American Academy of Family Physicians (AAFP): Congress of Delegates

PHILADELPHIA – Family physicians play a major role in delivering emergency-medicine care, especially in rural communities, and family physicians want more people to know that.

Family physicians took a big step toward raising their emergency-care profile 2 years ago, when they started the Special Interest Group in Emergency Medicine (SIG-EM) of the American Academy of Family Physicians (AAFP). When the group held its third annual meeting, during the AAFP’s annual sessions, a top goal was boosting recognition by the health care community that family-practice physicians are the backbone for delivering a large swath of American emergency medicine, especially in places with fewer than 20,000 people.

"I think ACEP sees that a collaborative, cooperative relationship with family medicine needs to happen."

Several SIG-EM members reported numbers documenting this last May at the Association of American Medical Colleges’ Workforce Research Conference in Washington. In U.S. communities with fewer than 20,000 people, emergency department physicians without emergency medicine residency training (primarily family physicians) supplied 40%-50% of the physician workforce, reported Dr. Kim Bullock, Dr. W. Anthony Gerard, and their associates.

During 2008-2010, family physicians specifically provided 42%-51% of emergency care in six states: Arkansas, Montana, Nebraska, North Dakota, South Dakota, and Wyoming. They also provided 32%-41% of emergency medicine care in another seven states: Alabama, Alaska, Idaho, Iowa, Kansas, Louisiana, and Mississippi.

Data presented to the Workforce Research Conference also showed that during 2006-2010, the extent of family physician involvement in delivering emergency care held steady, with 24%-30% of all family physicians providing emergency care as part of their practice. Among family physicians in rural settings, roughly 40% provided emergency care.

"We want to improve recognition of family physicians in emergency medicine among the wider health-care community," Dr. Gerard said in an interview following the SIG-EM meeting.

Family physicians who provide emergency care have shifted from seeking a formal certification process for their subspecialty to just broadened recognition that family-practice physicians play an important role in providing Americans with emergency care, said Dr. Gerard, a family physician and AAFP member who practices as an emergency medicine physician at Good Samaritan Hospital in Lebanon, Pa.

"The reality is that family physicians are the rural emergency-medicine providers," he said. But, "we need to open doors [for emergency medicine] in the city, too."

"The data we compiled showed that all emergency medicine training programs are in urban academic centers," with easy access to technology and specialists, said Dr. Perry A. Pugno, AAFP’s vice president for education at the Academy’s office in Leawood, Kan.

But, "family medicine is the emergency medicine workforce outside urban settings," he added, and emergency medicine organizations have been slow to acknowledge that.

"We can’t produce enough" emergency medicine physicians, but the emergency-medicine organizations and societies "won’t take the step to say that we should work with family medicine because they are the ones who are out there and doing it," Dr. Pugno said.

The American College of Emergency Physicians has noticed the AAFP’s SIG-EM, and that emergency medicine organization has held out the prospect of working with family physicians. ACEP’s senior director for membership and development, Michele Byers, came to last month’s gathering of about 30 AAFP attendees.

During the SIG-EM’s meeting, Ms. Byers acknowledged the role family physicians play in emergency care: "We realize that’s a reality," she said. "We are looking at opportunities to provide CME and information to family physicians working in emergency departments," Ms. Byers said.

"I think ACEP sees that a collaborative, cooperative relationship with family medicine needs to happen," said Dr. Gerard.

"It was no accident that someone from ACEP was here – I think they’re surprised at how quickly this group has grown," said Dr. Pugno. The SIG-EM "is not just an interest group. It is part of the AAFP infrastructure; that’s an important level of endorsement from the AAFP board," he noted.

"This group reports directly to the AAFP education commission," the group responsible for policy on workforce issues and career guidance. Last year, AAFP added to its policies a new section on emergency medicine that in part says family physicians "are qualified to provide emergency care in a variety of settings," particularly rural and remote settings.

"For 20 years, I paid dues to AAFP, but I felt like I didn’t have a home. Now we have a home," the SIG-EM, Dr. Gerard said during the group’s meeting. "We have a name, a place, and support from the [AAFP] Congress of Delegates. The AAFP policy statement is strong; it says that family medicine has a role in the future of emergency medicine."

The SIG-EM decided at its meeting to take its profile a step further by resolving to produce in the next year a policy paper on family physicians who provide emergency care in rural U.S. communities. The AAFP will then use this white paper "when we do advocacy work, when we speak with regulatory agencies" such as the Centers for Medicare and Medicaid Services and the Health Resources and Services Administration, said Dr. Pugno. "We will reference this paper and say we are concerned about continued funding of critical care access hospitals and that family medicine is the primary work force in that venue."

Dr. Gerard, Dr. Pugno, and Ms. Byers had no commercial disclosures. Dr. Pugno is an employee of the American Academy of Family Physicians. Ms. Byers is an employee of the American College of Emergency Physicians.

PHILADELPHIA – Family physicians play a major role in delivering emergency-medicine care, especially in rural communities, and family physicians want more people to know that.

Family physicians took a big step toward raising their emergency-care profile 2 years ago, when they started the Special Interest Group in Emergency Medicine (SIG-EM) of the American Academy of Family Physicians (AAFP). When the group held its third annual meeting, during the AAFP’s annual sessions, a top goal was boosting recognition by the health care community that family-practice physicians are the backbone for delivering a large swath of American emergency medicine, especially in places with fewer than 20,000 people.

"I think ACEP sees that a collaborative, cooperative relationship with family medicine needs to happen."

Several SIG-EM members reported numbers documenting this last May at the Association of American Medical Colleges’ Workforce Research Conference in Washington. In U.S. communities with fewer than 20,000 people, emergency department physicians without emergency medicine residency training (primarily family physicians) supplied 40%-50% of the physician workforce, reported Dr. Kim Bullock, Dr. W. Anthony Gerard, and their associates.

During 2008-2010, family physicians specifically provided 42%-51% of emergency care in six states: Arkansas, Montana, Nebraska, North Dakota, South Dakota, and Wyoming. They also provided 32%-41% of emergency medicine care in another seven states: Alabama, Alaska, Idaho, Iowa, Kansas, Louisiana, and Mississippi.

Data presented to the Workforce Research Conference also showed that during 2006-2010, the extent of family physician involvement in delivering emergency care held steady, with 24%-30% of all family physicians providing emergency care as part of their practice. Among family physicians in rural settings, roughly 40% provided emergency care.

"We want to improve recognition of family physicians in emergency medicine among the wider health-care community," Dr. Gerard said in an interview following the SIG-EM meeting.

Family physicians who provide emergency care have shifted from seeking a formal certification process for their subspecialty to just broadened recognition that family-practice physicians play an important role in providing Americans with emergency care, said Dr. Gerard, a family physician and AAFP member who practices as an emergency medicine physician at Good Samaritan Hospital in Lebanon, Pa.

"The reality is that family physicians are the rural emergency-medicine providers," he said. But, "we need to open doors [for emergency medicine] in the city, too."

"The data we compiled showed that all emergency medicine training programs are in urban academic centers," with easy access to technology and specialists, said Dr. Perry A. Pugno, AAFP’s vice president for education at the Academy’s office in Leawood, Kan.

But, "family medicine is the emergency medicine workforce outside urban settings," he added, and emergency medicine organizations have been slow to acknowledge that.

"We can’t produce enough" emergency medicine physicians, but the emergency-medicine organizations and societies "won’t take the step to say that we should work with family medicine because they are the ones who are out there and doing it," Dr. Pugno said.

The American College of Emergency Physicians has noticed the AAFP’s SIG-EM, and that emergency medicine organization has held out the prospect of working with family physicians. ACEP’s senior director for membership and development, Michele Byers, came to last month’s gathering of about 30 AAFP attendees.

During the SIG-EM’s meeting, Ms. Byers acknowledged the role family physicians play in emergency care: "We realize that’s a reality," she said. "We are looking at opportunities to provide CME and information to family physicians working in emergency departments," Ms. Byers said.

"I think ACEP sees that a collaborative, cooperative relationship with family medicine needs to happen," said Dr. Gerard.

"It was no accident that someone from ACEP was here – I think they’re surprised at how quickly this group has grown," said Dr. Pugno. The SIG-EM "is not just an interest group. It is part of the AAFP infrastructure; that’s an important level of endorsement from the AAFP board," he noted.

"This group reports directly to the AAFP education commission," the group responsible for policy on workforce issues and career guidance. Last year, AAFP added to its policies a new section on emergency medicine that in part says family physicians "are qualified to provide emergency care in a variety of settings," particularly rural and remote settings.

"For 20 years, I paid dues to AAFP, but I felt like I didn’t have a home. Now we have a home," the SIG-EM, Dr. Gerard said during the group’s meeting. "We have a name, a place, and support from the [AAFP] Congress of Delegates. The AAFP policy statement is strong; it says that family medicine has a role in the future of emergency medicine."

The SIG-EM decided at its meeting to take its profile a step further by resolving to produce in the next year a policy paper on family physicians who provide emergency care in rural U.S. communities. The AAFP will then use this white paper "when we do advocacy work, when we speak with regulatory agencies" such as the Centers for Medicare and Medicaid Services and the Health Resources and Services Administration, said Dr. Pugno. "We will reference this paper and say we are concerned about continued funding of critical care access hospitals and that family medicine is the primary work force in that venue."

Dr. Gerard, Dr. Pugno, and Ms. Byers had no commercial disclosures. Dr. Pugno is an employee of the American Academy of Family Physicians. Ms. Byers is an employee of the American College of Emergency Physicians.

PHILADELPHIA – Family physicians play a major role in delivering emergency-medicine care, especially in rural communities, and family physicians want more people to know that.

Family physicians took a big step toward raising their emergency-care profile 2 years ago, when they started the Special Interest Group in Emergency Medicine (SIG-EM) of the American Academy of Family Physicians (AAFP). When the group held its third annual meeting, during the AAFP’s annual sessions, a top goal was boosting recognition by the health care community that family-practice physicians are the backbone for delivering a large swath of American emergency medicine, especially in places with fewer than 20,000 people.

"I think ACEP sees that a collaborative, cooperative relationship with family medicine needs to happen."

Several SIG-EM members reported numbers documenting this last May at the Association of American Medical Colleges’ Workforce Research Conference in Washington. In U.S. communities with fewer than 20,000 people, emergency department physicians without emergency medicine residency training (primarily family physicians) supplied 40%-50% of the physician workforce, reported Dr. Kim Bullock, Dr. W. Anthony Gerard, and their associates.

During 2008-2010, family physicians specifically provided 42%-51% of emergency care in six states: Arkansas, Montana, Nebraska, North Dakota, South Dakota, and Wyoming. They also provided 32%-41% of emergency medicine care in another seven states: Alabama, Alaska, Idaho, Iowa, Kansas, Louisiana, and Mississippi.

Data presented to the Workforce Research Conference also showed that during 2006-2010, the extent of family physician involvement in delivering emergency care held steady, with 24%-30% of all family physicians providing emergency care as part of their practice. Among family physicians in rural settings, roughly 40% provided emergency care.

"We want to improve recognition of family physicians in emergency medicine among the wider health-care community," Dr. Gerard said in an interview following the SIG-EM meeting.

Family physicians who provide emergency care have shifted from seeking a formal certification process for their subspecialty to just broadened recognition that family-practice physicians play an important role in providing Americans with emergency care, said Dr. Gerard, a family physician and AAFP member who practices as an emergency medicine physician at Good Samaritan Hospital in Lebanon, Pa.

"The reality is that family physicians are the rural emergency-medicine providers," he said. But, "we need to open doors [for emergency medicine] in the city, too."

"The data we compiled showed that all emergency medicine training programs are in urban academic centers," with easy access to technology and specialists, said Dr. Perry A. Pugno, AAFP’s vice president for education at the Academy’s office in Leawood, Kan.

But, "family medicine is the emergency medicine workforce outside urban settings," he added, and emergency medicine organizations have been slow to acknowledge that.

"We can’t produce enough" emergency medicine physicians, but the emergency-medicine organizations and societies "won’t take the step to say that we should work with family medicine because they are the ones who are out there and doing it," Dr. Pugno said.

The American College of Emergency Physicians has noticed the AAFP’s SIG-EM, and that emergency medicine organization has held out the prospect of working with family physicians. ACEP’s senior director for membership and development, Michele Byers, came to last month’s gathering of about 30 AAFP attendees.

During the SIG-EM’s meeting, Ms. Byers acknowledged the role family physicians play in emergency care: "We realize that’s a reality," she said. "We are looking at opportunities to provide CME and information to family physicians working in emergency departments," Ms. Byers said.

"I think ACEP sees that a collaborative, cooperative relationship with family medicine needs to happen," said Dr. Gerard.

"It was no accident that someone from ACEP was here – I think they’re surprised at how quickly this group has grown," said Dr. Pugno. The SIG-EM "is not just an interest group. It is part of the AAFP infrastructure; that’s an important level of endorsement from the AAFP board," he noted.

"This group reports directly to the AAFP education commission," the group responsible for policy on workforce issues and career guidance. Last year, AAFP added to its policies a new section on emergency medicine that in part says family physicians "are qualified to provide emergency care in a variety of settings," particularly rural and remote settings.

"For 20 years, I paid dues to AAFP, but I felt like I didn’t have a home. Now we have a home," the SIG-EM, Dr. Gerard said during the group’s meeting. "We have a name, a place, and support from the [AAFP] Congress of Delegates. The AAFP policy statement is strong; it says that family medicine has a role in the future of emergency medicine."

The SIG-EM decided at its meeting to take its profile a step further by resolving to produce in the next year a policy paper on family physicians who provide emergency care in rural U.S. communities. The AAFP will then use this white paper "when we do advocacy work, when we speak with regulatory agencies" such as the Centers for Medicare and Medicaid Services and the Health Resources and Services Administration, said Dr. Pugno. "We will reference this paper and say we are concerned about continued funding of critical care access hospitals and that family medicine is the primary work force in that venue."

Dr. Gerard, Dr. Pugno, and Ms. Byers had no commercial disclosures. Dr. Pugno is an employee of the American Academy of Family Physicians. Ms. Byers is an employee of the American College of Emergency Physicians.

PHILADELPHIA – With the federal stage 2 deadline for the meaningful use of electronic health records looming less than 2 years from now, doctors need to start thinking about interoperability, directed exchange, and health Internet service providers.

The key capability that stage 2 demands is the ability to transfer patient data in a reliably secure, confidential way between physicians, between a physician and patient, or between a physician and a health care system.

Mitchel L. Zoler/IMNG Medical Media

These secure, Internet-based data transfers will depend on three elements, Dr. David C. Kibbe said at the annual Congress of Delegates of the American Academy of Family Physicians:

• A standardized format and language for recording the data that transcend the different electronic health record (EHR) formats used by different vendors.

• A method to securely move the data between two or more EHR users, a process known as directed exchange.

• A system to verify that the person engaged in a data exchange – for example, Dr. Smith – really is Dr. Smith.

Although the software that allows these secure exchanges is still being tweaked and has generally not yet rolled out to EHR users, the systems will likely become available in the next few months, said Dr. Kibbe, a senior adviser to the American Academy of Family Physicians in Oriental, N.C.

If the systems work the way they should, physicians will not need to sweat the details. Once EHR vendors get the software finalized and providers in place, all physicians will need to do is sign up for service with the EHR vendor, Dr. Kibbe said.

New Kind of Service Provider

A big part will be physicians becoming customers of a health Internet service provider. Those providers will be something like a conventional Internet service provider, except that they’ll be geared to operate with special certification and encryption procedures to guarantee secure data transmission and validate sender and recipient identities. EHR systems and health Internet service providers will need to use a certification process to establish and confirm the identity of each of their physician clients.

"Health Internet service providers didn’t exist 12 months ago; now many exist, and they are eager to have your business," he said.

Physicians who plan to comply with meaningful use stage 2 and don’t hear anything about this from the EHR vendor by mid-2013 should ask their vendor, "When can you provide it?" said Dr. Kibbe, who also is president of DirectTrust, a nonprofit group that facilitates implementation of directed exchange.

"While some vendors are on top of this, others are clueless," he warned.

And be prepared to pay a bit more for the ability to run secure directed exchange, he said. On the upside, having this capability for secure transmission of EHR data should eliminate the need to send patient information by fax, a step that should save most practices time and money, Dr. Kibbe said.

EHRs Penetrate Family Practice

When he spoke about the next phase of EHR meaningful use at the meeting, he addressed an audience that had already bought into the EHR concept.

"It’s been just about a decade since the AAFP’s Future of Family Medicine led a push for electronic health records for its members," and the push worked, said Dr. Kibbe. In 2004, roughly 10% of AAFP members used an EHR. By 2011, the percent had risen to about 60%, and by late 2012, it had grown to about 80% of the AAFP membership, according to results from recent surveys, he said.

"A few years ago, 40 or 50 EHR vendors exhibited at this meeting," Dr. Kibbe noted. "This year, only nine EHR vendors are exhibiting." That’s because they now find few new customers among family physicians.

Dr. Kibbe said that he had no disclosures.

PHILADELPHIA – With the federal stage 2 deadline for the meaningful use of electronic health records looming less than 2 years from now, doctors need to start thinking about interoperability, directed exchange, and health Internet service providers.

The key capability that stage 2 demands is the ability to transfer patient data in a reliably secure, confidential way between physicians, between a physician and patient, or between a physician and a health care system.

Mitchel L. Zoler/IMNG Medical Media

These secure, Internet-based data transfers will depend on three elements, Dr. David C. Kibbe said at the annual Congress of Delegates of the American Academy of Family Physicians:

• A standardized format and language for recording the data that transcend the different electronic health record (EHR) formats used by different vendors.

• A method to securely move the data between two or more EHR users, a process known as directed exchange.

• A system to verify that the person engaged in a data exchange – for example, Dr. Smith – really is Dr. Smith.

Although the software that allows these secure exchanges is still being tweaked and has generally not yet rolled out to EHR users, the systems will likely become available in the next few months, said Dr. Kibbe, a senior adviser to the American Academy of Family Physicians in Oriental, N.C.

If the systems work the way they should, physicians will not need to sweat the details. Once EHR vendors get the software finalized and providers in place, all physicians will need to do is sign up for service with the EHR vendor, Dr. Kibbe said.

New Kind of Service Provider

A big part will be physicians becoming customers of a health Internet service provider. Those providers will be something like a conventional Internet service provider, except that they’ll be geared to operate with special certification and encryption procedures to guarantee secure data transmission and validate sender and recipient identities. EHR systems and health Internet service providers will need to use a certification process to establish and confirm the identity of each of their physician clients.

"Health Internet service providers didn’t exist 12 months ago; now many exist, and they are eager to have your business," he said.

Physicians who plan to comply with meaningful use stage 2 and don’t hear anything about this from the EHR vendor by mid-2013 should ask their vendor, "When can you provide it?" said Dr. Kibbe, who also is president of DirectTrust, a nonprofit group that facilitates implementation of directed exchange.

"While some vendors are on top of this, others are clueless," he warned.

And be prepared to pay a bit more for the ability to run secure directed exchange, he said. On the upside, having this capability for secure transmission of EHR data should eliminate the need to send patient information by fax, a step that should save most practices time and money, Dr. Kibbe said.

EHRs Penetrate Family Practice

When he spoke about the next phase of EHR meaningful use at the meeting, he addressed an audience that had already bought into the EHR concept.

"It’s been just about a decade since the AAFP’s Future of Family Medicine led a push for electronic health records for its members," and the push worked, said Dr. Kibbe. In 2004, roughly 10% of AAFP members used an EHR. By 2011, the percent had risen to about 60%, and by late 2012, it had grown to about 80% of the AAFP membership, according to results from recent surveys, he said.

"A few years ago, 40 or 50 EHR vendors exhibited at this meeting," Dr. Kibbe noted. "This year, only nine EHR vendors are exhibiting." That’s because they now find few new customers among family physicians.

Dr. Kibbe said that he had no disclosures.

PHILADELPHIA – With the federal stage 2 deadline for the meaningful use of electronic health records looming less than 2 years from now, doctors need to start thinking about interoperability, directed exchange, and health Internet service providers.

The key capability that stage 2 demands is the ability to transfer patient data in a reliably secure, confidential way between physicians, between a physician and patient, or between a physician and a health care system.

Mitchel L. Zoler/IMNG Medical Media

These secure, Internet-based data transfers will depend on three elements, Dr. David C. Kibbe said at the annual Congress of Delegates of the American Academy of Family Physicians:

• A standardized format and language for recording the data that transcend the different electronic health record (EHR) formats used by different vendors.

• A method to securely move the data between two or more EHR users, a process known as directed exchange.

• A system to verify that the person engaged in a data exchange – for example, Dr. Smith – really is Dr. Smith.

Although the software that allows these secure exchanges is still being tweaked and has generally not yet rolled out to EHR users, the systems will likely become available in the next few months, said Dr. Kibbe, a senior adviser to the American Academy of Family Physicians in Oriental, N.C.

If the systems work the way they should, physicians will not need to sweat the details. Once EHR vendors get the software finalized and providers in place, all physicians will need to do is sign up for service with the EHR vendor, Dr. Kibbe said.

New Kind of Service Provider

A big part will be physicians becoming customers of a health Internet service provider. Those providers will be something like a conventional Internet service provider, except that they’ll be geared to operate with special certification and encryption procedures to guarantee secure data transmission and validate sender and recipient identities. EHR systems and health Internet service providers will need to use a certification process to establish and confirm the identity of each of their physician clients.

"Health Internet service providers didn’t exist 12 months ago; now many exist, and they are eager to have your business," he said.

Physicians who plan to comply with meaningful use stage 2 and don’t hear anything about this from the EHR vendor by mid-2013 should ask their vendor, "When can you provide it?" said Dr. Kibbe, who also is president of DirectTrust, a nonprofit group that facilitates implementation of directed exchange.

"While some vendors are on top of this, others are clueless," he warned.

And be prepared to pay a bit more for the ability to run secure directed exchange, he said. On the upside, having this capability for secure transmission of EHR data should eliminate the need to send patient information by fax, a step that should save most practices time and money, Dr. Kibbe said.

EHRs Penetrate Family Practice

When he spoke about the next phase of EHR meaningful use at the meeting, he addressed an audience that had already bought into the EHR concept.

"It’s been just about a decade since the AAFP’s Future of Family Medicine led a push for electronic health records for its members," and the push worked, said Dr. Kibbe. In 2004, roughly 10% of AAFP members used an EHR. By 2011, the percent had risen to about 60%, and by late 2012, it had grown to about 80% of the AAFP membership, according to results from recent surveys, he said.

"A few years ago, 40 or 50 EHR vendors exhibited at this meeting," Dr. Kibbe noted. "This year, only nine EHR vendors are exhibiting." That’s because they now find few new customers among family physicians.

Dr. Kibbe said that he had no disclosures.

PHILADELPHIA – Participants in a peer-mentoring program had lower hemoglobin A_1c levels and less severe diabetes over 6-10 months in an initiative that involved more than 550 patients at a single Texas health care organization.

Run at WellMed Medical Management in San Antonio, a primary care–oriented health care organization, the peer-mentoring program "shows what is possible with a well-designed health care system," Dr. Wilson D. Pace said at the annual Congress of Delegates of the American Academy of Family Physicians.

Mitchel L. Zoler/IMNG Medical Media

Peer mentoring "is what’s possible with reorganization [of health care delivery] from a strong primary care perspective. WellMed has worked on their model for more than 20 years," said Dr. Pace, a professor of family medicine at the University of Colorado in Denver, and director of the National Research Network of the American Academy of Family Physicians.

Programs like peer mentoring "are much more resource intensive at the primary care level" compared with standard models of care delivery, "but overall costs actually are reduced. Going beyond just health care is how you achieve health," Dr. Pace said in an interview.

"Putting in social systems and thinking about community resources are not usually seen in our health care systems. It takes [a system] willing to take on risk early, because it takes time to see the savings; they don’t happen in the first 6 months," he said.

Mitchel L. Zoler/IMNG Medical Media

Dr. Pace and his associates conducted a case study of WellMed to document the effect of management programs that the Accountable Care Organization already had in place. During the course of that evaluation, they suggested to WellMed officials that they also consider starting a peer-mentoring program. To bolster their case, the researchers reviewed reported results from 69 studies on peer mentoring, and found that 60 reported net benefits from this approach.

"We thought that we could put peer mentoring [at WellMed] and show some impact, and when we called they said that they had already been thinking about it; they were very receptive," Dr. Pace recalled.

The WellMed program initially rolled out to 15 of the 23 San Antonio practices in the plan. Over the course of the next 2 years, the peer-mentoring program, which is managed by a nurse practitioner, expanded to all 23 practices and is now overseen by six nurse practitioners. After full implementation, the program involved more than 50 recruited and trained patient mentors, and more than 500 patients with diabetes who were interested in being mentees.

Mentees attended a series of twelve 3-hour, peer-led workshop sessions that dealt with diabetes and self-management. Participants also attended one-on-one and small-group mentoring sessions. In addition, they received personal health records with information that included their blood sugar levels over time, their lab results, and their appointments, to help patients "own" their information.

After 6 months, mentored patients had statistically significant increases in the number of times a week they checked their blood glucose, their knowledge of what hemoglobin A_1c means, the quality of their diet, and their activity level. The percent of participants who knew their own A_1c level rose from 32% at baseline to 76% after 6 months.

Average hemoglobin A_1c levels among the mentored patients fell significantly more after 6 months compared with a control group of patients. Among the patients who received mentorship, average A_1c levels dropped from 6.34% at baseline to 6.13% at 6-10 months after the end of the mentoring program. Their average level of disease-related distress fell from a score of 4.08 at baseline to 3.40 6 months after the end of mentoring. The percentage of patients with a disease-related distress score greater than 6 – a marker of clinically significant distress – fell from 24% at baseline to 18% after 6 months. Both changes were statistically significant.

Even before peer mentoring started, WellMed outperformed most other health providers, according to an assessment of their methods and outcomes led by Dr. Robert L. Phillips, Jr., vice president for research and policy at the American Board of Family Medicine in Lexington, Ky.

In a case study led by Dr. Phillips, WellMed members in 2008 had an 18% rate of emergency department visits, a 14% hospitalization rate, a 14% rate of 30-day rehospitalizations, and a rate of 1,002 hospital bed days per 1,000 program members. In contrast, the Texas region’s Medicare program in 2006 had a 28% rate of ED visits, a 22% hospitalization rate, a 20% rate of 30-day rehospitalizations, and 2,559 hospital bed days per 1,000 program members. Those numbers were seen in a study that matched enrollees by age, gender, and number of chronic conditions. Dr. Phillips published a full report of his case study findings last year (J. Ambul. Care Manage. 2001;34:67-77).

"WellMed is really interesting because it does not include a hospital, and it’s primary care driven," Dr. Pace said. "The biggest issue [in creating a health care company like WellMed] is the way the health care dollars flow, and getting rid of the ‘silo-ing’ of dollars. The vision now is that hospitals and specialists are revenue centers that drive everything else; that’s how we think of health care."

WellMed "is an interesting model because it’s different from a hospital-led Accountable Care Organization. That gets you away from hospitals arguing about their bed days. Hospitals need to right-size. We think we can maintain this crazy misdistribution of specialists and hospitals, and it just can’t happen."

Dr. Pace and Dr. Phillips said that they had no disclosures.

PHILADELPHIA – Participants in a peer-mentoring program had lower hemoglobin A_1c levels and less severe diabetes over 6-10 months in an initiative that involved more than 550 patients at a single Texas health care organization.

Run at WellMed Medical Management in San Antonio, a primary care–oriented health care organization, the peer-mentoring program "shows what is possible with a well-designed health care system," Dr. Wilson D. Pace said at the annual Congress of Delegates of the American Academy of Family Physicians.

Mitchel L. Zoler/IMNG Medical Media

Peer mentoring "is what’s possible with reorganization [of health care delivery] from a strong primary care perspective. WellMed has worked on their model for more than 20 years," said Dr. Pace, a professor of family medicine at the University of Colorado in Denver, and director of the National Research Network of the American Academy of Family Physicians.

Programs like peer mentoring "are much more resource intensive at the primary care level" compared with standard models of care delivery, "but overall costs actually are reduced. Going beyond just health care is how you achieve health," Dr. Pace said in an interview.

"Putting in social systems and thinking about community resources are not usually seen in our health care systems. It takes [a system] willing to take on risk early, because it takes time to see the savings; they don’t happen in the first 6 months," he said.

Mitchel L. Zoler/IMNG Medical Media

Dr. Pace and his associates conducted a case study of WellMed to document the effect of management programs that the Accountable Care Organization already had in place. During the course of that evaluation, they suggested to WellMed officials that they also consider starting a peer-mentoring program. To bolster their case, the researchers reviewed reported results from 69 studies on peer mentoring, and found that 60 reported net benefits from this approach.

"We thought that we could put peer mentoring [at WellMed] and show some impact, and when we called they said that they had already been thinking about it; they were very receptive," Dr. Pace recalled.

The WellMed program initially rolled out to 15 of the 23 San Antonio practices in the plan. Over the course of the next 2 years, the peer-mentoring program, which is managed by a nurse practitioner, expanded to all 23 practices and is now overseen by six nurse practitioners. After full implementation, the program involved more than 50 recruited and trained patient mentors, and more than 500 patients with diabetes who were interested in being mentees.

Mentees attended a series of twelve 3-hour, peer-led workshop sessions that dealt with diabetes and self-management. Participants also attended one-on-one and small-group mentoring sessions. In addition, they received personal health records with information that included their blood sugar levels over time, their lab results, and their appointments, to help patients "own" their information.

After 6 months, mentored patients had statistically significant increases in the number of times a week they checked their blood glucose, their knowledge of what hemoglobin A_1c means, the quality of their diet, and their activity level. The percent of participants who knew their own A_1c level rose from 32% at baseline to 76% after 6 months.

Average hemoglobin A_1c levels among the mentored patients fell significantly more after 6 months compared with a control group of patients. Among the patients who received mentorship, average A_1c levels dropped from 6.34% at baseline to 6.13% at 6-10 months after the end of the mentoring program. Their average level of disease-related distress fell from a score of 4.08 at baseline to 3.40 6 months after the end of mentoring. The percentage of patients with a disease-related distress score greater than 6 – a marker of clinically significant distress – fell from 24% at baseline to 18% after 6 months. Both changes were statistically significant.

Even before peer mentoring started, WellMed outperformed most other health providers, according to an assessment of their methods and outcomes led by Dr. Robert L. Phillips, Jr., vice president for research and policy at the American Board of Family Medicine in Lexington, Ky.

In a case study led by Dr. Phillips, WellMed members in 2008 had an 18% rate of emergency department visits, a 14% hospitalization rate, a 14% rate of 30-day rehospitalizations, and a rate of 1,002 hospital bed days per 1,000 program members. In contrast, the Texas region’s Medicare program in 2006 had a 28% rate of ED visits, a 22% hospitalization rate, a 20% rate of 30-day rehospitalizations, and 2,559 hospital bed days per 1,000 program members. Those numbers were seen in a study that matched enrollees by age, gender, and number of chronic conditions. Dr. Phillips published a full report of his case study findings last year (J. Ambul. Care Manage. 2001;34:67-77).

"WellMed is really interesting because it does not include a hospital, and it’s primary care driven," Dr. Pace said. "The biggest issue [in creating a health care company like WellMed] is the way the health care dollars flow, and getting rid of the ‘silo-ing’ of dollars. The vision now is that hospitals and specialists are revenue centers that drive everything else; that’s how we think of health care."

WellMed "is an interesting model because it’s different from a hospital-led Accountable Care Organization. That gets you away from hospitals arguing about their bed days. Hospitals need to right-size. We think we can maintain this crazy misdistribution of specialists and hospitals, and it just can’t happen."

Dr. Pace and Dr. Phillips said that they had no disclosures.

PHILADELPHIA – Participants in a peer-mentoring program had lower hemoglobin A_1c levels and less severe diabetes over 6-10 months in an initiative that involved more than 550 patients at a single Texas health care organization.

Run at WellMed Medical Management in San Antonio, a primary care–oriented health care organization, the peer-mentoring program "shows what is possible with a well-designed health care system," Dr. Wilson D. Pace said at the annual Congress of Delegates of the American Academy of Family Physicians.

Mitchel L. Zoler/IMNG Medical Media

Peer mentoring "is what’s possible with reorganization [of health care delivery] from a strong primary care perspective. WellMed has worked on their model for more than 20 years," said Dr. Pace, a professor of family medicine at the University of Colorado in Denver, and director of the National Research Network of the American Academy of Family Physicians.

Programs like peer mentoring "are much more resource intensive at the primary care level" compared with standard models of care delivery, "but overall costs actually are reduced. Going beyond just health care is how you achieve health," Dr. Pace said in an interview.

"Putting in social systems and thinking about community resources are not usually seen in our health care systems. It takes [a system] willing to take on risk early, because it takes time to see the savings; they don’t happen in the first 6 months," he said.

Mitchel L. Zoler/IMNG Medical Media

Dr. Pace and his associates conducted a case study of WellMed to document the effect of management programs that the Accountable Care Organization already had in place. During the course of that evaluation, they suggested to WellMed officials that they also consider starting a peer-mentoring program. To bolster their case, the researchers reviewed reported results from 69 studies on peer mentoring, and found that 60 reported net benefits from this approach.

"We thought that we could put peer mentoring [at WellMed] and show some impact, and when we called they said that they had already been thinking about it; they were very receptive," Dr. Pace recalled.

The WellMed program initially rolled out to 15 of the 23 San Antonio practices in the plan. Over the course of the next 2 years, the peer-mentoring program, which is managed by a nurse practitioner, expanded to all 23 practices and is now overseen by six nurse practitioners. After full implementation, the program involved more than 50 recruited and trained patient mentors, and more than 500 patients with diabetes who were interested in being mentees.

Mentees attended a series of twelve 3-hour, peer-led workshop sessions that dealt with diabetes and self-management. Participants also attended one-on-one and small-group mentoring sessions. In addition, they received personal health records with information that included their blood sugar levels over time, their lab results, and their appointments, to help patients "own" their information.

After 6 months, mentored patients had statistically significant increases in the number of times a week they checked their blood glucose, their knowledge of what hemoglobin A_1c means, the quality of their diet, and their activity level. The percent of participants who knew their own A_1c level rose from 32% at baseline to 76% after 6 months.

Average hemoglobin A_1c levels among the mentored patients fell significantly more after 6 months compared with a control group of patients. Among the patients who received mentorship, average A_1c levels dropped from 6.34% at baseline to 6.13% at 6-10 months after the end of the mentoring program. Their average level of disease-related distress fell from a score of 4.08 at baseline to 3.40 6 months after the end of mentoring. The percentage of patients with a disease-related distress score greater than 6 – a marker of clinically significant distress – fell from 24% at baseline to 18% after 6 months. Both changes were statistically significant.

Even before peer mentoring started, WellMed outperformed most other health providers, according to an assessment of their methods and outcomes led by Dr. Robert L. Phillips, Jr., vice president for research and policy at the American Board of Family Medicine in Lexington, Ky.

In a case study led by Dr. Phillips, WellMed members in 2008 had an 18% rate of emergency department visits, a 14% hospitalization rate, a 14% rate of 30-day rehospitalizations, and a rate of 1,002 hospital bed days per 1,000 program members. In contrast, the Texas region’s Medicare program in 2006 had a 28% rate of ED visits, a 22% hospitalization rate, a 20% rate of 30-day rehospitalizations, and 2,559 hospital bed days per 1,000 program members. Those numbers were seen in a study that matched enrollees by age, gender, and number of chronic conditions. Dr. Phillips published a full report of his case study findings last year (J. Ambul. Care Manage. 2001;34:67-77).

"WellMed is really interesting because it does not include a hospital, and it’s primary care driven," Dr. Pace said. "The biggest issue [in creating a health care company like WellMed] is the way the health care dollars flow, and getting rid of the ‘silo-ing’ of dollars. The vision now is that hospitals and specialists are revenue centers that drive everything else; that’s how we think of health care."

WellMed "is an interesting model because it’s different from a hospital-led Accountable Care Organization. That gets you away from hospitals arguing about their bed days. Hospitals need to right-size. We think we can maintain this crazy misdistribution of specialists and hospitals, and it just can’t happen."

Dr. Pace and Dr. Phillips said that they had no disclosures.

PHILADELPHIA – Participants in a peer-mentoring program had lower hemoglobin A_1c levels and less severe diabetes over 6-10 months in an initiative that involved more than 550 patients at a single Texas health care organization.

Run at WellMed Medical Management in San Antonio, a primary care–oriented health care organization, the peer-mentoring program "shows what is possible with a well-designed health care system," Dr. Wilson D. Pace said at the annual Congress of Delegates of the American Academy of Family Physicians.

Peer mentoring "is what’s possible with reorganization [of health care delivery] from a strong primary care perspective. WellMed has worked on their model for more than 20 years," said Dr. Pace, a professor of family medicine at the University of Colorado in Denver, and director of the National Research Network of the American Academy of Family Physicians.

Programs like peer mentoring "are much more resource intensive at the primary care level" compared with standard models of care delivery, "but overall costs actually are reduced. Going beyond just health care is how you achieve health," Dr. Pace said in an interview.

"Putting in social systems and thinking about community resources are not usually seen in our health care systems. It takes [a system] willing to take on risk early, because it takes time to see the savings; they don’t happen in the first 6 months," he said.

Dr. Pace and his associates conducted a case study of WellMed to document the effect of management programs that the Accountable Care Organization already had in place. During the course of that evaluation, they suggested to WellMed officials that they also consider starting a peer-mentoring program. To bolster their case, the researchers reviewed reported results from 69 studies on peer mentoring, and found that 60 reported net benefits from this approach.

"We thought that we could put peer mentoring [at WellMed] and show some impact, and when we called they said that they had already been thinking about it; they were very receptive," Dr. Pace recalled.

The WellMed program initially rolled out to 15 of the 23 San Antonio practices in the plan. Over the course of the next 2 years, the peer-mentoring program, which is managed by a nurse practitioner, expanded to all 23 practices and is now overseen by six nurse practitioners. After full implementation, the program involved more than 50 recruited and trained patient mentors, and more than 500 patients with diabetes who were interested in being mentees.

Mentees attended a series of twelve 3-hour, peer-led workshop sessions that dealt with diabetes and self-management. Participants also attended one-on-one and small-group mentoring sessions. In addition, they received personal health records with information that included their blood sugar levels over time, their lab results, and their appointments, to help patients "own" their information.

After 6 months, mentored patients had statistically significant increases in the number of times a week they checked their blood glucose, their knowledge of what hemoglobin A_1c means, the quality of their diet, and their activity level. The percent of participants who knew their own A_1c level rose from 32% at baseline to 76% after 6 months.

Average hemoglobin A_1c levels among the mentored patients fell significantly more after 6 months compared with a control group of patients. Among the patients who received mentorship, average A_1c levels dropped from 6.34% at baseline to 6.13% at 6-10 months after the end of the mentoring program. Their average level of disease-related distress fell from a score of 4.08 at baseline to 3.40 6 months after the end of mentoring. The percentage of patients with a disease-related distress score greater than 6 – a marker of clinically significant distress – fell from 24% at baseline to 18% after 6 months. Both changes were statistically significant.

Even before peer mentoring started, WellMed outperformed most other health providers, according to an assessment of their methods and outcomes led by Dr. Robert L. Phillips, Jr., vice president for research and policy at the American Board of Family Medicine in Lexington, Ky.

In a case study led by Dr. Phillips, WellMed members in 2008 had an 18% rate of emergency department visits, a 14% hospitalization rate, a 14% rate of 30-day rehospitalizations, and a rate of 1,002 hospital bed days per 1,000 program members. In contrast, the Texas region’s Medicare program in 2006 had a 28% rate of ED visits, a 22% hospitalization rate, a 20% rate of 30-day rehospitalizations, and 2,559 hospital bed days per 1,000 program members. Those numbers were seen in a study that matched enrollees by age, gender, and number of chronic conditions. Dr. Phillips published a full report of his case study findings last year (J. Ambul. Care Manage. 2001;34:67-77).

"WellMed is really interesting because it does not include a hospital, and it’s primary care driven," Dr. Pace said. "The biggest issue [in creating a health care company like WellMed] is the way the health care dollars flow, and getting rid of the ‘silo-ing’ of dollars. The vision now is that hospitals and specialists are revenue centers that drive everything else; that’s how we think of health care."

WellMed "is an interesting model because it’s different from a hospital-led Accountable Care Organization. That gets you away from hospitals arguing about their bed days. Hospitals need to right-size. We think we can maintain this crazy misdistribution of specialists and hospitals, and it just can’t happen."

Dr. Pace and Dr. Phillips said that they had no disclosures.

PHILADELPHIA – Participants in a peer-mentoring program had lower hemoglobin A_1c levels and less severe diabetes over 6-10 months in an initiative that involved more than 550 patients at a single Texas health care organization.

Run at WellMed Medical Management in San Antonio, a primary care–oriented health care organization, the peer-mentoring program "shows what is possible with a well-designed health care system," Dr. Wilson D. Pace said at the annual Congress of Delegates of the American Academy of Family Physicians.

Peer mentoring "is what’s possible with reorganization [of health care delivery] from a strong primary care perspective. WellMed has worked on their model for more than 20 years," said Dr. Pace, a professor of family medicine at the University of Colorado in Denver, and director of the National Research Network of the American Academy of Family Physicians.

Programs like peer mentoring "are much more resource intensive at the primary care level" compared with standard models of care delivery, "but overall costs actually are reduced. Going beyond just health care is how you achieve health," Dr. Pace said in an interview.

"Putting in social systems and thinking about community resources are not usually seen in our health care systems. It takes [a system] willing to take on risk early, because it takes time to see the savings; they don’t happen in the first 6 months," he said.

Dr. Pace and his associates conducted a case study of WellMed to document the effect of management programs that the Accountable Care Organization already had in place. During the course of that evaluation, they suggested to WellMed officials that they also consider starting a peer-mentoring program. To bolster their case, the researchers reviewed reported results from 69 studies on peer mentoring, and found that 60 reported net benefits from this approach.

"We thought that we could put peer mentoring [at WellMed] and show some impact, and when we called they said that they had already been thinking about it; they were very receptive," Dr. Pace recalled.

The WellMed program initially rolled out to 15 of the 23 San Antonio practices in the plan. Over the course of the next 2 years, the peer-mentoring program, which is managed by a nurse practitioner, expanded to all 23 practices and is now overseen by six nurse practitioners. After full implementation, the program involved more than 50 recruited and trained patient mentors, and more than 500 patients with diabetes who were interested in being mentees.

Mentees attended a series of twelve 3-hour, peer-led workshop sessions that dealt with diabetes and self-management. Participants also attended one-on-one and small-group mentoring sessions. In addition, they received personal health records with information that included their blood sugar levels over time, their lab results, and their appointments, to help patients "own" their information.

After 6 months, mentored patients had statistically significant increases in the number of times a week they checked their blood glucose, their knowledge of what hemoglobin A_1c means, the quality of their diet, and their activity level. The percent of participants who knew their own A_1c level rose from 32% at baseline to 76% after 6 months.

Average hemoglobin A_1c levels among the mentored patients fell significantly more after 6 months compared with a control group of patients. Among the patients who received mentorship, average A_1c levels dropped from 6.34% at baseline to 6.13% at 6-10 months after the end of the mentoring program. Their average level of disease-related distress fell from a score of 4.08 at baseline to 3.40 6 months after the end of mentoring. The percentage of patients with a disease-related distress score greater than 6 – a marker of clinically significant distress – fell from 24% at baseline to 18% after 6 months. Both changes were statistically significant.

Even before peer mentoring started, WellMed outperformed most other health providers, according to an assessment of their methods and outcomes led by Dr. Robert L. Phillips, Jr., vice president for research and policy at the American Board of Family Medicine in Lexington, Ky.

In a case study led by Dr. Phillips, WellMed members in 2008 had an 18% rate of emergency department visits, a 14% hospitalization rate, a 14% rate of 30-day rehospitalizations, and a rate of 1,002 hospital bed days per 1,000 program members. In contrast, the Texas region’s Medicare program in 2006 had a 28% rate of ED visits, a 22% hospitalization rate, a 20% rate of 30-day rehospitalizations, and 2,559 hospital bed days per 1,000 program members. Those numbers were seen in a study that matched enrollees by age, gender, and number of chronic conditions. Dr. Phillips published a full report of his case study findings last year (J. Ambul. Care Manage. 2001;34:67-77).

"WellMed is really interesting because it does not include a hospital, and it’s primary care driven," Dr. Pace said. "The biggest issue [in creating a health care company like WellMed] is the way the health care dollars flow, and getting rid of the ‘silo-ing’ of dollars. The vision now is that hospitals and specialists are revenue centers that drive everything else; that’s how we think of health care."

WellMed "is an interesting model because it’s different from a hospital-led Accountable Care Organization. That gets you away from hospitals arguing about their bed days. Hospitals need to right-size. We think we can maintain this crazy misdistribution of specialists and hospitals, and it just can’t happen."

Dr. Pace and Dr. Phillips said that they had no disclosures.

PHILADELPHIA – Participants in a peer-mentoring program had lower hemoglobin A_1c levels and less severe diabetes over 6-10 months in an initiative that involved more than 550 patients at a single Texas health care organization.

Run at WellMed Medical Management in San Antonio, a primary care–oriented health care organization, the peer-mentoring program "shows what is possible with a well-designed health care system," Dr. Wilson D. Pace said at the annual Congress of Delegates of the American Academy of Family Physicians.

Peer mentoring "is what’s possible with reorganization [of health care delivery] from a strong primary care perspective. WellMed has worked on their model for more than 20 years," said Dr. Pace, a professor of family medicine at the University of Colorado in Denver, and director of the National Research Network of the American Academy of Family Physicians.

Programs like peer mentoring "are much more resource intensive at the primary care level" compared with standard models of care delivery, "but overall costs actually are reduced. Going beyond just health care is how you achieve health," Dr. Pace said in an interview.

"Putting in social systems and thinking about community resources are not usually seen in our health care systems. It takes [a system] willing to take on risk early, because it takes time to see the savings; they don’t happen in the first 6 months," he said.

Dr. Pace and his associates conducted a case study of WellMed to document the effect of management programs that the Accountable Care Organization already had in place. During the course of that evaluation, they suggested to WellMed officials that they also consider starting a peer-mentoring program. To bolster their case, the researchers reviewed reported results from 69 studies on peer mentoring, and found that 60 reported net benefits from this approach.

"We thought that we could put peer mentoring [at WellMed] and show some impact, and when we called they said that they had already been thinking about it; they were very receptive," Dr. Pace recalled.

The WellMed program initially rolled out to 15 of the 23 San Antonio practices in the plan. Over the course of the next 2 years, the peer-mentoring program, which is managed by a nurse practitioner, expanded to all 23 practices and is now overseen by six nurse practitioners. After full implementation, the program involved more than 50 recruited and trained patient mentors, and more than 500 patients with diabetes who were interested in being mentees.

Mentees attended a series of twelve 3-hour, peer-led workshop sessions that dealt with diabetes and self-management. Participants also attended one-on-one and small-group mentoring sessions. In addition, they received personal health records with information that included their blood sugar levels over time, their lab results, and their appointments, to help patients "own" their information.

After 6 months, mentored patients had statistically significant increases in the number of times a week they checked their blood glucose, their knowledge of what hemoglobin A_1c means, the quality of their diet, and their activity level. The percent of participants who knew their own A_1c level rose from 32% at baseline to 76% after 6 months.

Average hemoglobin A_1c levels among the mentored patients fell significantly more after 6 months compared with a control group of patients. Among the patients who received mentorship, average A_1c levels dropped from 6.34% at baseline to 6.13% at 6-10 months after the end of the mentoring program. Their average level of disease-related distress fell from a score of 4.08 at baseline to 3.40 6 months after the end of mentoring. The percentage of patients with a disease-related distress score greater than 6 – a marker of clinically significant distress – fell from 24% at baseline to 18% after 6 months. Both changes were statistically significant.

Even before peer mentoring started, WellMed outperformed most other health providers, according to an assessment of their methods and outcomes led by Dr. Robert L. Phillips, Jr., vice president for research and policy at the American Board of Family Medicine in Lexington, Ky.

In a case study led by Dr. Phillips, WellMed members in 2008 had an 18% rate of emergency department visits, a 14% hospitalization rate, a 14% rate of 30-day rehospitalizations, and a rate of 1,002 hospital bed days per 1,000 program members. In contrast, the Texas region’s Medicare program in 2006 had a 28% rate of ED visits, a 22% hospitalization rate, a 20% rate of 30-day rehospitalizations, and 2,559 hospital bed days per 1,000 program members. Those numbers were seen in a study that matched enrollees by age, gender, and number of chronic conditions. Dr. Phillips published a full report of his case study findings last year (J. Ambul. Care Manage. 2001;34:67-77).

"WellMed is really interesting because it does not include a hospital, and it’s primary care driven," Dr. Pace said. "The biggest issue [in creating a health care company like WellMed] is the way the health care dollars flow, and getting rid of the ‘silo-ing’ of dollars. The vision now is that hospitals and specialists are revenue centers that drive everything else; that’s how we think of health care."

WellMed "is an interesting model because it’s different from a hospital-led Accountable Care Organization. That gets you away from hospitals arguing about their bed days. Hospitals need to right-size. We think we can maintain this crazy misdistribution of specialists and hospitals, and it just can’t happen."

Dr. Pace and Dr. Phillips said that they had no disclosures.

PHILADELPHIA – The last 4 miles of a marathon can be a killer, in more ways than one.

Among U.S. marathon participants, the incidence of sudden cardiac arrests (SCA) peaked starting at mile 23 and continuing till the finish at 26.2 miles, based on data collected from more than 1.7 million runners who participated in U.S. marathons during 1976-2009.

© bytepark/iStockphoto.com

Among the 30 SCA experienced by 1,710,052 marathon runners, 16 (53%) occurred at mile 23 or beyond, Kevin M. DuPrey, D.O., and his associates reported in a poster at the annual congress of delegates of the American Academy of Family Physicians. Six of the other 14 SCA occurred during miles 15-22, so that 73% of all SCA occurred during the final 43% of the race. Five of the SCA occurred during miles 6-14, and three happened in the races’ first five miles.

The findings, derived from web-based survey responses by 88 marathon medical directors, also highlighted the life-saving impact of treating cardiac arrests with an automated external defibrillator (AED). Among the 20 cases known to have received AED treatment, 17 runners survived (85%). In contrast, among eight runners known to have not received AED treatment, two survived (25%). In two cases, definitive information about AED use was not available, and one of these patients died. Ten of the 30 runners who had an in-race SCA died. Statistical analysis showed that AED use was significantly linked with survival.

Given the life-saving potential of AED use and the link between SCA and distance into the race, marathon organizers should focus AED placement in the final miles of a race, the researchers concluded. "Results from a recent study showed that proximity of AED to a collapsed runner was a major determinant of survival," wrote Dr. DuPrey, a researcher at Crozier-Keystone Health System in Springfield, Pa., and his associates.

Another previously reported study they cited documented a sharp reduction in fatality among marathon runners who had an SCA starting in 1995, the period when AEDs became more routinely available at marathons (J. Amer. Coll. Cardiol. 2005;46:1373-4). In two large U.S. marathons, the fatality rate fell from one in 55,000 in 1976-1994 to one in 220,000 during 1995-2004.

Autopsies of 9 of the 10 fatalities in the current survey revealed coronary artery disease in seven, an anomalous coronary artery in one, and no clear pathology in one. Twenty-eight of the 30 SCA (93%) occurred in men, and the cases averaged 50 years old, ranging from 19 to 82 years old.

Dr. DuPrey and his associates had no disclosures.

PHILADELPHIA – The last 4 miles of a marathon can be a killer, in more ways than one.

Among U.S. marathon participants, the incidence of sudden cardiac arrests (SCA) peaked starting at mile 23 and continuing till the finish at 26.2 miles, based on data collected from more than 1.7 million runners who participated in U.S. marathons during 1976-2009.

© bytepark/iStockphoto.com

Among the 30 SCA experienced by 1,710,052 marathon runners, 16 (53%) occurred at mile 23 or beyond, Kevin M. DuPrey, D.O., and his associates reported in a poster at the annual congress of delegates of the American Academy of Family Physicians. Six of the other 14 SCA occurred during miles 15-22, so that 73% of all SCA occurred during the final 43% of the race. Five of the SCA occurred during miles 6-14, and three happened in the races’ first five miles.

The findings, derived from web-based survey responses by 88 marathon medical directors, also highlighted the life-saving impact of treating cardiac arrests with an automated external defibrillator (AED). Among the 20 cases known to have received AED treatment, 17 runners survived (85%). In contrast, among eight runners known to have not received AED treatment, two survived (25%). In two cases, definitive information about AED use was not available, and one of these patients died. Ten of the 30 runners who had an in-race SCA died. Statistical analysis showed that AED use was significantly linked with survival.

Given the life-saving potential of AED use and the link between SCA and distance into the race, marathon organizers should focus AED placement in the final miles of a race, the researchers concluded. "Results from a recent study showed that proximity of AED to a collapsed runner was a major determinant of survival," wrote Dr. DuPrey, a researcher at Crozier-Keystone Health System in Springfield, Pa., and his associates.

Another previously reported study they cited documented a sharp reduction in fatality among marathon runners who had an SCA starting in 1995, the period when AEDs became more routinely available at marathons (J. Amer. Coll. Cardiol. 2005;46:1373-4). In two large U.S. marathons, the fatality rate fell from one in 55,000 in 1976-1994 to one in 220,000 during 1995-2004.

Autopsies of 9 of the 10 fatalities in the current survey revealed coronary artery disease in seven, an anomalous coronary artery in one, and no clear pathology in one. Twenty-eight of the 30 SCA (93%) occurred in men, and the cases averaged 50 years old, ranging from 19 to 82 years old.

Dr. DuPrey and his associates had no disclosures.

PHILADELPHIA – The last 4 miles of a marathon can be a killer, in more ways than one.

Among U.S. marathon participants, the incidence of sudden cardiac arrests (SCA) peaked starting at mile 23 and continuing till the finish at 26.2 miles, based on data collected from more than 1.7 million runners who participated in U.S. marathons during 1976-2009.

© bytepark/iStockphoto.com

Among the 30 SCA experienced by 1,710,052 marathon runners, 16 (53%) occurred at mile 23 or beyond, Kevin M. DuPrey, D.O., and his associates reported in a poster at the annual congress of delegates of the American Academy of Family Physicians. Six of the other 14 SCA occurred during miles 15-22, so that 73% of all SCA occurred during the final 43% of the race. Five of the SCA occurred during miles 6-14, and three happened in the races’ first five miles.

The findings, derived from web-based survey responses by 88 marathon medical directors, also highlighted the life-saving impact of treating cardiac arrests with an automated external defibrillator (AED). Among the 20 cases known to have received AED treatment, 17 runners survived (85%). In contrast, among eight runners known to have not received AED treatment, two survived (25%). In two cases, definitive information about AED use was not available, and one of these patients died. Ten of the 30 runners who had an in-race SCA died. Statistical analysis showed that AED use was significantly linked with survival.

Given the life-saving potential of AED use and the link between SCA and distance into the race, marathon organizers should focus AED placement in the final miles of a race, the researchers concluded. "Results from a recent study showed that proximity of AED to a collapsed runner was a major determinant of survival," wrote Dr. DuPrey, a researcher at Crozier-Keystone Health System in Springfield, Pa., and his associates.

Another previously reported study they cited documented a sharp reduction in fatality among marathon runners who had an SCA starting in 1995, the period when AEDs became more routinely available at marathons (J. Amer. Coll. Cardiol. 2005;46:1373-4). In two large U.S. marathons, the fatality rate fell from one in 55,000 in 1976-1994 to one in 220,000 during 1995-2004.

Autopsies of 9 of the 10 fatalities in the current survey revealed coronary artery disease in seven, an anomalous coronary artery in one, and no clear pathology in one. Twenty-eight of the 30 SCA (93%) occurred in men, and the cases averaged 50 years old, ranging from 19 to 82 years old.

Dr. DuPrey and his associates had no disclosures.

PHILADELPHIA – About 1,000 St. Louis women who sought combined hormonal contraception as part of a research study had a 2.4% prevalence of a true medical contraindication for this form of contraception.

"This low prevalence supports provision of combined hormonal contraception without a prescription," concluded Hanna Xu and her associates in a poster at the meeting.

The finding may add impetus to an 8-year old project aimed at making at least some type of oral contraception available to U.S. women on an over-the-counter (OTC) basis, commented physicians involved in this effort.

©Tina Sbrigato/iStockphoto.com

"I’m pleased to see a 2.4% rate. It’s actually a bit lower than what we’ve seen in other studies," commented Dr. Anne E. Burke, an ob.gyn. at Johns Hopkins University, Baltimore. "This kind of information is important because it gets at one of the big barriers; data like this reassure us that OTC oral contraceptives are safe," she said in an interview.

Results from other studies have generally shown a higher contraindication prevalence. For example, a 2007 report based on data collected in the National Health and Nutrition Examination Survey (NHANES) 1999-2001 found a 16% prevalence of contraindications in American women aged 20-51 years (Contraception 2007;75:355-60).

Dr. Burke serves on the steering committee of the Oral Contraceptives Over the Counter (OCs OTC) Working Group, a coalition formed in 2004 aimed at making oral contraceptives available to U.S. women without need for prescriptions.

Since its founding, the group has worked to "consolidate what we know about this issue, build consensus, disseminate information, and engage with drug companies," said Dr. Daniel Grossman, an ob.gyn. who is vice president for research of Ibis Reproductive Health, a nonprofit organization that researches reproductive health, and coordinator of the OCs OTC Working Group.

"Although this result from the St. Louis program is very interesting, it is much more likely that the Food and Drug Administration will approve a progestin-only contraceptive for OTC use," Dr. Grossman said in an interview. In part, that’s because the FDA has already approved an OTC progestin-only emergency contraceptive formulation. "We see a progestin-only OTC contraceptive as an interim step, but a more realistic step. Getting a combined hormonal contraceptive made OTC by the FDA would be a real challenge," he said. Another advantage to progestin-only pills is they have fewer contraindications than do combined hormonal pills.

Eventually, the FDA may be willing to make a combined hormonal pill available OTC under conditions of safe use, such as having sales tied to an automated kiosk that would also guide women through the contraindications and record their blood pressure. Another option for the FDA is to limit initial sale of combined hormonal pills to women with prescriptions, but allow refills on an OTC basis.

A major barrier to any oral contraceptive becoming OTC is the need for a manufacturer to apply to the FDA. "No manufacturer has said it is willing to apply," Dr. Grossman said.

In addition to trying to persuade a manufacturer to cooperate, "the next step is to show the FDA that women can self-identify their contraindications," Dr. Grossman said. A study he published in 2008 showed that 7% of women incorrectly thought that they were candidates for oral contraceptive use when in fact they had a contraindication (Obstet. Gynecol. 2008;112:572-8). This rate was almost identical to the 6% rate of contraindications found in women who had received an oral contraceptive prescription in the 2007 NHANES analysis (Contraception 2007;75:355-60).The main contraindication women have trouble self-identifying is hypertension, especially when undiagnosed, he said. In the St. Louis study, hypertension caused 71% of the true contraindications.

Ob.gyn. researchers at Washington University in St. Louis enrolled roughly 10,000 area women in the Contraceptive CHOICE program and provided them with free contraception of their choice to promote reversible, long-term methods of contraception. The current study focused on 1,010 participants in the program who opted to receive a combined hormonal contraceptive. The researchers tallied the number of women with a true medical contraindication for a combined hormonal contraceptive based on health records, reported Ms. Xu, a researcher in the department of ob.gyn. at Washington University in St. Louis, and her associates. Contraindications were a documented history of breast cancer, hypertension, myocardial infarction, transient ischemic attack, cerebral vascular accident, migraines with aura, any migraine at age 35 years or older, venous thromboembolism, liver disease, or smoking at age 35 or older.

Ms. Xu and her associates had no disclosures. Dr. Burke said that she has received a training grant from Merck, which markets Nexplanon. Dr. Grossman said that he has no disclosures.

PHILADELPHIA – About 1,000 St. Louis women who sought combined hormonal contraception as part of a research study had a 2.4% prevalence of a true medical contraindication for this form of contraception.

"This low prevalence supports provision of combined hormonal contraception without a prescription," concluded Hanna Xu and her associates in a poster at the meeting.

The finding may add impetus to an 8-year old project aimed at making at least some type of oral contraception available to U.S. women on an over-the-counter (OTC) basis, commented physicians involved in this effort.

©Tina Sbrigato/iStockphoto.com

"I’m pleased to see a 2.4% rate. It’s actually a bit lower than what we’ve seen in other studies," commented Dr. Anne E. Burke, an ob.gyn. at Johns Hopkins University, Baltimore. "This kind of information is important because it gets at one of the big barriers; data like this reassure us that OTC oral contraceptives are safe," she said in an interview.

Results from other studies have generally shown a higher contraindication prevalence. For example, a 2007 report based on data collected in the National Health and Nutrition Examination Survey (NHANES) 1999-2001 found a 16% prevalence of contraindications in American women aged 20-51 years (Contraception 2007;75:355-60).

Dr. Burke serves on the steering committee of the Oral Contraceptives Over the Counter (OCs OTC) Working Group, a coalition formed in 2004 aimed at making oral contraceptives available to U.S. women without need for prescriptions.

Since its founding, the group has worked to "consolidate what we know about this issue, build consensus, disseminate information, and engage with drug companies," said Dr. Daniel Grossman, an ob.gyn. who is vice president for research of Ibis Reproductive Health, a nonprofit organization that researches reproductive health, and coordinator of the OCs OTC Working Group.

"Although this result from the St. Louis program is very interesting, it is much more likely that the Food and Drug Administration will approve a progestin-only contraceptive for OTC use," Dr. Grossman said in an interview. In part, that’s because the FDA has already approved an OTC progestin-only emergency contraceptive formulation. "We see a progestin-only OTC contraceptive as an interim step, but a more realistic step. Getting a combined hormonal contraceptive made OTC by the FDA would be a real challenge," he said. Another advantage to progestin-only pills is they have fewer contraindications than do combined hormonal pills.

Eventually, the FDA may be willing to make a combined hormonal pill available OTC under conditions of safe use, such as having sales tied to an automated kiosk that would also guide women through the contraindications and record their blood pressure. Another option for the FDA is to limit initial sale of combined hormonal pills to women with prescriptions, but allow refills on an OTC basis.

A major barrier to any oral contraceptive becoming OTC is the need for a manufacturer to apply to the FDA. "No manufacturer has said it is willing to apply," Dr. Grossman said.

In addition to trying to persuade a manufacturer to cooperate, "the next step is to show the FDA that women can self-identify their contraindications," Dr. Grossman said. A study he published in 2008 showed that 7% of women incorrectly thought that they were candidates for oral contraceptive use when in fact they had a contraindication (Obstet. Gynecol. 2008;112:572-8). This rate was almost identical to the 6% rate of contraindications found in women who had received an oral contraceptive prescription in the 2007 NHANES analysis (Contraception 2007;75:355-60).The main contraindication women have trouble self-identifying is hypertension, especially when undiagnosed, he said. In the St. Louis study, hypertension caused 71% of the true contraindications.

Ob.gyn. researchers at Washington University in St. Louis enrolled roughly 10,000 area women in the Contraceptive CHOICE program and provided them with free contraception of their choice to promote reversible, long-term methods of contraception. The current study focused on 1,010 participants in the program who opted to receive a combined hormonal contraceptive. The researchers tallied the number of women with a true medical contraindication for a combined hormonal contraceptive based on health records, reported Ms. Xu, a researcher in the department of ob.gyn. at Washington University in St. Louis, and her associates. Contraindications were a documented history of breast cancer, hypertension, myocardial infarction, transient ischemic attack, cerebral vascular accident, migraines with aura, any migraine at age 35 years or older, venous thromboembolism, liver disease, or smoking at age 35 or older.

Ms. Xu and her associates had no disclosures. Dr. Burke said that she has received a training grant from Merck, which markets Nexplanon. Dr. Grossman said that he has no disclosures.

PHILADELPHIA – About 1,000 St. Louis women who sought combined hormonal contraception as part of a research study had a 2.4% prevalence of a true medical contraindication for this form of contraception.

"This low prevalence supports provision of combined hormonal contraception without a prescription," concluded Hanna Xu and her associates in a poster at the meeting.

The finding may add impetus to an 8-year old project aimed at making at least some type of oral contraception available to U.S. women on an over-the-counter (OTC) basis, commented physicians involved in this effort.

©Tina Sbrigato/iStockphoto.com

"I’m pleased to see a 2.4% rate. It’s actually a bit lower than what we’ve seen in other studies," commented Dr. Anne E. Burke, an ob.gyn. at Johns Hopkins University, Baltimore. "This kind of information is important because it gets at one of the big barriers; data like this reassure us that OTC oral contraceptives are safe," she said in an interview.

Results from other studies have generally shown a higher contraindication prevalence. For example, a 2007 report based on data collected in the National Health and Nutrition Examination Survey (NHANES) 1999-2001 found a 16% prevalence of contraindications in American women aged 20-51 years (Contraception 2007;75:355-60).

Dr. Burke serves on the steering committee of the Oral Contraceptives Over the Counter (OCs OTC) Working Group, a coalition formed in 2004 aimed at making oral contraceptives available to U.S. women without need for prescriptions.

Since its founding, the group has worked to "consolidate what we know about this issue, build consensus, disseminate information, and engage with drug companies," said Dr. Daniel Grossman, an ob.gyn. who is vice president for research of Ibis Reproductive Health, a nonprofit organization that researches reproductive health, and coordinator of the OCs OTC Working Group.

"Although this result from the St. Louis program is very interesting, it is much more likely that the Food and Drug Administration will approve a progestin-only contraceptive for OTC use," Dr. Grossman said in an interview. In part, that’s because the FDA has already approved an OTC progestin-only emergency contraceptive formulation. "We see a progestin-only OTC contraceptive as an interim step, but a more realistic step. Getting a combined hormonal contraceptive made OTC by the FDA would be a real challenge," he said. Another advantage to progestin-only pills is they have fewer contraindications than do combined hormonal pills.

Eventually, the FDA may be willing to make a combined hormonal pill available OTC under conditions of safe use, such as having sales tied to an automated kiosk that would also guide women through the contraindications and record their blood pressure. Another option for the FDA is to limit initial sale of combined hormonal pills to women with prescriptions, but allow refills on an OTC basis.

A major barrier to any oral contraceptive becoming OTC is the need for a manufacturer to apply to the FDA. "No manufacturer has said it is willing to apply," Dr. Grossman said.

In addition to trying to persuade a manufacturer to cooperate, "the next step is to show the FDA that women can self-identify their contraindications," Dr. Grossman said. A study he published in 2008 showed that 7% of women incorrectly thought that they were candidates for oral contraceptive use when in fact they had a contraindication (Obstet. Gynecol. 2008;112:572-8). This rate was almost identical to the 6% rate of contraindications found in women who had received an oral contraceptive prescription in the 2007 NHANES analysis (Contraception 2007;75:355-60).The main contraindication women have trouble self-identifying is hypertension, especially when undiagnosed, he said. In the St. Louis study, hypertension caused 71% of the true contraindications.

Ob.gyn. researchers at Washington University in St. Louis enrolled roughly 10,000 area women in the Contraceptive CHOICE program and provided them with free contraception of their choice to promote reversible, long-term methods of contraception. The current study focused on 1,010 participants in the program who opted to receive a combined hormonal contraceptive. The researchers tallied the number of women with a true medical contraindication for a combined hormonal contraceptive based on health records, reported Ms. Xu, a researcher in the department of ob.gyn. at Washington University in St. Louis, and her associates. Contraindications were a documented history of breast cancer, hypertension, myocardial infarction, transient ischemic attack, cerebral vascular accident, migraines with aura, any migraine at age 35 years or older, venous thromboembolism, liver disease, or smoking at age 35 or older.

Ms. Xu and her associates had no disclosures. Dr. Burke said that she has received a training grant from Merck, which markets Nexplanon. Dr. Grossman said that he has no disclosures.

The aldosterone antagonists spironolactone and eplerenone are the new darlings of antihypertensive treatment.

This cozy drug category – with just these two agents available in the United States – is the one many experts now recommend for most hypertensive patients with blood pressure that remains elevated after treatment with two or three top-tier agents (diuretic, beta-blocker, or an ACE inhibitor/blocker).

"The best way to treat [resistant hypertension] is with a low dose of a mineralocorticoid antagonist. It has a profound blood pressure lowering effect. This has dramatically changed my outlook on treating hypertension," Dr. Frank Domino said earlier this month at the annual meeting of the American Academy of Family Physicians in Philadelphia. "I hate having patients on three blood pressure medications, with all their adverse effects, and still not controlled. With spironolactone you can often cut back to two meds and still have blood pressure controlled."

Dr. Domino cited a Dutch article last year that reported on 123 patients with "difficult-to-treat" hypertension who had "profound and sustained" blood pressure reductions on spironolactone or eplerenone, while generally well tolerated, with 13 reported adverse events (Int. J. Hypertens. 2011:2011;Article ID 368140 [doi: 10.4061/2011/368140]).

I first reported on the rising star of the aldosterone antagonists for blood pressure reduction almost 4 years ago, when hypertension opinion leader Dr. George Bakris called them his new weapon for treating resistant hypertension in obese patients. Dr. Bakris recently told me that he now views these drugs as the top option for all patients with resistant hypertension, obese or not.

Spironolactone and eplerenone had an interesting path from the outer fringe of hypertension treatment toward the spotlight over the past decade or so. Spironolactone labored in near obscurity for years, following approval in 1960 as Aldactone, a treatment for primary hyperaldosteronism. Landmark findings from the RALES trial in 1999 plucked the drug from the sidelines by showing that adding spironolactone to conventional treatment of patients with advanced heart failure led to substantial improvements in health and survival. Presciently, the authors of that study in 1999 said their results had "implications for the treatment of patients with other conditions in which ACE inhibitors are beneficial, such as patients with hypertension and those who have had a myocardial infarction."

A few years later, eplerenone (Inspra) came on the scene as a somewhat safer (and more expensive) alternative to spironolactone, and was shown in in 2003 in the EPHESUS trial to benefit post–myocardial infarction patients with left ventricular dysfunction, and then last year the EMPHASIS-HF results proved that eplerenone was also beneficial for treating patients with mild heart failure. Today, experts promote the twin aldosterone antagonists as must-use drugs for heart failure patients of all stripes.

Now hypertension is the next frontier for the aldosterone antagonists.

–Mitchel Zoler (on Twitter @mitchelzoler)

The aldosterone antagonists spironolactone and eplerenone are the new darlings of antihypertensive treatment.

This cozy drug category – with just these two agents available in the United States – is the one many experts now recommend for most hypertensive patients with blood pressure that remains elevated after treatment with two or three top-tier agents (diuretic, beta-blocker, or an ACE inhibitor/blocker).

"The best way to treat [resistant hypertension] is with a low dose of a mineralocorticoid antagonist. It has a profound blood pressure lowering effect. This has dramatically changed my outlook on treating hypertension," Dr. Frank Domino said earlier this month at the annual meeting of the American Academy of Family Physicians in Philadelphia. "I hate having patients on three blood pressure medications, with all their adverse effects, and still not controlled. With spironolactone you can often cut back to two meds and still have blood pressure controlled."

Dr. Domino cited a Dutch article last year that reported on 123 patients with "difficult-to-treat" hypertension who had "profound and sustained" blood pressure reductions on spironolactone or eplerenone, while generally well tolerated, with 13 reported adverse events (Int. J. Hypertens. 2011:2011;Article ID 368140 [doi: 10.4061/2011/368140]).

I first reported on the rising star of the aldosterone antagonists for blood pressure reduction almost 4 years ago, when hypertension opinion leader Dr. George Bakris called them his new weapon for treating resistant hypertension in obese patients. Dr. Bakris recently told me that he now views these drugs as the top option for all patients with resistant hypertension, obese or not.

Spironolactone and eplerenone had an interesting path from the outer fringe of hypertension treatment toward the spotlight over the past decade or so. Spironolactone labored in near obscurity for years, following approval in 1960 as Aldactone, a treatment for primary hyperaldosteronism. Landmark findings from the RALES trial in 1999 plucked the drug from the sidelines by showing that adding spironolactone to conventional treatment of patients with advanced heart failure led to substantial improvements in health and survival. Presciently, the authors of that study in 1999 said their results had "implications for the treatment of patients with other conditions in which ACE inhibitors are beneficial, such as patients with hypertension and those who have had a myocardial infarction."

A few years later, eplerenone (Inspra) came on the scene as a somewhat safer (and more expensive) alternative to spironolactone, and was shown in in 2003 in the EPHESUS trial to benefit post–myocardial infarction patients with left ventricular dysfunction, and then last year the EMPHASIS-HF results proved that eplerenone was also beneficial for treating patients with mild heart failure. Today, experts promote the twin aldosterone antagonists as must-use drugs for heart failure patients of all stripes.

Now hypertension is the next frontier for the aldosterone antagonists.

–Mitchel Zoler (on Twitter @mitchelzoler)

The aldosterone antagonists spironolactone and eplerenone are the new darlings of antihypertensive treatment.

This cozy drug category – with just these two agents available in the United States – is the one many experts now recommend for most hypertensive patients with blood pressure that remains elevated after treatment with two or three top-tier agents (diuretic, beta-blocker, or an ACE inhibitor/blocker).

"The best way to treat [resistant hypertension] is with a low dose of a mineralocorticoid antagonist. It has a profound blood pressure lowering effect. This has dramatically changed my outlook on treating hypertension," Dr. Frank Domino said earlier this month at the annual meeting of the American Academy of Family Physicians in Philadelphia. "I hate having patients on three blood pressure medications, with all their adverse effects, and still not controlled. With spironolactone you can often cut back to two meds and still have blood pressure controlled."

Dr. Domino cited a Dutch article last year that reported on 123 patients with "difficult-to-treat" hypertension who had "profound and sustained" blood pressure reductions on spironolactone or eplerenone, while generally well tolerated, with 13 reported adverse events (Int. J. Hypertens. 2011:2011;Article ID 368140 [doi: 10.4061/2011/368140]).

I first reported on the rising star of the aldosterone antagonists for blood pressure reduction almost 4 years ago, when hypertension opinion leader Dr. George Bakris called them his new weapon for treating resistant hypertension in obese patients. Dr. Bakris recently told me that he now views these drugs as the top option for all patients with resistant hypertension, obese or not.

Spironolactone and eplerenone had an interesting path from the outer fringe of hypertension treatment toward the spotlight over the past decade or so. Spironolactone labored in near obscurity for years, following approval in 1960 as Aldactone, a treatment for primary hyperaldosteronism. Landmark findings from the RALES trial in 1999 plucked the drug from the sidelines by showing that adding spironolactone to conventional treatment of patients with advanced heart failure led to substantial improvements in health and survival. Presciently, the authors of that study in 1999 said their results had "implications for the treatment of patients with other conditions in which ACE inhibitors are beneficial, such as patients with hypertension and those who have had a myocardial infarction."

A few years later, eplerenone (Inspra) came on the scene as a somewhat safer (and more expensive) alternative to spironolactone, and was shown in in 2003 in the EPHESUS trial to benefit post–myocardial infarction patients with left ventricular dysfunction, and then last year the EMPHASIS-HF results proved that eplerenone was also beneficial for treating patients with mild heart failure. Today, experts promote the twin aldosterone antagonists as must-use drugs for heart failure patients of all stripes.

Now hypertension is the next frontier for the aldosterone antagonists.

–Mitchel Zoler (on Twitter @mitchelzoler)

PHILADELPHIA – The American Academy of Family Physicians concluded its 3-day Congress of Delegates meeting with a bold move forward – but it was probably not in an area that most members were expecting.

Debate among the 223 delegates and alternates regarding the academy’s participation in the American Medical Association’s Relative Value Scale Update Committee (RUC) ended up taking a backseat to controversy over resolutions urging the organization to endorse same-sex civil marriage*. In the end, delegates decided to maintain the status quo on the AAFP’s RUC efforts, but ended a 3-year gridlock over same-sex civil marriage by endorsing it by a vote of 75 to 44.

Alicia Ault/IMNG Medical Media

Debate over civil marriage for same-sex couples was intense and heated, with at least an hour of impassioned discussion at the Reference Committee on Advocacy, and close to that on the floor before the delegates voted to close debate.

Many supporters testified that their own same-sex partnerships had suffered as a result of their being denied the ability to marry.

Dr. Mark Dressner, president-elect of the California chapter, said that he felt that he and his partner had been treated as second-class citizens. Others spoke of the emotional and physical damage they had witnessed in patients and family members as a result of discrimination against homosexuals.

Dr. Lloyd Van Winkle of Castroville, Tex., who was just elected to the AAFP board, said that his cousin's son Christopher committed suicide at age 19 because he felt persecuted about his homosexuality.**

Dr. Paul W. Davis, a delegate from Alaska, spoke about his long journey from "the extreme conservative religious right wing on this debate to a committed solidarity with the opposite pole."

Dr. Davis said that he had watched patients struggle with major depression over their sexual and gender identity. "I am not proud of the fact that I am a late adopter on this important issue," he said, urging his fellow delegates that "we need to boldly make a decision and move forward."

But opponents said that the AAFP should not be wading so deeply into what they considered largely treacherous political waters.

Dr. Justin V. Bartos, a delegate from Texas, said that his state’s chapter opposed the resolution because it was too much of a political statement and diverged from the AAFP’s mission.

Members of the Texas Academy of Family Physicians "do not want us to endorse such a politically polarizing issue," Dr. Bartos said. He noted that family doctors in Texas are struggling to get their state legislature to restore funding for community-based residencies, and that lawmakers in the largely conservative state would note the AAFP’s support of gay marriage.

The Tennessee delegation also opposed the policy change for the same reasons – that it would politicize the AAFP.

Another Texas delegate, Dr. Erica Swegler, said that current AAFP policy was enough to indicate the organization’s support for equal access to health care for all Americans*.

During testimony before the reference committee charged with weighing the policy change, an Arkansas delegate said that more than 300 members might leave the AAFP if it gave its approval to gay marriage.

The AAFP policy will now state that the organization supports "civil marriage for same-gender couples to contribute to overall health and longevity, improved family stability and to benefit children of gay, lesbian, bisexual, transgender (GLBT) families."

That language was crafted in two resolutions brought forward by the resident and student sections. The AAFP joins the American Psychiatric Association and the American Psychological Association in supporting same-sex marriage. The psychiatrists approved a resolution of support in 2005, and the psychology association made it official policy in 2011.

The American Medical Association has not backed gay marriage specifically, but has a host of policies supporting equality for same-sex households.

The American College of Obstetricians and Gynecologists in 2009 issued a policy statement that same-sex couples should get the same legal rights as married heterosexuals.

Staying the Course on RUC

Many AAFP members have been dissatisfied with the RUC’s handling of primary care valuations and family medicine valuations in particular. Several resolutions were put forward at the congress to create a family medicine–specific set of codes and to make the AAFP the exclusive body for establishing billing codes for preventive and primary care services for Medicare.

The resolutions fostered some discussion – but most of it was fairly muted. The delegates, in the end, decided to instruct the organization to continue its efforts to seek higher valuations for primary care.

"This congress is very familiar with family medicine’s frustration with the RUC," said Dr. Glen Stream, whose term as AAFP president ended at the meeting. But he said that for the moment, "remaining in the RUC allows the opportunity to advocate and press for [the] changes" that the AAFP has requested.

Among those: creating primary care–specific E&M codes, valuing the codes to reflect the intensity and complexity of primary care, and paying for certain non-face-to-face services.

The AAFP has also hired Avalere Health to come up with data to support higher valuations, which the academy will take to the Centers for Medicare and Medicaid Services to use as a basis for the 2014 Medicare Physician Fee Schedule, said Dr. Stream, who now serves as AAFP board chair.

In Other Issues

The Congress of Delegates also approved a controversial resolution to end age restrictions on over-the-counter emergency contraception (EC). Under current law, women under age 16 must get a prescription to get EC. Supporters said that there is no scientific basis to prohibit younger women from getting the drug over the counter, and that it could help avert many abortions. Opponents, however, said that OTC availability would lead to fewer counseling opportunities with those young patients, and might lead to even greater sexual activity.

Among other resolutions, a proposal to oppose telemedicine when it is provided in the absence of a preexisting physician-patient relationship, was referred to the board of directors for study.

The board will also report back to the congress next year on developing model legislation that would exempt primary physicians from antitrust laws so they can collectively negotiate with health insurers. The goal is to help independent practices survive in the changing health delivery system.

Much discussion also centered on how to advance the patient-centered medical home model of care, including which, or how many organizations should certify the entities.

Dr. Douglas Henley, AAFP executive vice president, said that the medical home is the perfect environment to help control health costs and improve quality of care. The family physician can help prevent patients from becoming victims of unnecessary care, he said. Dr. Henley coined a new acronym to describe those patients: VOMIT, or "victims of multiple interventional technologies."

Finally, the AAFP leadership said that the board had given approval to generate a new report on what family medicine should look like over the next decade. The AAFP developed just such a blueprint 8 years ago; however, the research supporting that paper has become dated, said Dr. Henley.

"Now is a critical time to begin a discussion and perhaps revisit research or even initiate new research about what comprehensive primary care means in 2012 and into the future," said Dr. Henley.

That process has begun, he said, adding that AAFP members should expect to hear more in January.

*Correction, 11/06/12: A previous version of this story misstated the number of delegates and alternates at the meeting and misstated Dr. Erica Swegler's last name. The photo caption also misstated the name of the governing body.

**Correction, 12/10/12: A previous version of this story misstated Dr. Van Winkle's relation to Christopher.

PHILADELPHIA – The American Academy of Family Physicians concluded its 3-day Congress of Delegates meeting with a bold move forward – but it was probably not in an area that most members were expecting.

Debate among the 223 delegates and alternates regarding the academy’s participation in the American Medical Association’s Relative Value Scale Update Committee (RUC) ended up taking a backseat to controversy over resolutions urging the organization to endorse same-sex civil marriage*. In the end, delegates decided to maintain the status quo on the AAFP’s RUC efforts, but ended a 3-year gridlock over same-sex civil marriage by endorsing it by a vote of 75 to 44.

Alicia Ault/IMNG Medical Media

Debate over civil marriage for same-sex couples was intense and heated, with at least an hour of impassioned discussion at the Reference Committee on Advocacy, and close to that on the floor before the delegates voted to close debate.

Many supporters testified that their own same-sex partnerships had suffered as a result of their being denied the ability to marry.

Dr. Mark Dressner, president-elect of the California chapter, said that he felt that he and his partner had been treated as second-class citizens. Others spoke of the emotional and physical damage they had witnessed in patients and family members as a result of discrimination against homosexuals.

Dr. Lloyd Van Winkle of Castroville, Tex., who was just elected to the AAFP board, said that his cousin's son Christopher committed suicide at age 19 because he felt persecuted about his homosexuality.**

Dr. Paul W. Davis, a delegate from Alaska, spoke about his long journey from "the extreme conservative religious right wing on this debate to a committed solidarity with the opposite pole."

Dr. Davis said that he had watched patients struggle with major depression over their sexual and gender identity. "I am not proud of the fact that I am a late adopter on this important issue," he said, urging his fellow delegates that "we need to boldly make a decision and move forward."

But opponents said that the AAFP should not be wading so deeply into what they considered largely treacherous political waters.

Dr. Justin V. Bartos, a delegate from Texas, said that his state’s chapter opposed the resolution because it was too much of a political statement and diverged from the AAFP’s mission.

Members of the Texas Academy of Family Physicians "do not want us to endorse such a politically polarizing issue," Dr. Bartos said. He noted that family doctors in Texas are struggling to get their state legislature to restore funding for community-based residencies, and that lawmakers in the largely conservative state would note the AAFP’s support of gay marriage.

The Tennessee delegation also opposed the policy change for the same reasons – that it would politicize the AAFP.

Another Texas delegate, Dr. Erica Swegler, said that current AAFP policy was enough to indicate the organization’s support for equal access to health care for all Americans*.

During testimony before the reference committee charged with weighing the policy change, an Arkansas delegate said that more than 300 members might leave the AAFP if it gave its approval to gay marriage.

The AAFP policy will now state that the organization supports "civil marriage for same-gender couples to contribute to overall health and longevity, improved family stability and to benefit children of gay, lesbian, bisexual, transgender (GLBT) families."

That language was crafted in two resolutions brought forward by the resident and student sections. The AAFP joins the American Psychiatric Association and the American Psychological Association in supporting same-sex marriage. The psychiatrists approved a resolution of support in 2005, and the psychology association made it official policy in 2011.

The American Medical Association has not backed gay marriage specifically, but has a host of policies supporting equality for same-sex households.

The American College of Obstetricians and Gynecologists in 2009 issued a policy statement that same-sex couples should get the same legal rights as married heterosexuals.

Staying the Course on RUC

Many AAFP members have been dissatisfied with the RUC’s handling of primary care valuations and family medicine valuations in particular. Several resolutions were put forward at the congress to create a family medicine–specific set of codes and to make the AAFP the exclusive body for establishing billing codes for preventive and primary care services for Medicare.

The resolutions fostered some discussion – but most of it was fairly muted. The delegates, in the end, decided to instruct the organization to continue its efforts to seek higher valuations for primary care.

"This congress is very familiar with family medicine’s frustration with the RUC," said Dr. Glen Stream, whose term as AAFP president ended at the meeting. But he said that for the moment, "remaining in the RUC allows the opportunity to advocate and press for [the] changes" that the AAFP has requested.

Among those: creating primary care–specific E&M codes, valuing the codes to reflect the intensity and complexity of primary care, and paying for certain non-face-to-face services.

The AAFP has also hired Avalere Health to come up with data to support higher valuations, which the academy will take to the Centers for Medicare and Medicaid Services to use as a basis for the 2014 Medicare Physician Fee Schedule, said Dr. Stream, who now serves as AAFP board chair.

In Other Issues

The Congress of Delegates also approved a controversial resolution to end age restrictions on over-the-counter emergency contraception (EC). Under current law, women under age 16 must get a prescription to get EC. Supporters said that there is no scientific basis to prohibit younger women from getting the drug over the counter, and that it could help avert many abortions. Opponents, however, said that OTC availability would lead to fewer counseling opportunities with those young patients, and might lead to even greater sexual activity.

Among other resolutions, a proposal to oppose telemedicine when it is provided in the absence of a preexisting physician-patient relationship, was referred to the board of directors for study.

The board will also report back to the congress next year on developing model legislation that would exempt primary physicians from antitrust laws so they can collectively negotiate with health insurers. The goal is to help independent practices survive in the changing health delivery system.

Much discussion also centered on how to advance the patient-centered medical home model of care, including which, or how many organizations should certify the entities.

Dr. Douglas Henley, AAFP executive vice president, said that the medical home is the perfect environment to help control health costs and improve quality of care. The family physician can help prevent patients from becoming victims of unnecessary care, he said. Dr. Henley coined a new acronym to describe those patients: VOMIT, or "victims of multiple interventional technologies."

Finally, the AAFP leadership said that the board had given approval to generate a new report on what family medicine should look like over the next decade. The AAFP developed just such a blueprint 8 years ago; however, the research supporting that paper has become dated, said Dr. Henley.

"Now is a critical time to begin a discussion and perhaps revisit research or even initiate new research about what comprehensive primary care means in 2012 and into the future," said Dr. Henley.

That process has begun, he said, adding that AAFP members should expect to hear more in January.

*Correction, 11/06/12: A previous version of this story misstated the number of delegates and alternates at the meeting and misstated Dr. Erica Swegler's last name. The photo caption also misstated the name of the governing body.

**Correction, 12/10/12: A previous version of this story misstated Dr. Van Winkle's relation to Christopher.

PHILADELPHIA – The American Academy of Family Physicians concluded its 3-day Congress of Delegates meeting with a bold move forward – but it was probably not in an area that most members were expecting.

Debate among the 223 delegates and alternates regarding the academy’s participation in the American Medical Association’s Relative Value Scale Update Committee (RUC) ended up taking a backseat to controversy over resolutions urging the organization to endorse same-sex civil marriage*. In the end, delegates decided to maintain the status quo on the AAFP’s RUC efforts, but ended a 3-year gridlock over same-sex civil marriage by endorsing it by a vote of 75 to 44.

Alicia Ault/IMNG Medical Media

Debate over civil marriage for same-sex couples was intense and heated, with at least an hour of impassioned discussion at the Reference Committee on Advocacy, and close to that on the floor before the delegates voted to close debate.

Many supporters testified that their own same-sex partnerships had suffered as a result of their being denied the ability to marry.

Dr. Mark Dressner, president-elect of the California chapter, said that he felt that he and his partner had been treated as second-class citizens. Others spoke of the emotional and physical damage they had witnessed in patients and family members as a result of discrimination against homosexuals.

Dr. Lloyd Van Winkle of Castroville, Tex., who was just elected to the AAFP board, said that his cousin's son Christopher committed suicide at age 19 because he felt persecuted about his homosexuality.**

Dr. Paul W. Davis, a delegate from Alaska, spoke about his long journey from "the extreme conservative religious right wing on this debate to a committed solidarity with the opposite pole."

Dr. Davis said that he had watched patients struggle with major depression over their sexual and gender identity. "I am not proud of the fact that I am a late adopter on this important issue," he said, urging his fellow delegates that "we need to boldly make a decision and move forward."

But opponents said that the AAFP should not be wading so deeply into what they considered largely treacherous political waters.

Dr. Justin V. Bartos, a delegate from Texas, said that his state’s chapter opposed the resolution because it was too much of a political statement and diverged from the AAFP’s mission.

Members of the Texas Academy of Family Physicians "do not want us to endorse such a politically polarizing issue," Dr. Bartos said. He noted that family doctors in Texas are struggling to get their state legislature to restore funding for community-based residencies, and that lawmakers in the largely conservative state would note the AAFP’s support of gay marriage.

The Tennessee delegation also opposed the policy change for the same reasons – that it would politicize the AAFP.

Another Texas delegate, Dr. Erica Swegler, said that current AAFP policy was enough to indicate the organization’s support for equal access to health care for all Americans*.

During testimony before the reference committee charged with weighing the policy change, an Arkansas delegate said that more than 300 members might leave the AAFP if it gave its approval to gay marriage.

The AAFP policy will now state that the organization supports "civil marriage for same-gender couples to contribute to overall health and longevity, improved family stability and to benefit children of gay, lesbian, bisexual, transgender (GLBT) families."

That language was crafted in two resolutions brought forward by the resident and student sections. The AAFP joins the American Psychiatric Association and the American Psychological Association in supporting same-sex marriage. The psychiatrists approved a resolution of support in 2005, and the psychology association made it official policy in 2011.

The American Medical Association has not backed gay marriage specifically, but has a host of policies supporting equality for same-sex households.

The American College of Obstetricians and Gynecologists in 2009 issued a policy statement that same-sex couples should get the same legal rights as married heterosexuals.

Staying the Course on RUC

Many AAFP members have been dissatisfied with the RUC’s handling of primary care valuations and family medicine valuations in particular. Several resolutions were put forward at the congress to create a family medicine–specific set of codes and to make the AAFP the exclusive body for establishing billing codes for preventive and primary care services for Medicare.

The resolutions fostered some discussion – but most of it was fairly muted. The delegates, in the end, decided to instruct the organization to continue its efforts to seek higher valuations for primary care.

"This congress is very familiar with family medicine’s frustration with the RUC," said Dr. Glen Stream, whose term as AAFP president ended at the meeting. But he said that for the moment, "remaining in the RUC allows the opportunity to advocate and press for [the] changes" that the AAFP has requested.

Among those: creating primary care–specific E&M codes, valuing the codes to reflect the intensity and complexity of primary care, and paying for certain non-face-to-face services.

The AAFP has also hired Avalere Health to come up with data to support higher valuations, which the academy will take to the Centers for Medicare and Medicaid Services to use as a basis for the 2014 Medicare Physician Fee Schedule, said Dr. Stream, who now serves as AAFP board chair.

In Other Issues

The Congress of Delegates also approved a controversial resolution to end age restrictions on over-the-counter emergency contraception (EC). Under current law, women under age 16 must get a prescription to get EC. Supporters said that there is no scientific basis to prohibit younger women from getting the drug over the counter, and that it could help avert many abortions. Opponents, however, said that OTC availability would lead to fewer counseling opportunities with those young patients, and might lead to even greater sexual activity.

Among other resolutions, a proposal to oppose telemedicine when it is provided in the absence of a preexisting physician-patient relationship, was referred to the board of directors for study.

The board will also report back to the congress next year on developing model legislation that would exempt primary physicians from antitrust laws so they can collectively negotiate with health insurers. The goal is to help independent practices survive in the changing health delivery system.

Much discussion also centered on how to advance the patient-centered medical home model of care, including which, or how many organizations should certify the entities.

Dr. Douglas Henley, AAFP executive vice president, said that the medical home is the perfect environment to help control health costs and improve quality of care. The family physician can help prevent patients from becoming victims of unnecessary care, he said. Dr. Henley coined a new acronym to describe those patients: VOMIT, or "victims of multiple interventional technologies."

Finally, the AAFP leadership said that the board had given approval to generate a new report on what family medicine should look like over the next decade. The AAFP developed just such a blueprint 8 years ago; however, the research supporting that paper has become dated, said Dr. Henley.

"Now is a critical time to begin a discussion and perhaps revisit research or even initiate new research about what comprehensive primary care means in 2012 and into the future," said Dr. Henley.

That process has begun, he said, adding that AAFP members should expect to hear more in January.

*Correction, 11/06/12: A previous version of this story misstated the number of delegates and alternates at the meeting and misstated Dr. Erica Swegler's last name. The photo caption also misstated the name of the governing body.

**Correction, 12/10/12: A previous version of this story misstated Dr. Van Winkle's relation to Christopher.

No one ever said treating type 2 diabetes is easy, but there are certainly two distinct schools of thought on how to do it: the physicians who use insulin, and the ones who don’t.

This month, I covered a diabetes meeting, the European Association for the Study of Diabetes (EASD) and, 2 weeks later, a primary care meeting, the American Academy of Family Physicians (AAFP), and they posed a contrast in styles for managing obese patients with type 2 diabetes whose glycemia doesn’t improve with two or so oral drugs.

Courtesy of Wikimedia Commons

Among the diabetologists and endocrinologists at the EASD, opinion seemed tipped toward using insulin when type 2 patients get hard to manage. "We want to encourage physicians to use insulin earlier in type 2 diabetes in general practice, but doctors are afraid of using insulin. They are afraid of hypoglycemia," Dr. John Leahy told me at that meeting. He applauded the results of a study that randomized patients with type 2 diabetes with inadequate glucose control on one or two oral drugs to treatment with insulin or sitagliptin (Januvia), a popular oral drug. The findings showed that insulin did significantly better controlling glucose levels than sitagliptin, with a decent safety profile.

But the fear about insulin goes beyond hypoglycemia, noted Dr. Frank Domino, when he spoke last week at the AAFP meeting in Philadelphia.

"I hate putting patients on insulin. It will only make the patient more obese and insulin resistant," he bemoaned. "If you just treat the [hemoglobin] A_1c, it doesn’t improve outcomes and probably make some things worse," he said.

Obese patient’s whose HbA_1c remains above 9% despite treatment with two or three oral drugs need treatment for their chronic disease, obesity, said Dr. Domino, and that means treatments that go beyond HbA_1c. He then gave a qualified shout out to the two newly FDA-approved weight loss drugs, Qsymia, which combines phentermine and topiramate, and lorcaserin, Belviq. While he characterized the Food and Drug Administration as "finally coming to the rescue" by approving this pair of weight-loss drugs, he quickly added: "I’m not encouraging you to use these drugs. I’m encouraging you to think of obesity as a chronic disease that needs all modalities of treatment."

Dr. Domino isn’t alone being cautious with weight-loss meds. An article in the Oct. 25 issue of New England Journal of Medicine from staffers at the the FDA laid out their rationale for approving the two formulations (2012; 367:1577-9). Also in the issue is an interview with drug guru Dr. Jerry Avorn, who spells out his reservations about using these two drugs in practice right now.

Dr. Avorn’s concern is the dicey safety history of weight-loss drugs of the past, and the scant safety record that the two new agents have so far.

"The average doc with a patient who wants to lose weight would be advised to wait until we have a known track record on these drugs, and restrict their use now to patients with morbid obesity" who face substantial health risks from their high excess weight." Dr. Avorn said he would have preferred Qsymia and lorcaserin get qualified FDA approvals that restricted the drugs to patients who met obesity thresholds and were treated by obesity specialists. But the FDA does not do qualified approvals.

No one ever said treating type 2 diabetes is easy, but there are certainly two distinct schools of thought on how to do it: the physicians who use insulin, and the ones who don’t.

This month, I covered a diabetes meeting, the European Association for the Study of Diabetes (EASD) and, 2 weeks later, a primary care meeting, the American Academy of Family Physicians (AAFP), and they posed a contrast in styles for managing obese patients with type 2 diabetes whose glycemia doesn’t improve with two or so oral drugs.

Courtesy of Wikimedia Commons

Among the diabetologists and endocrinologists at the EASD, opinion seemed tipped toward using insulin when type 2 patients get hard to manage. "We want to encourage physicians to use insulin earlier in type 2 diabetes in general practice, but doctors are afraid of using insulin. They are afraid of hypoglycemia," Dr. John Leahy told me at that meeting. He applauded the results of a study that randomized patients with type 2 diabetes with inadequate glucose control on one or two oral drugs to treatment with insulin or sitagliptin (Januvia), a popular oral drug. The findings showed that insulin did significantly better controlling glucose levels than sitagliptin, with a decent safety profile.

But the fear about insulin goes beyond hypoglycemia, noted Dr. Frank Domino, when he spoke last week at the AAFP meeting in Philadelphia.

"I hate putting patients on insulin. It will only make the patient more obese and insulin resistant," he bemoaned. "If you just treat the [hemoglobin] A_1c, it doesn’t improve outcomes and probably make some things worse," he said.

Obese patient’s whose HbA_1c remains above 9% despite treatment with two or three oral drugs need treatment for their chronic disease, obesity, said Dr. Domino, and that means treatments that go beyond HbA_1c. He then gave a qualified shout out to the two newly FDA-approved weight loss drugs, Qsymia, which combines phentermine and topiramate, and lorcaserin, Belviq. While he characterized the Food and Drug Administration as "finally coming to the rescue" by approving this pair of weight-loss drugs, he quickly added: "I’m not encouraging you to use these drugs. I’m encouraging you to think of obesity as a chronic disease that needs all modalities of treatment."

Dr. Domino isn’t alone being cautious with weight-loss meds. An article in the Oct. 25 issue of New England Journal of Medicine from staffers at the the FDA laid out their rationale for approving the two formulations (2012; 367:1577-9). Also in the issue is an interview with drug guru Dr. Jerry Avorn, who spells out his reservations about using these two drugs in practice right now.

Dr. Avorn’s concern is the dicey safety history of weight-loss drugs of the past, and the scant safety record that the two new agents have so far.

"The average doc with a patient who wants to lose weight would be advised to wait until we have a known track record on these drugs, and restrict their use now to patients with morbid obesity" who face substantial health risks from their high excess weight." Dr. Avorn said he would have preferred Qsymia and lorcaserin get qualified FDA approvals that restricted the drugs to patients who met obesity thresholds and were treated by obesity specialists. But the FDA does not do qualified approvals.

No one ever said treating type 2 diabetes is easy, but there are certainly two distinct schools of thought on how to do it: the physicians who use insulin, and the ones who don’t.

This month, I covered a diabetes meeting, the European Association for the Study of Diabetes (EASD) and, 2 weeks later, a primary care meeting, the American Academy of Family Physicians (AAFP), and they posed a contrast in styles for managing obese patients with type 2 diabetes whose glycemia doesn’t improve with two or so oral drugs.

Courtesy of Wikimedia Commons

Among the diabetologists and endocrinologists at the EASD, opinion seemed tipped toward using insulin when type 2 patients get hard to manage. "We want to encourage physicians to use insulin earlier in type 2 diabetes in general practice, but doctors are afraid of using insulin. They are afraid of hypoglycemia," Dr. John Leahy told me at that meeting. He applauded the results of a study that randomized patients with type 2 diabetes with inadequate glucose control on one or two oral drugs to treatment with insulin or sitagliptin (Januvia), a popular oral drug. The findings showed that insulin did significantly better controlling glucose levels than sitagliptin, with a decent safety profile.

But the fear about insulin goes beyond hypoglycemia, noted Dr. Frank Domino, when he spoke last week at the AAFP meeting in Philadelphia.

"I hate putting patients on insulin. It will only make the patient more obese and insulin resistant," he bemoaned. "If you just treat the [hemoglobin] A_1c, it doesn’t improve outcomes and probably make some things worse," he said.

Obese patient’s whose HbA_1c remains above 9% despite treatment with two or three oral drugs need treatment for their chronic disease, obesity, said Dr. Domino, and that means treatments that go beyond HbA_1c. He then gave a qualified shout out to the two newly FDA-approved weight loss drugs, Qsymia, which combines phentermine and topiramate, and lorcaserin, Belviq. While he characterized the Food and Drug Administration as "finally coming to the rescue" by approving this pair of weight-loss drugs, he quickly added: "I’m not encouraging you to use these drugs. I’m encouraging you to think of obesity as a chronic disease that needs all modalities of treatment."

Dr. Domino isn’t alone being cautious with weight-loss meds. An article in the Oct. 25 issue of New England Journal of Medicine from staffers at the the FDA laid out their rationale for approving the two formulations (2012; 367:1577-9). Also in the issue is an interview with drug guru Dr. Jerry Avorn, who spells out his reservations about using these two drugs in practice right now.

Dr. Avorn’s concern is the dicey safety history of weight-loss drugs of the past, and the scant safety record that the two new agents have so far.

"The average doc with a patient who wants to lose weight would be advised to wait until we have a known track record on these drugs, and restrict their use now to patients with morbid obesity" who face substantial health risks from their high excess weight." Dr. Avorn said he would have preferred Qsymia and lorcaserin get qualified FDA approvals that restricted the drugs to patients who met obesity thresholds and were treated by obesity specialists. But the FDA does not do qualified approvals.

PHILADELPHIA – The American Academy of Family Physicians Congress of Delegates has approved a new policy to support civil marriage for same-sex couples, making it one of the few medical societies to explicitly endorse gay marriage.

AAFP policy now states that the organization supports "civil marriage for same-gender couples to contribute to overall health and longevity, improved family stability, and to benefit children of gay, lesbian, bisexual, transgender (GLBT) families."

Alicia Ault/IMNG Medical Media

The congress voted 75-44 to approve that language, which was crafted from two resolutions brought forward by the resident and student sections. This was the third year in a row that the congress had weighed whether the organization should give its backing to same-sex marriage. And, as in past years, debate was lengthy and impassioned.

Many supporters testified that their own same-sex partnerships had suffered as a result of being denied the ability to marry.

Dr. Mark Dressner, president-elect of the California chapter, said that he felt that he and his partner had been treated as second-class citizens. Others spoke of the emotional and physical damage they had witnessed in patients and family members as a result of discrimination against homosexuals.

Dr. Lloyd Van Winkle of Castroville, Tex., who was just elected to the AAFP board, said that a young relation* committed suicide at age 19 because he felt persecuted about his homosexuality.

Dr. Paul W. Davis, a delegate from Alaska, spoke about his long journey from "the extreme conservative religious right wing on this debate to a committed solidarity with the opposite pole."

Dr. Davis said that he had watched patients struggle with major depression over their sexual and gender identity. "I am not proud of the fact that I am a late adopter on this important issue," he said, urging his fellow delegates that "we need to boldly make a decision and move forward."

But opponents said that AAFP should not be wading so deeply into what they considered largely treacherous political waters.

Dr. Justin V. Bartos, a delegate from Texas, said that his state’s chapter opposed the resolution because it was too much of a political statement and diverged from the AAFP’s mission.

Members of the Texas Academy of Family Physicians "do not want us to endorse such a politically polarizing issue," Dr. Bartos said. He noted that family doctors in Texas are struggling to get their state legislature to restore funding for community-based residencies, and that lawmakers in the largely conservative state would note the AAFP’s support of gay marriage.

The Tennessee delegation also opposed the policy change for the same reasons – that it would politicize the AAFP.

Another Texas delegate, Dr. Erica Swegler*, said that current AAFP policy was enough to indicate the organization’s support for equal access to health care for all Americans.

During testimony before the reference committee charged with weighing the policy change, an Arkansas delegate said that more than 300 members might leave the AAFP if it gave its approval to gay marriage.

The AAFP joins the American Psychiatric Association and the American Psychological Association in supporting same sex marriage. The psychiatrists approved a resolution of support in 2005, and the psychology association made it official policy in 2011.

The American Medical Association has not backed gay marriage specifically, but has a host of policies supporting equality for same-sex households.

The American College of Obstetricians and Gynecologists in 2009 issued a policy statement that same-sex couples should get same legal rights as married heterosexuals.

*Correction, 11/8/12: An earlier version of this story misidentified Dr. Van Winkle's relation and misspelled Dr. Swegler's name.

PHILADELPHIA – The American Academy of Family Physicians Congress of Delegates has approved a new policy to support civil marriage for same-sex couples, making it one of the few medical societies to explicitly endorse gay marriage.

AAFP policy now states that the organization supports "civil marriage for same-gender couples to contribute to overall health and longevity, improved family stability, and to benefit children of gay, lesbian, bisexual, transgender (GLBT) families."

Alicia Ault/IMNG Medical Media

The congress voted 75-44 to approve that language, which was crafted from two resolutions brought forward by the resident and student sections. This was the third year in a row that the congress had weighed whether the organization should give its backing to same-sex marriage. And, as in past years, debate was lengthy and impassioned.

Many supporters testified that their own same-sex partnerships had suffered as a result of being denied the ability to marry.

Dr. Mark Dressner, president-elect of the California chapter, said that he felt that he and his partner had been treated as second-class citizens. Others spoke of the emotional and physical damage they had witnessed in patients and family members as a result of discrimination against homosexuals.

Dr. Lloyd Van Winkle of Castroville, Tex., who was just elected to the AAFP board, said that a young relation* committed suicide at age 19 because he felt persecuted about his homosexuality.

Dr. Paul W. Davis, a delegate from Alaska, spoke about his long journey from "the extreme conservative religious right wing on this debate to a committed solidarity with the opposite pole."

Dr. Davis said that he had watched patients struggle with major depression over their sexual and gender identity. "I am not proud of the fact that I am a late adopter on this important issue," he said, urging his fellow delegates that "we need to boldly make a decision and move forward."

But opponents said that AAFP should not be wading so deeply into what they considered largely treacherous political waters.

Dr. Justin V. Bartos, a delegate from Texas, said that his state’s chapter opposed the resolution because it was too much of a political statement and diverged from the AAFP’s mission.

Members of the Texas Academy of Family Physicians "do not want us to endorse such a politically polarizing issue," Dr. Bartos said. He noted that family doctors in Texas are struggling to get their state legislature to restore funding for community-based residencies, and that lawmakers in the largely conservative state would note the AAFP’s support of gay marriage.

The Tennessee delegation also opposed the policy change for the same reasons – that it would politicize the AAFP.

Another Texas delegate, Dr. Erica Swegler*, said that current AAFP policy was enough to indicate the organization’s support for equal access to health care for all Americans.

During testimony before the reference committee charged with weighing the policy change, an Arkansas delegate said that more than 300 members might leave the AAFP if it gave its approval to gay marriage.

The AAFP joins the American Psychiatric Association and the American Psychological Association in supporting same sex marriage. The psychiatrists approved a resolution of support in 2005, and the psychology association made it official policy in 2011.

The American Medical Association has not backed gay marriage specifically, but has a host of policies supporting equality for same-sex households.

The American College of Obstetricians and Gynecologists in 2009 issued a policy statement that same-sex couples should get same legal rights as married heterosexuals.

*Correction, 11/8/12: An earlier version of this story misidentified Dr. Van Winkle's relation and misspelled Dr. Swegler's name.

PHILADELPHIA – The American Academy of Family Physicians Congress of Delegates has approved a new policy to support civil marriage for same-sex couples, making it one of the few medical societies to explicitly endorse gay marriage.

AAFP policy now states that the organization supports "civil marriage for same-gender couples to contribute to overall health and longevity, improved family stability, and to benefit children of gay, lesbian, bisexual, transgender (GLBT) families."

Alicia Ault/IMNG Medical Media

The congress voted 75-44 to approve that language, which was crafted from two resolutions brought forward by the resident and student sections. This was the third year in a row that the congress had weighed whether the organization should give its backing to same-sex marriage. And, as in past years, debate was lengthy and impassioned.

Many supporters testified that their own same-sex partnerships had suffered as a result of being denied the ability to marry.

Dr. Mark Dressner, president-elect of the California chapter, said that he felt that he and his partner had been treated as second-class citizens. Others spoke of the emotional and physical damage they had witnessed in patients and family members as a result of discrimination against homosexuals.

Dr. Lloyd Van Winkle of Castroville, Tex., who was just elected to the AAFP board, said that a young relation* committed suicide at age 19 because he felt persecuted about his homosexuality.

Dr. Paul W. Davis, a delegate from Alaska, spoke about his long journey from "the extreme conservative religious right wing on this debate to a committed solidarity with the opposite pole."

Dr. Davis said that he had watched patients struggle with major depression over their sexual and gender identity. "I am not proud of the fact that I am a late adopter on this important issue," he said, urging his fellow delegates that "we need to boldly make a decision and move forward."

But opponents said that AAFP should not be wading so deeply into what they considered largely treacherous political waters.

Dr. Justin V. Bartos, a delegate from Texas, said that his state’s chapter opposed the resolution because it was too much of a political statement and diverged from the AAFP’s mission.

Members of the Texas Academy of Family Physicians "do not want us to endorse such a politically polarizing issue," Dr. Bartos said. He noted that family doctors in Texas are struggling to get their state legislature to restore funding for community-based residencies, and that lawmakers in the largely conservative state would note the AAFP’s support of gay marriage.

The Tennessee delegation also opposed the policy change for the same reasons – that it would politicize the AAFP.

Another Texas delegate, Dr. Erica Swegler*, said that current AAFP policy was enough to indicate the organization’s support for equal access to health care for all Americans.

During testimony before the reference committee charged with weighing the policy change, an Arkansas delegate said that more than 300 members might leave the AAFP if it gave its approval to gay marriage.

The AAFP joins the American Psychiatric Association and the American Psychological Association in supporting same sex marriage. The psychiatrists approved a resolution of support in 2005, and the psychology association made it official policy in 2011.

The American Medical Association has not backed gay marriage specifically, but has a host of policies supporting equality for same-sex households.

The American College of Obstetricians and Gynecologists in 2009 issued a policy statement that same-sex couples should get same legal rights as married heterosexuals.

*Correction, 11/8/12: An earlier version of this story misidentified Dr. Van Winkle's relation and misspelled Dr. Swegler's name.