydroxyvitamin D concentration of 46 ng/mL (or 115 nmol/L), according to a study (Br. J. Nutr. 2012 Jan. 23 [doi:10.1017/S0007114511007161]).
This serum concentration is much greater than the IOM’s target of "sufficient" levels (defined as greater than 30 nmol/L). Levels between 20 and 30 nmol/L are considered insufficient, and less than 12 is considered deficient. According to these IOM figures, some 80% of whites have sufficient levels, whereas 71% of African Americans and 46% of Mexican Americans have low levels of serum vitamin D. Dr. Binkley said that he considers the IOM cut-offs to be conservative, but even according to those numbers, as much as a third of the U.S. population may be deficient.
Guidelines subsequently issued by the Endocrine Society called for higher RDAs than that recommended by the IOM, underscoring the lack of consensus around what constitutes a sufficient vitamin D intake, said Dr. Binkley.
There’s also lack of consensus around who should be screened for serum vitamin D levels. The Endocrine Society has called for screening of those "at risk," but then categorizes so many people as being at risk that it’s essentially equivalent to total population screening, said Dr. Binkley. He supports screening, in particular of older adults with a history of falls, and of others with a history of nontraumatic fractures. But he does not advocate total population screening.
What should physicians do? First, recognize that not all patients are the same and that a serum concentration of 20 ng/L may not be sufficient for every individual. Also, just urging sun exposure may not be enough for some patients, either. Multiple studies in the literature have shown that serum concentrations can vary widely among individuals, even when they have had equivalent levels of sun exposure, said Dr. Binkley.
Lab tests for serum vitamin D levels have improved over the years, but they are far from perfect.
So what are adequate levels? According to several studies in sun-exposed individuals, 20 ng/mL seems low and levels in the mid-30s seem reasonable, said Dr. Binkley. "I think we need to be above 30," he said, noting that, for many patients, that means a daily intake of 1,000-2,000 IU of vitamin D daily.
That advice jibes with a statement the American Association of Clinical Endocrinologists issued shortly after the IOM report. AACE recommended that an optimal range for most patients should be 30-50 ng/mL. To achieve that, it would be necessary to take 1,000-2,000 IU of vitamin D daily. The group also said that physicians should use the IOM recommendations "in conjunction with clinical judgment to determine the proper vitamin D requirement for any given patient."
The evidence seems to support that higher serum levels (greater than 30 ng/mL) are associated with reduced fracture and fall risk, but that at super-high levels, vitamin D actually increases falls and fractures, said Dr. Binkley. It’s not clear why that is. In the study, women were given a megadose of 500,000 IU of vitamin D once a year; findings suggested that a big blast of the vitamin is not helpful, he said (JAMA 2010:303:1815-22).
The data show that for each additional 1,000 IU daily, the serum level goes up by about 6 ng/mL. Increases will be greater for patients who start with lower serum levels. To determine what’s optimal, it’s probably necessary to measure serum levels periodically, Dr. Binkley said.
If you write a prescription, you’re likely to get the less optimal form of vitamin D, that is, vitamin D2. Humans make vitamin D3 when they are exposed to sunlight, but only D2 is available in prescription form. Dr. Binkley said that he prefers patients to take D3, which is available over the counter. But if he’s going for a big repletion – say a typical 50,000 IU dose – he has to use the D2 form.
It is possible to have vitamin D intoxication. Most studies have never documented anyone with serum levels greater than 70 ng/mL. Patients who have levels above 70 are probably getting too much vitamin D, he said.
Equally intoxicating is the hype surrounding vitamin D, which recently has been touted as a veritable fountain of youth. Almost every tissue in the body has a vitamin D receptor and it is produced locally by many tissues. But the evidence does not support the notion that low levels are responsible for a laundry list of diseases, Dr. Binkley said. It is plausible that low vitamin D contributes to impaired immune function, diabetes, vascular disease, and a higher risk for bone loss and fractures, among other conditions. Sufficient vitamin D may also reduce cancer risk.
But so far, too many studies show association, and not causation. "We need to stay tuned," said Dr. Binkley, noting that there need to be more randomized, prospective studies and no more meta-analyses.
The IOM report "is too weak," but trying to get patients to serum vitamin D levels greater than 40 ng/mL is not responsible, Dr. Binkley stressed.
Dr. Binkley has consulting arrangements with Eli Lilly and Merck, and grants from those companies as well as Amgen and Tarsa, but none relate to vitamin D.
NEW ORLEANS – When the Institute of Medicine released updated recommendations on calcium and vitamin D intake in late 2010, the report became the backbone for clinical guidance. But since then, they have been hotly debated among those who say that the recommendations were too weak, and others who say that it has been inappropriately used to herald vitamin D as the next wonder substance, with little scientific evidence backing that claim.
The IOM guidelines "fail the smell test," said Dr. Neil Binkley, a geriatrician and research scientist at the University of Wisconsin–Madison. The recommended intake for a 1-year-old (600 IU/day) is the same as for a 70-year-old. That would make the recommended dietary allowance for vitamin D one of the few RDAs that do not adjust for age, he said at the annual meeting of the American College of Physicians.
In addition, the recommendations were formulated from a public health standpoint. That makes them less useful for determining the best recommended dietary allowance for an individual patient. Knowing an individual’s particular risk factors and variables in his or her life are crucial for determining an appropriate intake, he said.
Vitamin D deficiency is likely a growing issue, not just in the United States, but worldwide. Vitamin D is not commonly found in food, but is easily synthesized from sunlight. Centuries ago, humans wore less clothing and did not wear sunscreen. Now, of course, avoidance of sun exposure is common practice and has likely contributed to lower serum vitamin D levels in modern humans, he said.
For instance, a recent study showed that two traditional sub-Saharan tribes – the Maasai and the Hadzabe – who wear little clothing, do not use sunscreen, and have darkly pigmented skin (putting them at greater risk for vitamin D deficiency) – had a mean serum 25-hydroxyvitamin D concentration of 46 ng/mL (or 115 nmol/L), according to a study (Br. J. Nutr. 2012 Jan. 23 [doi:10.1017/S0007114511007161]).
This serum concentration is much greater than the IOM’s target of "sufficient" levels (defined as greater than 30 nmol/L). Levels between 20 and 30 nmol/L are considered insufficient, and less than 12 is considered deficient. According to these IOM figures, some 80% of whites have sufficient levels, whereas 71% of African Americans and 46% of Mexican Americans have low levels of serum vitamin D. Dr. Binkley said that he considers the IOM cut-offs to be conservative, but even according to those numbers, as much as a third of the U.S. population may be deficient.
Guidelines subsequently issued by the Endocrine Society called for higher RDAs than that recommended by the IOM, underscoring the lack of consensus around what constitutes a sufficient vitamin D intake, said Dr. Binkley.
There’s also lack of consensus around who should be screened for serum vitamin D levels. The Endocrine Society has called for screening of those "at risk," but then categorizes so many people as being at risk that it’s essentially equivalent to total population screening, said Dr. Binkley. He supports screening, in particular of older adults with a history of falls, and of others with a history of nontraumatic fractures. But he does not advocate total population screening.
What should physicians do? First, recognize that not all patients are the same and that a serum concentration of 20 ng/L may not be sufficient for every individual. Also, just urging sun exposure may not be enough for some patients, either. Multiple studies in the literature have shown that serum concentrations can vary widely among individuals, even when they have had equivalent levels of sun exposure, said Dr. Binkley.
Lab tests for serum vitamin D levels have improved over the years, but they are far from perfect.
So what are adequate levels? According to several studies in sun-exposed individuals, 20 ng/mL seems low and levels in the mid-30s seem reasonable, said Dr. Binkley. "I think we need to be above 30," he said, noting that, for many patients, that means a daily intake of 1,000-2,000 IU of vitamin D daily.
That advice jibes with a statement the American Association of Clinical Endocrinologists issued shortly after the IOM report. AACE recommended that an optimal range for most patients should be 30-50 ng/mL. To achieve that, it would be necessary to take 1,000-2,000 IU of vitamin D daily. The group also said that physicians should use the IOM recommendations "in conjunction with clinical judgment to determine the proper vitamin D requirement for any given patient."
The evidence seems to support that higher serum levels (greater than 30 ng/mL) are associated with reduced fracture and fall risk, but that at super-high levels, vitamin D actually increases falls and fractures, said Dr. Binkley. It’s not clear why that is. In the study, women were given a megadose of 500,000 IU of vitamin D once a year; findings suggested that a big blast of the vitamin is not helpful, he said (JAMA 2010:303:1815-22).
The data show that for each additional 1,000 IU daily, the serum level goes up by about 6 ng/mL. Increases will be greater for patients who start with lower serum levels. To determine what’s optimal, it’s probably necessary to measure serum levels periodically, Dr. Binkley said.
If you write a prescription, you’re likely to get the less optimal form of vitamin D, that is, vitamin D2. Humans make vitamin D3 when they are exposed to sunlight, but only D2 is available in prescription form. Dr. Binkley said that he prefers patients to take D3, which is available over the counter. But if he’s going for a big repletion – say a typical 50,000 IU dose – he has to use the D2 form.
It is possible to have vitamin D intoxication. Most studies have never documented anyone with serum levels greater than 70 ng/mL. Patients who have levels above 70 are probably getting too much vitamin D, he said.
Equally intoxicating is the hype surrounding vitamin D, which recently has been touted as a veritable fountain of youth. Almost every tissue in the body has a vitamin D receptor and it is produced locally by many tissues. But the evidence does not support the notion that low levels are responsible for a laundry list of diseases, Dr. Binkley said. It is plausible that low vitamin D contributes to impaired immune function, diabetes, vascular disease, and a higher risk for bone loss and fractures, among other conditions. Sufficient vitamin D may also reduce cancer risk.
But so far, too many studies show association, and not causation. "We need to stay tuned," said Dr. Binkley, noting that there need to be more randomized, prospective studies and no more meta-analyses.
The IOM report "is too weak," but trying to get patients to serum vitamin D levels greater than 40 ng/mL is not responsible, Dr. Binkley stressed.
Dr. Binkley has consulting arrangements with Eli Lilly and Merck, and grants from those companies as well as Amgen and Tarsa, but none relate to vitamin D.
EXPERT ANALYSIS FROM THE ANNUAL MEETING OF THE AMERICAN COLLEGE OF PHYSICIANS
Hiatal Hernia History? Consider Gastric Volvulus
NEW ORLEANS – Think ‘chronic gastric volvulus’ when a patient with a history of hiatal hernia presents with nonspecific symptoms such as difficulty in swallowing food and uncomfortable fullness after eating.
Gastric volvulus – a torsional twisting of the stomach – is an underrecognized complication of hiatal hernia. It occurs most often in patients with a large paraesophageal hiatal hernia or with an intrathoracic stomach that has come loose from its abdominal moorings, Dr. Conor G. Loftus explained at the conference.
Acute gastric volvulus is a surgical emergency. It typically presents suddenly with severe pain in the lower chest or upper abdomen, often accompanied by persistent nonproductive retching. It’s often mistaken for an acute MI. Yet acute gastric volvulus is no less serious an event, according to Dr. Loftus, a gastroenterologist at the Mayo Clinic, Rochester, Minn.
In contrast, chronic gastric volvulus is characterized by considerably milder, nonspecific symptoms. When clinical suspicion focuses on this possible diagnosis, the best confirmatory test is a barium esophagram.
Dr. Loftus presented an illustrative case: a 70-year-old man who presents complaining of nonpainful difficulty in swallowing solid food but not liquids for the past several years. He has a history of hiatal hernia as well as long-standing gastroesophageal reflux disease controlled with once-daily proton pump inhibitor therapy. He hasn’t lost weight. A gastroenterologist performed upper endoscopy with grossly normal findings, albeit with a notation that it was somewhat difficult to pass the probe across a tortuous esophagus and stomach.
In this vignette, Dr. Loftus observed, the clinical presentation and endoscopic findings raise a red flag for chronic gastric volvulus. In particular, the reported earlier difficulty in passing the endoscope suggests a mechanical problem.
Ordering esophageal manometry would be the right choice if a dysmotility disorder were suspected; however, a recent-onset dysmotility disorder would be unusual in an aged individual and, in any case, it would typically present with both liquid and solid food dysphagia.
Endoscopic ultrasound of the gastroesophageal junction or CT scan of the chest would be the appropriate imaging study if a malignancy was suspected. But the lack of weight loss in a patient with a 3-year history of symptoms argues strongly against that possibility, he continued.
Repeating the earlier upper endoscopy, this time obtaining esophageal biopsies, would be a good move if eosinophilic esophagitis was suspected; however, this disorder is uncommon at an advanced age, Dr. Loftus noted.
He reported having no financial conflicts.
NEW ORLEANS – Think ‘chronic gastric volvulus’ when a patient with a history of hiatal hernia presents with nonspecific symptoms such as difficulty in swallowing food and uncomfortable fullness after eating.
Gastric volvulus – a torsional twisting of the stomach – is an underrecognized complication of hiatal hernia. It occurs most often in patients with a large paraesophageal hiatal hernia or with an intrathoracic stomach that has come loose from its abdominal moorings, Dr. Conor G. Loftus explained at the conference.
Acute gastric volvulus is a surgical emergency. It typically presents suddenly with severe pain in the lower chest or upper abdomen, often accompanied by persistent nonproductive retching. It’s often mistaken for an acute MI. Yet acute gastric volvulus is no less serious an event, according to Dr. Loftus, a gastroenterologist at the Mayo Clinic, Rochester, Minn.
In contrast, chronic gastric volvulus is characterized by considerably milder, nonspecific symptoms. When clinical suspicion focuses on this possible diagnosis, the best confirmatory test is a barium esophagram.
Dr. Loftus presented an illustrative case: a 70-year-old man who presents complaining of nonpainful difficulty in swallowing solid food but not liquids for the past several years. He has a history of hiatal hernia as well as long-standing gastroesophageal reflux disease controlled with once-daily proton pump inhibitor therapy. He hasn’t lost weight. A gastroenterologist performed upper endoscopy with grossly normal findings, albeit with a notation that it was somewhat difficult to pass the probe across a tortuous esophagus and stomach.
In this vignette, Dr. Loftus observed, the clinical presentation and endoscopic findings raise a red flag for chronic gastric volvulus. In particular, the reported earlier difficulty in passing the endoscope suggests a mechanical problem.
Ordering esophageal manometry would be the right choice if a dysmotility disorder were suspected; however, a recent-onset dysmotility disorder would be unusual in an aged individual and, in any case, it would typically present with both liquid and solid food dysphagia.
Endoscopic ultrasound of the gastroesophageal junction or CT scan of the chest would be the appropriate imaging study if a malignancy was suspected. But the lack of weight loss in a patient with a 3-year history of symptoms argues strongly against that possibility, he continued.
Repeating the earlier upper endoscopy, this time obtaining esophageal biopsies, would be a good move if eosinophilic esophagitis was suspected; however, this disorder is uncommon at an advanced age, Dr. Loftus noted.
He reported having no financial conflicts.
NEW ORLEANS – Think ‘chronic gastric volvulus’ when a patient with a history of hiatal hernia presents with nonspecific symptoms such as difficulty in swallowing food and uncomfortable fullness after eating.
Gastric volvulus – a torsional twisting of the stomach – is an underrecognized complication of hiatal hernia. It occurs most often in patients with a large paraesophageal hiatal hernia or with an intrathoracic stomach that has come loose from its abdominal moorings, Dr. Conor G. Loftus explained at the conference.
Acute gastric volvulus is a surgical emergency. It typically presents suddenly with severe pain in the lower chest or upper abdomen, often accompanied by persistent nonproductive retching. It’s often mistaken for an acute MI. Yet acute gastric volvulus is no less serious an event, according to Dr. Loftus, a gastroenterologist at the Mayo Clinic, Rochester, Minn.
In contrast, chronic gastric volvulus is characterized by considerably milder, nonspecific symptoms. When clinical suspicion focuses on this possible diagnosis, the best confirmatory test is a barium esophagram.
Dr. Loftus presented an illustrative case: a 70-year-old man who presents complaining of nonpainful difficulty in swallowing solid food but not liquids for the past several years. He has a history of hiatal hernia as well as long-standing gastroesophageal reflux disease controlled with once-daily proton pump inhibitor therapy. He hasn’t lost weight. A gastroenterologist performed upper endoscopy with grossly normal findings, albeit with a notation that it was somewhat difficult to pass the probe across a tortuous esophagus and stomach.
In this vignette, Dr. Loftus observed, the clinical presentation and endoscopic findings raise a red flag for chronic gastric volvulus. In particular, the reported earlier difficulty in passing the endoscope suggests a mechanical problem.
Ordering esophageal manometry would be the right choice if a dysmotility disorder were suspected; however, a recent-onset dysmotility disorder would be unusual in an aged individual and, in any case, it would typically present with both liquid and solid food dysphagia.
Endoscopic ultrasound of the gastroesophageal junction or CT scan of the chest would be the appropriate imaging study if a malignancy was suspected. But the lack of weight loss in a patient with a 3-year history of symptoms argues strongly against that possibility, he continued.
Repeating the earlier upper endoscopy, this time obtaining esophageal biopsies, would be a good move if eosinophilic esophagitis was suspected; however, this disorder is uncommon at an advanced age, Dr. Loftus noted.
He reported having no financial conflicts.
EXPERT ANALYSIS FROM THE ANNUAL MEETING OF AMERICAN COLLEGE OF PHYSICIANS
Persistent Daytime Sleepiness Common Despite Effective CPAP
NEW ORLEANS – Excessive daytime sleepiness in patients with obstructive sleep apnea remains a common and often debilitating problem, despite optimal use of continuous positive airway pressure treatment, according to Dr. Janine R.E. Vintch.
The two drugs most beneficial as adjunctive therapy for these patients are modafinil (Provigil) and armodafinil (Nuvigil). Both are approved by the Food and Drug Administration for the management of persistent sleepiness and fatigue in patients with sleep apnea who are compliant with their CPAP therapy, Dr. Vintch said at the annual meeting of the American College of Physicians.
In one study, 22% of patients with obstructive sleep apnea using effective CPAP – that is, CPAP for more than 6 hours per night – still had impaired daytime functioning because of excessive daytime sleepiness documented on objective tests, including the Multiple Sleep Latency Test. This persistent daytime somnolence can manifest as cognitive impairment, diminished vigilance, and increased rates of workplace and motor vehicle accidents.
Before turning to drug therapy, however, it’s crucial to rule out other causes of persistent daytime sleepiness. The No. 1 reason is the patient is less adherent to CPAP than claimed. Other possible explanations include an improperly fitting CPAP mask, poor sleep hygiene, depression, and additional sleep disorders, such as restless legs, said Dr. Vintch of the University of California, Los Angeles.
Modafinil is a novel wake-promoting agent approved in 2004 for the management of residual sleepiness in CPAP-compliant patients. In 2006 the American Academy of Sleep Medicine published a practice parameter on the medical therapy of obstructive sleep apnea that endorsed modafinil as a standard recommendation for this indication (Sleep 2006;29:1031-5). It has a low abuse potential. Its mechanism of action remains controversial. Modafinil is cleared by both the liver and kidneys, so lower doses are appropriate in patients with either hepatic or renal dysfunction.
Modafinil has several important interactions with other drugs. These medications include propranolol, diltiazem, phenytoin, carbamazepine, and diazepam; the levels of all these drugs are increased in patients on modafinil. Also, women of childbearing age who are on ethinyl estradiol need to be given an alternative method of contraception, she said.
The most common side effects attributed to modafinil are headache, nausea, and nervousness. The headaches typically disappear after the first 3 days of treatment.
Armodafinil is the R-isomer of modafinil. Its 10- to 15-hour half-life is slightly longer than modafinil’s. It has the same side effects as modafinil.
Long-term studies of both drugs have documented good safety and tolerability along with improved objective and subjective measures of wakefulness and cognition.
Dr. Vintch reported having no relevant financial relationships.
NEW ORLEANS – Excessive daytime sleepiness in patients with obstructive sleep apnea remains a common and often debilitating problem, despite optimal use of continuous positive airway pressure treatment, according to Dr. Janine R.E. Vintch.
The two drugs most beneficial as adjunctive therapy for these patients are modafinil (Provigil) and armodafinil (Nuvigil). Both are approved by the Food and Drug Administration for the management of persistent sleepiness and fatigue in patients with sleep apnea who are compliant with their CPAP therapy, Dr. Vintch said at the annual meeting of the American College of Physicians.
In one study, 22% of patients with obstructive sleep apnea using effective CPAP – that is, CPAP for more than 6 hours per night – still had impaired daytime functioning because of excessive daytime sleepiness documented on objective tests, including the Multiple Sleep Latency Test. This persistent daytime somnolence can manifest as cognitive impairment, diminished vigilance, and increased rates of workplace and motor vehicle accidents.
Before turning to drug therapy, however, it’s crucial to rule out other causes of persistent daytime sleepiness. The No. 1 reason is the patient is less adherent to CPAP than claimed. Other possible explanations include an improperly fitting CPAP mask, poor sleep hygiene, depression, and additional sleep disorders, such as restless legs, said Dr. Vintch of the University of California, Los Angeles.
Modafinil is a novel wake-promoting agent approved in 2004 for the management of residual sleepiness in CPAP-compliant patients. In 2006 the American Academy of Sleep Medicine published a practice parameter on the medical therapy of obstructive sleep apnea that endorsed modafinil as a standard recommendation for this indication (Sleep 2006;29:1031-5). It has a low abuse potential. Its mechanism of action remains controversial. Modafinil is cleared by both the liver and kidneys, so lower doses are appropriate in patients with either hepatic or renal dysfunction.
Modafinil has several important interactions with other drugs. These medications include propranolol, diltiazem, phenytoin, carbamazepine, and diazepam; the levels of all these drugs are increased in patients on modafinil. Also, women of childbearing age who are on ethinyl estradiol need to be given an alternative method of contraception, she said.
The most common side effects attributed to modafinil are headache, nausea, and nervousness. The headaches typically disappear after the first 3 days of treatment.
Armodafinil is the R-isomer of modafinil. Its 10- to 15-hour half-life is slightly longer than modafinil’s. It has the same side effects as modafinil.
Long-term studies of both drugs have documented good safety and tolerability along with improved objective and subjective measures of wakefulness and cognition.
Dr. Vintch reported having no relevant financial relationships.
NEW ORLEANS – Excessive daytime sleepiness in patients with obstructive sleep apnea remains a common and often debilitating problem, despite optimal use of continuous positive airway pressure treatment, according to Dr. Janine R.E. Vintch.
The two drugs most beneficial as adjunctive therapy for these patients are modafinil (Provigil) and armodafinil (Nuvigil). Both are approved by the Food and Drug Administration for the management of persistent sleepiness and fatigue in patients with sleep apnea who are compliant with their CPAP therapy, Dr. Vintch said at the annual meeting of the American College of Physicians.
In one study, 22% of patients with obstructive sleep apnea using effective CPAP – that is, CPAP for more than 6 hours per night – still had impaired daytime functioning because of excessive daytime sleepiness documented on objective tests, including the Multiple Sleep Latency Test. This persistent daytime somnolence can manifest as cognitive impairment, diminished vigilance, and increased rates of workplace and motor vehicle accidents.
Before turning to drug therapy, however, it’s crucial to rule out other causes of persistent daytime sleepiness. The No. 1 reason is the patient is less adherent to CPAP than claimed. Other possible explanations include an improperly fitting CPAP mask, poor sleep hygiene, depression, and additional sleep disorders, such as restless legs, said Dr. Vintch of the University of California, Los Angeles.
Modafinil is a novel wake-promoting agent approved in 2004 for the management of residual sleepiness in CPAP-compliant patients. In 2006 the American Academy of Sleep Medicine published a practice parameter on the medical therapy of obstructive sleep apnea that endorsed modafinil as a standard recommendation for this indication (Sleep 2006;29:1031-5). It has a low abuse potential. Its mechanism of action remains controversial. Modafinil is cleared by both the liver and kidneys, so lower doses are appropriate in patients with either hepatic or renal dysfunction.
Modafinil has several important interactions with other drugs. These medications include propranolol, diltiazem, phenytoin, carbamazepine, and diazepam; the levels of all these drugs are increased in patients on modafinil. Also, women of childbearing age who are on ethinyl estradiol need to be given an alternative method of contraception, she said.
The most common side effects attributed to modafinil are headache, nausea, and nervousness. The headaches typically disappear after the first 3 days of treatment.
Armodafinil is the R-isomer of modafinil. Its 10- to 15-hour half-life is slightly longer than modafinil’s. It has the same side effects as modafinil.
Long-term studies of both drugs have documented good safety and tolerability along with improved objective and subjective measures of wakefulness and cognition.
Dr. Vintch reported having no relevant financial relationships.
EXPERT ANALYSIS FROM THE ANNUAL MEETING OF THE AMERICAN COLLEGE OF PHYSICIANS
Antibiotics/Probiotics Helpful in Irritable Bowel Syndrome
NEW ORLEANS – Both probiotics and antibiotics can be considered legitimate, evidence-based treatments for irritable bowel syndrome.
The gut flora of patients with irritable bowel syndrome (IBS) differs both quantitatively and qualitatively from that of unaffected individuals. The proposed mechanism of the demonstrated benefit for probiotics and antibiotics lies in the controversial notion that bacterial overgrowth in the small intestines may account for some cases of IBS.
"The thought is that if you can restore a balanced intestinal flora in somebody with IBS, you may be able to eliminate the symptoms. So a better biome may mean a better life," explained Cmdr. Patrick E. Young, USN, a gastroenterologist at Walter Reed National Military Medical Center in Bethesda, Md.
By far the best-studied probiotic in the treatment of IBS is Bifidobacterium infantis. It is supported by "very powerful" data showing reductions in bloating, abdominal pain, and passing of gas, as well as easing of bowel movement difficulty and normalization of aberrant peripheral cytokine levels, according to Dr. Young.
The effective dose as demonstrated in a 362-patient, multicenter, randomized trial is 1 × 108 CFU/mL (Am. J. Gastroenterol. 2006;101:1581-90). Bifidobacterium infantis is commercially available as a nutritional supplement in fortified yogurt or in capsule form. Long-term efficacy data are lacking, but the probiotic is devoid of significant side effects, the gastroenterologist said.
He noted that a recent meta-analysis concluded that oral rifaximin (Xifaxan) provides significant short-term relief of bloating as well as improved global quality of life scores in patients with IBS. The meta-analysis included five randomized, placebo-controlled clinical trials with a total of 1,803 patients. The number needed to treat was roughly 10 for both outcomes. The outcomes were better in older female patients.
The investigators characterized the 10% therapeutic gain over placebo as "modest" and similar to that provided by other accepted therapies for IBS (Am. J. Gastroenterol. 2012;107:28-35).
To this Dr. Young added his own caveat: The longest study of rifaximin followed patients for only 12 weeks.
"I would caution you in using antibiotics for a benign, incurable condition in general. These typically 20- to 30-year-old patients are going to live for another 40-50 years with the consequences of repetitive antibiotic exposure. This is a relatively new agent, and we don’t know what the long-term effect is going to be. That being said, there have been cases where I have used this with some success," Dr. Young said.
The standard dosing is 550 mg TID for 14 days, he said.
Dr. Young reported having no financial conflicts.
NEW ORLEANS – Both probiotics and antibiotics can be considered legitimate, evidence-based treatments for irritable bowel syndrome.
The gut flora of patients with irritable bowel syndrome (IBS) differs both quantitatively and qualitatively from that of unaffected individuals. The proposed mechanism of the demonstrated benefit for probiotics and antibiotics lies in the controversial notion that bacterial overgrowth in the small intestines may account for some cases of IBS.
"The thought is that if you can restore a balanced intestinal flora in somebody with IBS, you may be able to eliminate the symptoms. So a better biome may mean a better life," explained Cmdr. Patrick E. Young, USN, a gastroenterologist at Walter Reed National Military Medical Center in Bethesda, Md.
By far the best-studied probiotic in the treatment of IBS is Bifidobacterium infantis. It is supported by "very powerful" data showing reductions in bloating, abdominal pain, and passing of gas, as well as easing of bowel movement difficulty and normalization of aberrant peripheral cytokine levels, according to Dr. Young.
The effective dose as demonstrated in a 362-patient, multicenter, randomized trial is 1 × 108 CFU/mL (Am. J. Gastroenterol. 2006;101:1581-90). Bifidobacterium infantis is commercially available as a nutritional supplement in fortified yogurt or in capsule form. Long-term efficacy data are lacking, but the probiotic is devoid of significant side effects, the gastroenterologist said.
He noted that a recent meta-analysis concluded that oral rifaximin (Xifaxan) provides significant short-term relief of bloating as well as improved global quality of life scores in patients with IBS. The meta-analysis included five randomized, placebo-controlled clinical trials with a total of 1,803 patients. The number needed to treat was roughly 10 for both outcomes. The outcomes were better in older female patients.
The investigators characterized the 10% therapeutic gain over placebo as "modest" and similar to that provided by other accepted therapies for IBS (Am. J. Gastroenterol. 2012;107:28-35).
To this Dr. Young added his own caveat: The longest study of rifaximin followed patients for only 12 weeks.
"I would caution you in using antibiotics for a benign, incurable condition in general. These typically 20- to 30-year-old patients are going to live for another 40-50 years with the consequences of repetitive antibiotic exposure. This is a relatively new agent, and we don’t know what the long-term effect is going to be. That being said, there have been cases where I have used this with some success," Dr. Young said.
The standard dosing is 550 mg TID for 14 days, he said.
Dr. Young reported having no financial conflicts.
NEW ORLEANS – Both probiotics and antibiotics can be considered legitimate, evidence-based treatments for irritable bowel syndrome.
The gut flora of patients with irritable bowel syndrome (IBS) differs both quantitatively and qualitatively from that of unaffected individuals. The proposed mechanism of the demonstrated benefit for probiotics and antibiotics lies in the controversial notion that bacterial overgrowth in the small intestines may account for some cases of IBS.
"The thought is that if you can restore a balanced intestinal flora in somebody with IBS, you may be able to eliminate the symptoms. So a better biome may mean a better life," explained Cmdr. Patrick E. Young, USN, a gastroenterologist at Walter Reed National Military Medical Center in Bethesda, Md.
By far the best-studied probiotic in the treatment of IBS is Bifidobacterium infantis. It is supported by "very powerful" data showing reductions in bloating, abdominal pain, and passing of gas, as well as easing of bowel movement difficulty and normalization of aberrant peripheral cytokine levels, according to Dr. Young.
The effective dose as demonstrated in a 362-patient, multicenter, randomized trial is 1 × 108 CFU/mL (Am. J. Gastroenterol. 2006;101:1581-90). Bifidobacterium infantis is commercially available as a nutritional supplement in fortified yogurt or in capsule form. Long-term efficacy data are lacking, but the probiotic is devoid of significant side effects, the gastroenterologist said.
He noted that a recent meta-analysis concluded that oral rifaximin (Xifaxan) provides significant short-term relief of bloating as well as improved global quality of life scores in patients with IBS. The meta-analysis included five randomized, placebo-controlled clinical trials with a total of 1,803 patients. The number needed to treat was roughly 10 for both outcomes. The outcomes were better in older female patients.
The investigators characterized the 10% therapeutic gain over placebo as "modest" and similar to that provided by other accepted therapies for IBS (Am. J. Gastroenterol. 2012;107:28-35).
To this Dr. Young added his own caveat: The longest study of rifaximin followed patients for only 12 weeks.
"I would caution you in using antibiotics for a benign, incurable condition in general. These typically 20- to 30-year-old patients are going to live for another 40-50 years with the consequences of repetitive antibiotic exposure. This is a relatively new agent, and we don’t know what the long-term effect is going to be. That being said, there have been cases where I have used this with some success," Dr. Young said.
The standard dosing is 550 mg TID for 14 days, he said.
Dr. Young reported having no financial conflicts.
EXPERT ANALYSIS FROM THE ANNUAL MEETING OF AMERICAN COLLEGE OF PHYSICIANS
Prescribe Chronic Opiates Safely and Efficiently
NEW ORLEANS – Patient visits involving prescription of opiates for chronic pain can be among the most cringe-producing encounters in primary care medicine.
These visits place physicians in the difficult position of determining whether a patient is lying or in chronic pain, said Dr. Barak Gaster, a general internist at the University of Washington, Seattle.
The goal is to help slow the arc of the pendulum of opiate prescribing. Fueled by recent reports of overdose deaths from opiates being greater than those from heroin and cocaine combined, the pendulum is rapidly swinging away from a period of overprescribing, which fed the nation’s huge prescription drug misuse problem, and is now headed back towards undertreatment of chronic pain.
"I think if we all get too freaked out by the [risk of] fatal overdoses and too frustrated by what a difficult area this is, more and more doctors will say, ‘I just don’t [prescribe opiates] anymore.’ And that would be a shame because there are definitely people who benefit from being on chronic opiates," he said at the annual meeting of the American College of Physicians.
A few practical tools make opiate prescribing safer and more efficient in a busy primary care practice, according to Dr. Gaster. Here are his recommendations for safer, more manageable opiate prescribing:
Establish a clear upper limit on dosing: An upper limit is, quite simply, the most important thing physicians can do to limit inappropriate opiate prescribing. The epidemiologic literature indicates that the risk of unintentional fatal overdose jumps at more than 120 milliequivalents of morphine per day, a value that "exceeds my comfort zone," Dr. Gaster said. But wherever the line is drawn – say, 60 or 80 milliequivalents per day – stay the course no matter what the patient says.
"What little research has been done in this area suggests that opiates have mild to moderate efficacy for chronic pain, that very low doses are about as likely to work as very high doses, and that in situations where you’re not achieving adequate pain control at lower doses the idea that you can just go to higher and higher doses is wrong and you’ll end up causing harm," he said.
The notion that dosing should continue to increase until pain control is achieved is appropriate for cancer pain, which is the setting where most physicians-in-training learned to use opiates, but it’s all wrong for noncancer chronic pain, he noted.
Have your patter down: Physicians need to have a pre-rehearsed response in mind for when they walk into the examination room and patients say that the maximum dose isn’t getting the job done. That ready-made response will keep the office visit moving briskly along. Here’s what Dr. Gaster suggested: "Honestly, I don’t believe that higher doses would be safe for you. This is the maximum dose that I feel comfortable prescribing in a safe way."
Make smart use of written care agreements: Many physicians try to list every possible aberrant behavior and transgression in the care agreement. That’s a mistake, Dr. Gaster said. The document ends up becoming a multipage contract, and nobody except lawyers read multipage contracts. Keep the agreement short.
"The main value of a care agreement is to quickly communicate what the rules of opiate prescribing are in your clinic. If you’ve effectively communicated those rules and patients are not able to follow them, that is when you have actionable information to identify those at high risk for prescription drug abuse," he explained. "If you’re confident that you’ve been clear, and yet the rules aren’t being followed, that’s when you can feel okay about saying, ‘This isn’t safe. It needs to stop.’ "
To be an effective communication tool, the care agreement needs to say that the medication cannot be refilled early, refills are done by clinic appointment only, and appointments for refills must be requested at least two business days in advance. Also, lost or stolen medications can’t be refilled.
"The number of lost or stolen opioid scripts, compared to the number of lost or stolen blood pressure medication scripts, is pretty impressive," he noted. "You have to be up front with people and say, ‘This bottle of pills is like cash and if you lose it I can’t replace it.’ "
The clear message must be that failure to follow these rules will result in discontinuation of opiates.
And don’t simply tuck the signed care agreement away in the patient’s file.
"Repeating what the rules of opiate prescribing are in your clinic at least two, three, or even four times on different occasions is absolutely essential, just so that you feel really confident that the patient got the message," Dr. Gaster continued.
Keep track of red flags for prescription drug misuse in one place in the patient’s file: That’s how to prevent signs of a pattern of problematic behavior from slipping through the cracks. One major red flag is a history of substance abuse.
"It’s super important to at least ask about alcohol or substance abuse and document it in the chart, recognizing that you may not get an honest answer," Dr. Gaster advised.
"Anyone with a history of substance abuse should be treated with opiates for bad somatic pain only with extreme caution. The risk of prescription drug abuse in someone who has a history of substance abuse is dramatically higher. This is a completely different class of prescribing. It’s hard to say such people should never be on chronic opiates, but a much, much higher level of caution is required," he said.
As for patients with an ongoing substance abuse problem who also have obvious severe somatic pain, on balance the risk of harm in prescribing chronic opiates exceeds the potential benefit.
"These are terrible situations. I’d say primary care doctors shouldn’t be doing this at all. Such patients should be offered a referral for substance abuse treatment," he said.
Hepatitis C infection is another major red flag because it’s an important epidemiologic indicator of past illicit drug use.
Use a urine toxicology screen: An "absolutely essential part of the tool kit" because it’s the only source of hard data regarding whether a patient is abusing or diverting prescription drugs. Do it randomly but fairly frequently, and let the patient know that any time a urine screen is ordered, leaving the clinic without providing a urine sample that day will be considered tantamount to a positive test and will result in discontinuation of opiate therapy.
"If you were to pick out the one thing on a urine toxicology screen that’s most informative, I’d say it’s a positive result for cocaine. Cocaine use has a very, very high correlation with prescription drug abuse, and there are virtually no false-positive results for cocaine," the internist said.
In contrast, false-positive results for amphetamines are a real problem. The ELISA assay for amphetamines turns out to have cross-reactivity with at least 20 prescription drugs, including bupropion, phenergan, and legitimate medications for attention-deficit/hyperactivity disorder. Having the lab run a gas chromatography test will differentiate prescription stimulant medications from illicit street amphetamines.
Another key point about urine toxicology screens is they don’t reliably detect synthetic opiates such as fentanyl, or semisynthetic opiates such as oxycodone.
"Patients taking oxycodone may very well have a negative toxicology result, so you always need to make sure to order a separate oxycodone assay as part of your toxicology screen," he advised.
Also, before bringing up the need for a urine screen that very day, be sure to ask when the patient took his last opiate pill. That will be most helpful in interpreting a negative result.
For patients on dialysis who are anuric, use serum drug testing.
Utilize the statewide prescription monitoring system: It’s an essential tool for detection of patients who are sneaking around and obtaining opiate prescriptions from multiple physicians and then selling them.
"The giant street market for prescription opiates is, to some extent, happening from pharmacies and warehouses being robbed, but the vast majority of those pills are coming from doctors’ offices," Dr. Gaster noted.
Stop chronic opiates in response to red flags: This is one of the most difficult and emotion-charged interactions that occur between physicians and patients. "I rank it right up there with having to deliver a cancer diagnosis," Dr. Gaster said.
Patients seldom take this news well, so it’s a good idea to practice this straightforward phrasing beforehand: "In my medical opinion, this type of pain medication is simply not safe for you and I cannot prescribe it for you anymore."
To avoid legal and ethical problems, it’s important to emphasize that patients are not being fired or abandoned. Explain that you’re willing to continue as the patient’s physician, but not in prescribing opiates, he said.
Dr. Gaster reported having no financial conflicts.
NEW ORLEANS – Patient visits involving prescription of opiates for chronic pain can be among the most cringe-producing encounters in primary care medicine.
These visits place physicians in the difficult position of determining whether a patient is lying or in chronic pain, said Dr. Barak Gaster, a general internist at the University of Washington, Seattle.
The goal is to help slow the arc of the pendulum of opiate prescribing. Fueled by recent reports of overdose deaths from opiates being greater than those from heroin and cocaine combined, the pendulum is rapidly swinging away from a period of overprescribing, which fed the nation’s huge prescription drug misuse problem, and is now headed back towards undertreatment of chronic pain.
"I think if we all get too freaked out by the [risk of] fatal overdoses and too frustrated by what a difficult area this is, more and more doctors will say, ‘I just don’t [prescribe opiates] anymore.’ And that would be a shame because there are definitely people who benefit from being on chronic opiates," he said at the annual meeting of the American College of Physicians.
A few practical tools make opiate prescribing safer and more efficient in a busy primary care practice, according to Dr. Gaster. Here are his recommendations for safer, more manageable opiate prescribing:
Establish a clear upper limit on dosing: An upper limit is, quite simply, the most important thing physicians can do to limit inappropriate opiate prescribing. The epidemiologic literature indicates that the risk of unintentional fatal overdose jumps at more than 120 milliequivalents of morphine per day, a value that "exceeds my comfort zone," Dr. Gaster said. But wherever the line is drawn – say, 60 or 80 milliequivalents per day – stay the course no matter what the patient says.
"What little research has been done in this area suggests that opiates have mild to moderate efficacy for chronic pain, that very low doses are about as likely to work as very high doses, and that in situations where you’re not achieving adequate pain control at lower doses the idea that you can just go to higher and higher doses is wrong and you’ll end up causing harm," he said.
The notion that dosing should continue to increase until pain control is achieved is appropriate for cancer pain, which is the setting where most physicians-in-training learned to use opiates, but it’s all wrong for noncancer chronic pain, he noted.
Have your patter down: Physicians need to have a pre-rehearsed response in mind for when they walk into the examination room and patients say that the maximum dose isn’t getting the job done. That ready-made response will keep the office visit moving briskly along. Here’s what Dr. Gaster suggested: "Honestly, I don’t believe that higher doses would be safe for you. This is the maximum dose that I feel comfortable prescribing in a safe way."
Make smart use of written care agreements: Many physicians try to list every possible aberrant behavior and transgression in the care agreement. That’s a mistake, Dr. Gaster said. The document ends up becoming a multipage contract, and nobody except lawyers read multipage contracts. Keep the agreement short.
"The main value of a care agreement is to quickly communicate what the rules of opiate prescribing are in your clinic. If you’ve effectively communicated those rules and patients are not able to follow them, that is when you have actionable information to identify those at high risk for prescription drug abuse," he explained. "If you’re confident that you’ve been clear, and yet the rules aren’t being followed, that’s when you can feel okay about saying, ‘This isn’t safe. It needs to stop.’ "
To be an effective communication tool, the care agreement needs to say that the medication cannot be refilled early, refills are done by clinic appointment only, and appointments for refills must be requested at least two business days in advance. Also, lost or stolen medications can’t be refilled.
"The number of lost or stolen opioid scripts, compared to the number of lost or stolen blood pressure medication scripts, is pretty impressive," he noted. "You have to be up front with people and say, ‘This bottle of pills is like cash and if you lose it I can’t replace it.’ "
The clear message must be that failure to follow these rules will result in discontinuation of opiates.
And don’t simply tuck the signed care agreement away in the patient’s file.
"Repeating what the rules of opiate prescribing are in your clinic at least two, three, or even four times on different occasions is absolutely essential, just so that you feel really confident that the patient got the message," Dr. Gaster continued.
Keep track of red flags for prescription drug misuse in one place in the patient’s file: That’s how to prevent signs of a pattern of problematic behavior from slipping through the cracks. One major red flag is a history of substance abuse.
"It’s super important to at least ask about alcohol or substance abuse and document it in the chart, recognizing that you may not get an honest answer," Dr. Gaster advised.
"Anyone with a history of substance abuse should be treated with opiates for bad somatic pain only with extreme caution. The risk of prescription drug abuse in someone who has a history of substance abuse is dramatically higher. This is a completely different class of prescribing. It’s hard to say such people should never be on chronic opiates, but a much, much higher level of caution is required," he said.
As for patients with an ongoing substance abuse problem who also have obvious severe somatic pain, on balance the risk of harm in prescribing chronic opiates exceeds the potential benefit.
"These are terrible situations. I’d say primary care doctors shouldn’t be doing this at all. Such patients should be offered a referral for substance abuse treatment," he said.
Hepatitis C infection is another major red flag because it’s an important epidemiologic indicator of past illicit drug use.
Use a urine toxicology screen: An "absolutely essential part of the tool kit" because it’s the only source of hard data regarding whether a patient is abusing or diverting prescription drugs. Do it randomly but fairly frequently, and let the patient know that any time a urine screen is ordered, leaving the clinic without providing a urine sample that day will be considered tantamount to a positive test and will result in discontinuation of opiate therapy.
"If you were to pick out the one thing on a urine toxicology screen that’s most informative, I’d say it’s a positive result for cocaine. Cocaine use has a very, very high correlation with prescription drug abuse, and there are virtually no false-positive results for cocaine," the internist said.
In contrast, false-positive results for amphetamines are a real problem. The ELISA assay for amphetamines turns out to have cross-reactivity with at least 20 prescription drugs, including bupropion, phenergan, and legitimate medications for attention-deficit/hyperactivity disorder. Having the lab run a gas chromatography test will differentiate prescription stimulant medications from illicit street amphetamines.
Another key point about urine toxicology screens is they don’t reliably detect synthetic opiates such as fentanyl, or semisynthetic opiates such as oxycodone.
"Patients taking oxycodone may very well have a negative toxicology result, so you always need to make sure to order a separate oxycodone assay as part of your toxicology screen," he advised.
Also, before bringing up the need for a urine screen that very day, be sure to ask when the patient took his last opiate pill. That will be most helpful in interpreting a negative result.
For patients on dialysis who are anuric, use serum drug testing.
Utilize the statewide prescription monitoring system: It’s an essential tool for detection of patients who are sneaking around and obtaining opiate prescriptions from multiple physicians and then selling them.
"The giant street market for prescription opiates is, to some extent, happening from pharmacies and warehouses being robbed, but the vast majority of those pills are coming from doctors’ offices," Dr. Gaster noted.
Stop chronic opiates in response to red flags: This is one of the most difficult and emotion-charged interactions that occur between physicians and patients. "I rank it right up there with having to deliver a cancer diagnosis," Dr. Gaster said.
Patients seldom take this news well, so it’s a good idea to practice this straightforward phrasing beforehand: "In my medical opinion, this type of pain medication is simply not safe for you and I cannot prescribe it for you anymore."
To avoid legal and ethical problems, it’s important to emphasize that patients are not being fired or abandoned. Explain that you’re willing to continue as the patient’s physician, but not in prescribing opiates, he said.
Dr. Gaster reported having no financial conflicts.
NEW ORLEANS – Patient visits involving prescription of opiates for chronic pain can be among the most cringe-producing encounters in primary care medicine.
These visits place physicians in the difficult position of determining whether a patient is lying or in chronic pain, said Dr. Barak Gaster, a general internist at the University of Washington, Seattle.
The goal is to help slow the arc of the pendulum of opiate prescribing. Fueled by recent reports of overdose deaths from opiates being greater than those from heroin and cocaine combined, the pendulum is rapidly swinging away from a period of overprescribing, which fed the nation’s huge prescription drug misuse problem, and is now headed back towards undertreatment of chronic pain.
"I think if we all get too freaked out by the [risk of] fatal overdoses and too frustrated by what a difficult area this is, more and more doctors will say, ‘I just don’t [prescribe opiates] anymore.’ And that would be a shame because there are definitely people who benefit from being on chronic opiates," he said at the annual meeting of the American College of Physicians.
A few practical tools make opiate prescribing safer and more efficient in a busy primary care practice, according to Dr. Gaster. Here are his recommendations for safer, more manageable opiate prescribing:
Establish a clear upper limit on dosing: An upper limit is, quite simply, the most important thing physicians can do to limit inappropriate opiate prescribing. The epidemiologic literature indicates that the risk of unintentional fatal overdose jumps at more than 120 milliequivalents of morphine per day, a value that "exceeds my comfort zone," Dr. Gaster said. But wherever the line is drawn – say, 60 or 80 milliequivalents per day – stay the course no matter what the patient says.
"What little research has been done in this area suggests that opiates have mild to moderate efficacy for chronic pain, that very low doses are about as likely to work as very high doses, and that in situations where you’re not achieving adequate pain control at lower doses the idea that you can just go to higher and higher doses is wrong and you’ll end up causing harm," he said.
The notion that dosing should continue to increase until pain control is achieved is appropriate for cancer pain, which is the setting where most physicians-in-training learned to use opiates, but it’s all wrong for noncancer chronic pain, he noted.
Have your patter down: Physicians need to have a pre-rehearsed response in mind for when they walk into the examination room and patients say that the maximum dose isn’t getting the job done. That ready-made response will keep the office visit moving briskly along. Here’s what Dr. Gaster suggested: "Honestly, I don’t believe that higher doses would be safe for you. This is the maximum dose that I feel comfortable prescribing in a safe way."
Make smart use of written care agreements: Many physicians try to list every possible aberrant behavior and transgression in the care agreement. That’s a mistake, Dr. Gaster said. The document ends up becoming a multipage contract, and nobody except lawyers read multipage contracts. Keep the agreement short.
"The main value of a care agreement is to quickly communicate what the rules of opiate prescribing are in your clinic. If you’ve effectively communicated those rules and patients are not able to follow them, that is when you have actionable information to identify those at high risk for prescription drug abuse," he explained. "If you’re confident that you’ve been clear, and yet the rules aren’t being followed, that’s when you can feel okay about saying, ‘This isn’t safe. It needs to stop.’ "
To be an effective communication tool, the care agreement needs to say that the medication cannot be refilled early, refills are done by clinic appointment only, and appointments for refills must be requested at least two business days in advance. Also, lost or stolen medications can’t be refilled.
"The number of lost or stolen opioid scripts, compared to the number of lost or stolen blood pressure medication scripts, is pretty impressive," he noted. "You have to be up front with people and say, ‘This bottle of pills is like cash and if you lose it I can’t replace it.’ "
The clear message must be that failure to follow these rules will result in discontinuation of opiates.
And don’t simply tuck the signed care agreement away in the patient’s file.
"Repeating what the rules of opiate prescribing are in your clinic at least two, three, or even four times on different occasions is absolutely essential, just so that you feel really confident that the patient got the message," Dr. Gaster continued.
Keep track of red flags for prescription drug misuse in one place in the patient’s file: That’s how to prevent signs of a pattern of problematic behavior from slipping through the cracks. One major red flag is a history of substance abuse.
"It’s super important to at least ask about alcohol or substance abuse and document it in the chart, recognizing that you may not get an honest answer," Dr. Gaster advised.
"Anyone with a history of substance abuse should be treated with opiates for bad somatic pain only with extreme caution. The risk of prescription drug abuse in someone who has a history of substance abuse is dramatically higher. This is a completely different class of prescribing. It’s hard to say such people should never be on chronic opiates, but a much, much higher level of caution is required," he said.
As for patients with an ongoing substance abuse problem who also have obvious severe somatic pain, on balance the risk of harm in prescribing chronic opiates exceeds the potential benefit.
"These are terrible situations. I’d say primary care doctors shouldn’t be doing this at all. Such patients should be offered a referral for substance abuse treatment," he said.
Hepatitis C infection is another major red flag because it’s an important epidemiologic indicator of past illicit drug use.
Use a urine toxicology screen: An "absolutely essential part of the tool kit" because it’s the only source of hard data regarding whether a patient is abusing or diverting prescription drugs. Do it randomly but fairly frequently, and let the patient know that any time a urine screen is ordered, leaving the clinic without providing a urine sample that day will be considered tantamount to a positive test and will result in discontinuation of opiate therapy.
"If you were to pick out the one thing on a urine toxicology screen that’s most informative, I’d say it’s a positive result for cocaine. Cocaine use has a very, very high correlation with prescription drug abuse, and there are virtually no false-positive results for cocaine," the internist said.
In contrast, false-positive results for amphetamines are a real problem. The ELISA assay for amphetamines turns out to have cross-reactivity with at least 20 prescription drugs, including bupropion, phenergan, and legitimate medications for attention-deficit/hyperactivity disorder. Having the lab run a gas chromatography test will differentiate prescription stimulant medications from illicit street amphetamines.
Another key point about urine toxicology screens is they don’t reliably detect synthetic opiates such as fentanyl, or semisynthetic opiates such as oxycodone.
"Patients taking oxycodone may very well have a negative toxicology result, so you always need to make sure to order a separate oxycodone assay as part of your toxicology screen," he advised.
Also, before bringing up the need for a urine screen that very day, be sure to ask when the patient took his last opiate pill. That will be most helpful in interpreting a negative result.
For patients on dialysis who are anuric, use serum drug testing.
Utilize the statewide prescription monitoring system: It’s an essential tool for detection of patients who are sneaking around and obtaining opiate prescriptions from multiple physicians and then selling them.
"The giant street market for prescription opiates is, to some extent, happening from pharmacies and warehouses being robbed, but the vast majority of those pills are coming from doctors’ offices," Dr. Gaster noted.
Stop chronic opiates in response to red flags: This is one of the most difficult and emotion-charged interactions that occur between physicians and patients. "I rank it right up there with having to deliver a cancer diagnosis," Dr. Gaster said.
Patients seldom take this news well, so it’s a good idea to practice this straightforward phrasing beforehand: "In my medical opinion, this type of pain medication is simply not safe for you and I cannot prescribe it for you anymore."
To avoid legal and ethical problems, it’s important to emphasize that patients are not being fired or abandoned. Explain that you’re willing to continue as the patient’s physician, but not in prescribing opiates, he said.
Dr. Gaster reported having no financial conflicts.
EXPERT ANALYSIS FROM THE ANNUAL MEETING OF AMERICAN COLLEGE OF PHYSICIANS
Wellness Visits Work for Medicare Patients and the Bottom Line
NEW ORLEANS – Annual Medicare wellness exams are being unperformed, resulting in lost opportunities and revenue, according to Dr. Mary M. Newman.
In 2011, more than 32 million Medicare beneficiaries in the traditional program (excluding Medicare Advantage) received one or more of the covered services, which are free for enrollees. They include the "Welcome to Medicare," or Initial Preventive Physical Examination (IPPE); the annual wellness visit; and other preventive services that may occur outside those visits. So far in 2012, 8.9 million enrollees have received a free service, including 562,000 who had an annual wellness visit. That’s up from the 312,809 beneficiaries who received the wellness visit during the first 3 months of 2011, according to the Centers for Medicare and Medicaid Services.
The program got off to a slow start because of an awareness gap, Dr. Newman said. Also, correctly coding and billing for the visits takes practice. An electronic health record aids in delivering the benefits consistently and well.
Dr. Newman, an internist at a group practice in Lutherville, Md., explained that Medicare pays about $166 for the initial wellness visit, with subsequent visits paid at a slightly lower rate. The typical office visit for a Medicare patient is reimbursed at about $70. In addition, the CMS is paying a slight premium for the wellness visits starting this year because the agency is now requiring the completion of a health risk assessment for each beneficiary.
Before the Affordable Care Act, only one preventive/wellness visit was covered for beneficiaries during their lifetime. Now, the IPPE visit initiates a continuum of care, with an update on the care plan and screenings on an annual basis. The IPPE visit, which must be used in the first 12 months after a beneficiary is enrolled, includes a medical/surgical history; review of current medications and supplements; family history; history of alcohol, tobacco, and illicit drug use; and discussion of diet and physical activity. Risk factors for depression should be reviewed and functional ability assessed.
The basic physical exam covers blood pressure, vision, weight, and height. Written or verbal end of life planning should be offered, and recommended screenings and vaccinations should be checked. The findings are used to compile a written care plan, complete with recommendations for screening or other preventive services. Annual wellness visits then follow, but annual visits also can occur without having first had the IPPE, according to the CMS.
The IPPE is billed using the G0402 visit code and the V.70 diagnosis code, said Dr. Newman. The first annual wellness visit is billed using the G0438 code, and each subsequent visit uses the G0439 code. The wellness visit can be conducted by a physician or any medical professional working under a physician’s supervision.
Before each visit, Dr. Newman’s practice staff verifies that patients are eligible for either the IPPE or the annual wellness visit and explains the visit and what’s covered. Patients are also encouraged to fill out a form they can download from the practice’s website that helps them organize their medication list, family history, and names of all current physicians.
During the initial wellness visit, Dr. Newman conducts a two-question depression screen and a four-question functional assessment. She has patients walk the hallway as she observes them for motor skill, balance, and other functional measures. After discussing preventive care and advance directives, assessing risk factors, and taking vital signs, she issues a written care plan.
The plan includes a list of risk factors and conditions; referrals for screening tests and, as appropriate, nutritional counseling, smoking cessation, fall prevention, and weight loss; a screening schedule for 5-10 years; and end of life planning. It is updated at each subsequent wellness visit. This is where an EHR can really help, she noted. Ask the vendor to embed the wellness elements, and that way it can be simply updated.
In addition to the wellness visits, a host of preventive services are covered, but there are rules for how the services are delivered, she said. For instance, beneficiaries can receive a one-time screen for abdominal aortic aneurysms; the referral must be made during the first year someone is on Medicare, and they must have certain specific risk factors.
Bone density tests are covered every 2 years. Beneficiaries are liable for 20% of the service if the physician does not accept assignment. New benefits added in 2012 include screening and counseling for alcohol misuse and for sexually transmitted diseases for high-risk patients. Once-a-year screening for depression is covered; if the patient is depressed, the physician must have a care plan.
The new intensive obesity therapy coverage is a "terrific benefit," said Dr. Newman. If a patient has a body mass index of more than 30, the physician can see the patient weekly for the first month, then biweekly for months 2-6, and monthly after that, out to a year. "This is a real advance," she said.
Finally, there is the health risk assessment, which is used to collect self-reported information about the beneficiary. The process takes no more than 20 minutes. It overlaps with some of the assessments conducted during the wellness visit, but is still required.
Dr. Newman said she uses an assessment tool that was developed by the ACP. Patients receive the tool at the front desk when they come in for a visit.
The important thing to understand about this assessment is "you don’t have to fix the problems today," said Dr. Newman. You can bring patients] back to work on components or hand off the patients to a nurse or a social worker, she said.
Also, the assessment does not have to be done completely and perfectly in 2012. The CMS has said it will allow for some variation in content for the time being and physicians will still be reimbursed for conducting the assessment.
NEW ORLEANS – Annual Medicare wellness exams are being unperformed, resulting in lost opportunities and revenue, according to Dr. Mary M. Newman.
In 2011, more than 32 million Medicare beneficiaries in the traditional program (excluding Medicare Advantage) received one or more of the covered services, which are free for enrollees. They include the "Welcome to Medicare," or Initial Preventive Physical Examination (IPPE); the annual wellness visit; and other preventive services that may occur outside those visits. So far in 2012, 8.9 million enrollees have received a free service, including 562,000 who had an annual wellness visit. That’s up from the 312,809 beneficiaries who received the wellness visit during the first 3 months of 2011, according to the Centers for Medicare and Medicaid Services.
The program got off to a slow start because of an awareness gap, Dr. Newman said. Also, correctly coding and billing for the visits takes practice. An electronic health record aids in delivering the benefits consistently and well.
Dr. Newman, an internist at a group practice in Lutherville, Md., explained that Medicare pays about $166 for the initial wellness visit, with subsequent visits paid at a slightly lower rate. The typical office visit for a Medicare patient is reimbursed at about $70. In addition, the CMS is paying a slight premium for the wellness visits starting this year because the agency is now requiring the completion of a health risk assessment for each beneficiary.
Before the Affordable Care Act, only one preventive/wellness visit was covered for beneficiaries during their lifetime. Now, the IPPE visit initiates a continuum of care, with an update on the care plan and screenings on an annual basis. The IPPE visit, which must be used in the first 12 months after a beneficiary is enrolled, includes a medical/surgical history; review of current medications and supplements; family history; history of alcohol, tobacco, and illicit drug use; and discussion of diet and physical activity. Risk factors for depression should be reviewed and functional ability assessed.
The basic physical exam covers blood pressure, vision, weight, and height. Written or verbal end of life planning should be offered, and recommended screenings and vaccinations should be checked. The findings are used to compile a written care plan, complete with recommendations for screening or other preventive services. Annual wellness visits then follow, but annual visits also can occur without having first had the IPPE, according to the CMS.
The IPPE is billed using the G0402 visit code and the V.70 diagnosis code, said Dr. Newman. The first annual wellness visit is billed using the G0438 code, and each subsequent visit uses the G0439 code. The wellness visit can be conducted by a physician or any medical professional working under a physician’s supervision.
Before each visit, Dr. Newman’s practice staff verifies that patients are eligible for either the IPPE or the annual wellness visit and explains the visit and what’s covered. Patients are also encouraged to fill out a form they can download from the practice’s website that helps them organize their medication list, family history, and names of all current physicians.
During the initial wellness visit, Dr. Newman conducts a two-question depression screen and a four-question functional assessment. She has patients walk the hallway as she observes them for motor skill, balance, and other functional measures. After discussing preventive care and advance directives, assessing risk factors, and taking vital signs, she issues a written care plan.
The plan includes a list of risk factors and conditions; referrals for screening tests and, as appropriate, nutritional counseling, smoking cessation, fall prevention, and weight loss; a screening schedule for 5-10 years; and end of life planning. It is updated at each subsequent wellness visit. This is where an EHR can really help, she noted. Ask the vendor to embed the wellness elements, and that way it can be simply updated.
In addition to the wellness visits, a host of preventive services are covered, but there are rules for how the services are delivered, she said. For instance, beneficiaries can receive a one-time screen for abdominal aortic aneurysms; the referral must be made during the first year someone is on Medicare, and they must have certain specific risk factors.
Bone density tests are covered every 2 years. Beneficiaries are liable for 20% of the service if the physician does not accept assignment. New benefits added in 2012 include screening and counseling for alcohol misuse and for sexually transmitted diseases for high-risk patients. Once-a-year screening for depression is covered; if the patient is depressed, the physician must have a care plan.
The new intensive obesity therapy coverage is a "terrific benefit," said Dr. Newman. If a patient has a body mass index of more than 30, the physician can see the patient weekly for the first month, then biweekly for months 2-6, and monthly after that, out to a year. "This is a real advance," she said.
Finally, there is the health risk assessment, which is used to collect self-reported information about the beneficiary. The process takes no more than 20 minutes. It overlaps with some of the assessments conducted during the wellness visit, but is still required.
Dr. Newman said she uses an assessment tool that was developed by the ACP. Patients receive the tool at the front desk when they come in for a visit.
The important thing to understand about this assessment is "you don’t have to fix the problems today," said Dr. Newman. You can bring patients] back to work on components or hand off the patients to a nurse or a social worker, she said.
Also, the assessment does not have to be done completely and perfectly in 2012. The CMS has said it will allow for some variation in content for the time being and physicians will still be reimbursed for conducting the assessment.
NEW ORLEANS – Annual Medicare wellness exams are being unperformed, resulting in lost opportunities and revenue, according to Dr. Mary M. Newman.
In 2011, more than 32 million Medicare beneficiaries in the traditional program (excluding Medicare Advantage) received one or more of the covered services, which are free for enrollees. They include the "Welcome to Medicare," or Initial Preventive Physical Examination (IPPE); the annual wellness visit; and other preventive services that may occur outside those visits. So far in 2012, 8.9 million enrollees have received a free service, including 562,000 who had an annual wellness visit. That’s up from the 312,809 beneficiaries who received the wellness visit during the first 3 months of 2011, according to the Centers for Medicare and Medicaid Services.
The program got off to a slow start because of an awareness gap, Dr. Newman said. Also, correctly coding and billing for the visits takes practice. An electronic health record aids in delivering the benefits consistently and well.
Dr. Newman, an internist at a group practice in Lutherville, Md., explained that Medicare pays about $166 for the initial wellness visit, with subsequent visits paid at a slightly lower rate. The typical office visit for a Medicare patient is reimbursed at about $70. In addition, the CMS is paying a slight premium for the wellness visits starting this year because the agency is now requiring the completion of a health risk assessment for each beneficiary.
Before the Affordable Care Act, only one preventive/wellness visit was covered for beneficiaries during their lifetime. Now, the IPPE visit initiates a continuum of care, with an update on the care plan and screenings on an annual basis. The IPPE visit, which must be used in the first 12 months after a beneficiary is enrolled, includes a medical/surgical history; review of current medications and supplements; family history; history of alcohol, tobacco, and illicit drug use; and discussion of diet and physical activity. Risk factors for depression should be reviewed and functional ability assessed.
The basic physical exam covers blood pressure, vision, weight, and height. Written or verbal end of life planning should be offered, and recommended screenings and vaccinations should be checked. The findings are used to compile a written care plan, complete with recommendations for screening or other preventive services. Annual wellness visits then follow, but annual visits also can occur without having first had the IPPE, according to the CMS.
The IPPE is billed using the G0402 visit code and the V.70 diagnosis code, said Dr. Newman. The first annual wellness visit is billed using the G0438 code, and each subsequent visit uses the G0439 code. The wellness visit can be conducted by a physician or any medical professional working under a physician’s supervision.
Before each visit, Dr. Newman’s practice staff verifies that patients are eligible for either the IPPE or the annual wellness visit and explains the visit and what’s covered. Patients are also encouraged to fill out a form they can download from the practice’s website that helps them organize their medication list, family history, and names of all current physicians.
During the initial wellness visit, Dr. Newman conducts a two-question depression screen and a four-question functional assessment. She has patients walk the hallway as she observes them for motor skill, balance, and other functional measures. After discussing preventive care and advance directives, assessing risk factors, and taking vital signs, she issues a written care plan.
The plan includes a list of risk factors and conditions; referrals for screening tests and, as appropriate, nutritional counseling, smoking cessation, fall prevention, and weight loss; a screening schedule for 5-10 years; and end of life planning. It is updated at each subsequent wellness visit. This is where an EHR can really help, she noted. Ask the vendor to embed the wellness elements, and that way it can be simply updated.
In addition to the wellness visits, a host of preventive services are covered, but there are rules for how the services are delivered, she said. For instance, beneficiaries can receive a one-time screen for abdominal aortic aneurysms; the referral must be made during the first year someone is on Medicare, and they must have certain specific risk factors.
Bone density tests are covered every 2 years. Beneficiaries are liable for 20% of the service if the physician does not accept assignment. New benefits added in 2012 include screening and counseling for alcohol misuse and for sexually transmitted diseases for high-risk patients. Once-a-year screening for depression is covered; if the patient is depressed, the physician must have a care plan.
The new intensive obesity therapy coverage is a "terrific benefit," said Dr. Newman. If a patient has a body mass index of more than 30, the physician can see the patient weekly for the first month, then biweekly for months 2-6, and monthly after that, out to a year. "This is a real advance," she said.
Finally, there is the health risk assessment, which is used to collect self-reported information about the beneficiary. The process takes no more than 20 minutes. It overlaps with some of the assessments conducted during the wellness visit, but is still required.
Dr. Newman said she uses an assessment tool that was developed by the ACP. Patients receive the tool at the front desk when they come in for a visit.
The important thing to understand about this assessment is "you don’t have to fix the problems today," said Dr. Newman. You can bring patients] back to work on components or hand off the patients to a nurse or a social worker, she said.
Also, the assessment does not have to be done completely and perfectly in 2012. The CMS has said it will allow for some variation in content for the time being and physicians will still be reimbursed for conducting the assessment.
FROM THE ANNUAL MEETING OF THE AMERICAN COLLEGE OF PHYSICIANS