Best Practice
Hand-held prescription software provides clear link for doctor-pharmacist dialog
Quality Improvement
What's New in Prevention?
Technology
New and Emerging Technology
CareFirst Commitment
CareFirst Commitment Initiative
Disease Management
Recent Literature Related to CareFirst and CareFirst Disease Management Initiatives
Current News
Influenza Vaccine Reminder
Philosophy of Care
Philosophy of Care and CareFirst's Mission
Hand-held prescription software provides clear link for doctor-pharmacist dialog
| InFocus has expanded its Best Practice feature to include all medical
professionals – physicians, providers and institutions - and
highlight and acknowledge the innovative approaches to patient care
that are being adopted by CareFirst BlueCross BlueShield (CareFirst)
and CareFirst BlueChoice, Inc. (CareFirst BlueChoice) providers in
Maryland, Washington, D.C. and Northern Virginia. Their “best
practice” approach to patient care is not only improving the
quality of care, but helps contain the rising cost of care. |
|
 A
year-long pilot program to familiarize Maryland doctors with the advantages
of electronic prescription writing has produced positive results and continues
to demonstrate how new technology can improve the health care system and reduce
costs. About 500 doctors are currently participating in the program which is
sponsored jointly by CareFirst and CareFirst BlueChoice in cooperation with
DrFirst, a Rockville,Md. company that focuses on developing innovative technology
for the health care industry.
After a modest start in the fall of 2004, the pilot program has gained momentum
this year. The most recent review of the program shows that more than 300 active
users wrote about 80,000 electronic prescriptions during the June-July period
this year. By avoiding the most common errors in administering drugs –
non-compliance with established formularies, adverse reactions and mis-filled
prescriptions – the program has demonstrated a potential for substantial
savings in the first 12 months.
Physicians participating in the program use hand-held personal digital assistance
(PDA) and desktop computers to access an electronic prescription writing system
called Rcopia. The systems, developed by DrFirst, allows doctors to access the
Internet and prescribe medicine with greater knowledge, information and accuracy
than ever before possible.
New Medical Technology
The trend toward greater use of new medical technology at the patient level
continues to gain momentum. More and more, physicians are adopting inventive
tools – from prosthetic heart valves, to beeper-sized insulin pumps, to
spinal neurostimulators that block pain. These patient-oriented medical inventions
are complex and often very costly. Others are considerably less complicated
and relatively inexpensive – but save time and money for doctors and patients,
nonetheless. More importantly, the very best of the new technology is also saving
lives.
Rcopia, one of several prescription writing systems available to doctors and
similar in concept to communications tools now widely used in business, construction,
transportation and medicine, is changing the way doctors communicate with pharmacists.
It is also improving the ease and accuracy of doctor-to-doctor information exchanges,
access to patient medical histories and communications with nurses, physician
assistants, and front office staff. And, for doctors who use such new technology
to take notes and record reminders, the system is a useful aid in organizing
the many details of a busy day.
Maislyn Christie, M.D., a pediatric physician in Cheverly, Md., has used Rcopia
for nearly a year. “I have put my life in that device right now. I had
some experience with electronic prescriptions before Rcopia, and was a little
concerned at first if it would work for me,” she says. “I sometimes
write four or five prescriptions for a single patient. But, I am very comfortable
with it now. It fits right into my practice and patient routine. And my patients
like it. It has become a standard of care they look for now.”
Rcopia was developed and brought to market four years ago by DrFirst. The company’s
name – DrFirst -- is derived from the purpose of its products: to ease
the administrative burdens of modern medicine and let physicians “get
back to being a doctor first.”
The pilot program started last fall with doctors in Maryland, Virginia and
the Washington D.C. area who were identified as those frequently writing a large
number of prescriptions.
Eric R. Baugh,M.D., CareFirst’s chiefmedical officer and senior vice
president of Medical Affairs, says that patient safety and cost efficiency were
the major factors that prompted the company to develop its pilot project.
“We are engaged in this statewide patient safety and cost reduction initiative
because we see a great benefit to our members, our network physicians, the pharmacies
they use, and, in fact, the entire health care system in Maryland,” Baugh
says.
Patient Saftey Comes First
Patient safety clearly tops the list of benefits that result from electronic
prescription management. A 1999 study by the Institute of Medicine found that
medical errors – including those related to improperly prescribed medications
– were the eighth leading cause of death in the United States, ranking
ahead of motor vehicle accidents, breast cancer and AIDS.
How does electronic prescribing help? First and foremost, it reduces the potential
for error in prescribing medications. The importance of that is found in statistics
released by the National Association of Boards of Pharmacy showing that as many
as 5 percent of the three billion prescriptions filled each year in the United
States are incorrect and may contribute to as many as 7,000 deaths a year.
In addition, physicians who write electronic prescriptions are able to access
more than 3,300 drug monographs and formularies to check for proper dosage,
look up accurate medication history for the past 10 years, and receive immediate
warnings regarding contraindications and adverse drug-todrug and drug/allergy
interactions for both brand and generic drugs. In combination with a home or
office Internet connection, a doctor can e-mail a prescription, include specific
instructions for its use, check the patient’s medical history to avoid
adverse effects, get cost information and otherwise remotely manage the entire
patient medication procedure from start to finish.
Because the scripts are clear and easily read, electronic prescriptions virtually
eliminate calls and faxes between physicians and pharmacists to verify or decipher.
And because the electronic process is accessible on almost any hand-held and
portable web-enabled device, prescriptions can be written from almost anywhere
at any time, giving physicians greater freedom to “be doctors first.”
For example, Rcopia’s e-mail feature allows a physician not only to check
a patient’s treatment record and medication history, but also to confer
with other medical professionals prior to writing a prescription.
In addition, Rcopia offers a number of other features including MultiCheck,
a cross referenced database check on multiple drug interactions, and MedMath,
a medical calculator that includes a body mass index, creatinine clearance and
other measures of importance in prescribing medications. Rcopia software also
alerts physicians to avoid potentially dangerous drug interactions. In a recent
month, for example, the system intercepted 342 prescriptions that could have
resulted in adverse patient reactions.
Other useful features include an integrated Epocrates ID infectious disease
treatment guide, a guide to more than 400 alternative (herbal) medicines and
their possible interactions with prescription drugs, and an IV compatibility
checker.
All this information is literally available at the finger tips of physicians
who have adopted electronic prescription writing.
Howard Goldstein, M.D., who practices internal medicine in Annapolis, is one
of them. "We are, in our practice,moving to electronic medical records, and
this is one aspect, one feature of electronic medical records,” he says.
Apparent Advantages
The advantages of electronic prescription writing become quickly apparent to
those who have tried it. Marketing representatives of DrFirst report that the
only hurdle they have experienced is reluctance on the part of some physicians
to adopt new technology and new routines in their practice. Once that hurdle
is cleared, electronic prescriptions quickly become another welcomed tool in
their daily practice workflow.
The physicians participating in the program can use the system for all patients,
not just those with health insurance coverage from CareFirst or CareFirst BlueChoice.
CareFirst’s participation in and support of the electronic prescription
pilot program is a reflection of the company’s commitment to the advancement
of quality health care. As new products and new medical procedures are introduced
to improve the quality of care available in the Mid-Atlantic region, CareFirst
will continue to step forward to assist in their evaluation and encourage adoption
of those that deliver better care and better value consistent with the highest
standards of a “best practice” approach to patient care.
| The CareFirst and CareFirst BlueChoice electronic prescription pilot
program is currently full. If you would like to learn more about the
Rcopia interface, contact DrFirst at 888-271-9898, ext. 147 or visit
www.drfirst.com |
|
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What's New in Prevention?
The United States Preventive Services Task Force (USPSTF) recommends screening
for Abdominal Aortic Aneurysm once between ages 65-75 in men with a history
of smoking.
The Task Force last released a statement on screening for abdominal aortic
aneurysms (AAA) in 1996. At that time, there was insufficient evidence to support
or discourage routine screening of asymptomatic adults (Grade C recommendation).
Since then, four randomized, controlled trials addressing the question of AAA
screening have been performed. The USPSTF has concluded:
- Men, aged 65-75 years, who have ever smoked, one-time screening for AAA
by ultrasonography. Grade B recommendation.
- Men, aged 65-75 years, who have never smoked, no recommendation for AAA
screening. Grade C recommendation.
- Women are advised not to be screened for AAA. Grade D recommendation.
Repair of an AAA should not be taken lightly, as about one-third of these surgical
patients have significant complications and there is a 4-to-5 percent operative
mortality rate. Still, screening in the appropriate population can reduce AAA-related
mortality by 42 percent. Do not harbor a false sense of security by palpating
for an AAA, as this technique has poor accuracy. Order an abdominal ultrasound
which has 95 percent sensitivity and almost 100 percent specificity.
U.S. Preventive Services Task Force Recommendations and Ratings
| Grade |
Recommendation |
| A |
The USPSTF strongly recommends that clinicians
provide (the service) to eligible patients. The USPSTF found good
evidence that (the service) improves important health outcomes and
concludes that benefits substantially outweigh harms. |
| B |
The USPSTF recommends that clinicians provide (the service) to eligible
patients. The USPSTF found at least fair evidence that (the service)
improves important health outcomes and concludes that benefits outweigh
harms. |
| C |
The USPSTF makes no recommendation for or against routine provision
of (the service). The USPSTF found at least fair evidence that (the
service) can improve health outcomes but concludes that the balance
of benefits and harms is too close to justify a general recommendation. |
| D |
The USPSTF recommends against routinely providing (the service)
to asymptomatic patients. The USPSTF found at least fair evidence
that (the service) is ineffective or that harms outweigh benefits. |
| I |
The USPSTF concludes that the evidence is insufficient to recommend
for or against routinely providing (the service). Evidence that (the
service) is effective is lacking, of poor quality, or conflicting,
and the balance of benefits and harms cannot be determined. |
|
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New and Emerging Technology
CareFirst and CareFirst BlueChoice’s Technology Assessment Committee —
which includes CareFirst and CareFirst BlueChoice physicians, nurses and external
consulting physicians — reviews new and developing technologies. The committee
relies on current medical literature, local expert consultants and physicians
to determine whether those technologies meet CareFirst and CareFirst BlueChoice’s
criteria for coverage. Coverage policies applicable to national Blue Cross Blue
Shield accounts and Federal Employees Benefits Programs may differ from those
at the local account level. The review criteria can be found in the Providers
& Physicians section by clicking on Medical Policies.
The Technology Assessment Committee recently made the following determinations:
| Total vertebral disc
replacement (Charite® lumbar disc prosthesis) |
|
Painful degenerative disc disease is one of the most common ailments
that lead to reduced quality of life and varying degrees of disability.
Many patients can be treated conservatively with analgesics, physical
therapy and lifestyle changes. For those patients whose disease
becomes severe or refractory to conservative treatment, surgical
intervention may be indicated. Removal of the degenerated intervertebral
disc and fusion of the vertebral segments is often performed. Total
vertebral disc replacement is a technique that maintains flexibility
of the lower spine by replacing the disc with a prosthetic and avoids
a fusion of the vertebral segments.
CareFirst and CareFirst BlueChoice determination
The Charite® disc prosthesis has been used in Europe for 17
years, but is relatively new to the United States, having only recently
received approval by the FDA for U.S. distribution. Only a few U.S.
studies have been published, generally involving small groups of
patients, in caseseries type reports. A larger, randomized, multicenter
study was undertaken using a non-inferiority type of design, in
which patients were randomized to receive either treatment with
a Charite prosthesis or by a more conventional diskectomy and fusion
procedure. The results of these studies show promise, but follow-up
periods have generally been reported at one to two years. Longer
follow-up is needed to properly determine whether Charite is sufficiently
durable as an alternative to fusion surgery. One European study
reported on longer term results of 105 patients, but it was not
clear as to how patients were selected. The possibility of selection
bias limits conclusions based on this report. Based on the data
to date, and the cautious interpretation given by expert reviewers,
CareFirst and CareFirst BlueChoice determine the procedure to be
experimental / investigational.
|
| Laparoscopic adjustable
gastric banding (LAGB) for treatment of morbid obesity |
|
Placement of a silicone banding device about the stomach severely
restricts the ability of a patient to take in food, but does not
alter the absorption of nutrients as does the more traditional gastric
bypass.
CareFirst and CareFirst BlueChoice determination
This type of device, one example of which is the Lap-Band®,
has been FDA approved for use for a number of years, but early outcomes
were disappointing in terms of insufficient weight loss and complication
rates. Complication rates have decreased during the last two years
and loss of excess body weight by percent has improved, owing to
changes in the surgical technique, more careful selection of patients
for the procedure and improved preoperative preparation and postoperative
ongoing support. Furthermore, the procedure has become more widely
accepted by the bariatric surgery specialty. As a result, CareFirst
and CareFirst BlueChoice now consider the procedure medically necessary
as a surgical intervention for patients who meet established criteria
for morbid obesity.
|
| FDG-PET imaging for diagnosis
of Alzheimer’s disease and dementias |
|
The use of positron emission tomography has developed into a valuable
tool for diagnosis and staging of various cancers as well as to
assess myocardial perfusion and viability. Less clear has been PET’s
application to neurodegenerative processes, such as Alzheimer’s
and other dementias. CareFirst and CareFirst BlueChoice’s latest
evidence review was prompted by a change in Medicare’s coverage
policy.
CareFirst and CareFirst BlueChoice determination
The published evidence continues to indicate that PET is actively
involved as a research tool in the study of dementias, to aid in
the study of the physical processes involved, the influence of medications
on these processes and in the development of potential medical therapies.
It is less clear as to the clinical utility of PET as a diagnostic
procedure. Evidence has been evaluated by bodies such as the AHRQ
and expert panels of the American Academy of Neurology, the American
College of Radiology and the Society of Nuclear Medicine. Although
recommendations from the expert panels support the coverage decision
as framed by Medicare, the panels caution that there is insufficient
evidence to support routine clinical use of FDG-PET as a diagnostic
tool for dementias. Therefore, CareFirst and CareFirst BlueChoice’s
current medical policy remains unchanged, and CareFirst and CareFirst
BlueChoice continue to regard FDG-PET scans for Alzheimer’s
disease and dementias as experimental / investigational.
|
| Pharmacogenomic and serologic
markers for selection and therapeutic monitoring of patients with
inflammatory bowel disease (IBD) and treatment with azathioprine |
|
Most patients with IBD are managed with steroids or other medications,
but some may become steroid resistant or dependant, and may thus
be considered for treatment with azathioprine (AZA). Studies have
shown that metabolism of AZA to its therapeutic metabolite 6-thioguanine
(6-TG) is genetically determined,with 10 percent of the population
having insufficient activity of the enzyme TPMT to properly metabolize
AZA. These patients may be susceptible to myelosuppression at lower
doses of AZA than for normal patients, and may be candidates for
lowered initial dosing or the use of AZA may be contraindicated.
Genetic testing for traits related to TPMT activity is now available
to identify these patients. There is also a test available to monitor
levels of 6-TG present in serum, which has been proposed as a therapeutic
monitoring test to maintain IBD patients above a certain threshold
to theoretically prolong periods of remission.
CareFirst and CareFirst BlueChoice determination
Validation studies have shown that TPMT activity can be determined
using the established molecular DNA identification procedures. CareFirst
and CareFirst BlueChoice have determined that the genetic test may
be considered medically necessary for patients whose physician has
determined that there may be risk for myelosuppression related to
AZA, where a margin of safety is necessary. This test is available
within the CareFirst and CareFirst BlueChoice network.
6-TG therapeutic monitoring is a part of the Pro-Predict™
laboratory test product offered by Prometheus Laboratories®,
and is available from them exclusively.Clinical studies have attempted
to establish a therapeutic level for 6-TG.However, results are conflicting
in that patients below the suggested therapeutic level have shown
sustained periods of remission of IBD in response to AZA therapy,
and others have not sustained their remissions even though their
6-TG levels have been kept above the suggested threshold. Therefore,
expert reviewers have called for additional studies, particularly
large-scale dose response studies, before routine use of such therapeutic
monitoring can be recommended. Furthermore, the use of 6-TG monitoring
does not reduce or eliminate the need for laboratory monitoring
for myelosuppression or hepatotoxicity. Therefore, as the clinical
utility of this test has not yet been established, CareFirst and
CareFirst BlueChoice considers the test to be experimental / investigational.
|
| Posterior tibial nerve
(PTN) stimulation for voiding dysfunctions |
|
Electrical stimulation of the sacral nerve plexus has been used
in treating non-neurogenic voiding dysfunctions (urge incontinence,
stress incontinence, frequency-urgency syndrome,“overactive
bladder”) that have not responded to more conservative treatments
such as pelvic muscle retraining.The procedure entails surgical
implantation of a pulse generator and electrodes. Experimentally,
researchers have shown that the sacral nerve plexus can be stimulated
by stimulation of the posterior tibial nerve. Treatments are typically
30 minutes weekly, for a course of eight to12 weeks.
CareFirst and CareFirst BlueChoice determination
Although study groups have been small, there is evidence that PTN
stimulation helps control symptoms in terms of incontinent episodes
in patients who have not responded to treatment with medication
and pelvic muscle exercise. The level of improvement, measured as
a percentage of reduction of voiding episodes and pad counts, appears
to be close to those achieved by pelvic muscle retraining. PTN stimulation
is regarded as an intermediate therapy between pelvic muscle exercise
and surgical sacral nerve stimulator implantation. The procedure
is well tolerated, even by children, and no untoward effects have
been documented. CareFirst and CareFirst BlueChoice considers PTN
stimulation medically necessary for non-neurogenic voiding dysfunctions,
and experimental / investigational for neurogenic bladder dysfunctions
secondary to multiple sclerosis, Parkinson’s disease, traumatic
injury or stroke, since evidence for PTN stimulation for neurogenic
bladder dysfunctions has not been published in the peer-reviewed
literature.
|
|
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CareFirst Commitment Initiative
 Through
its CareFirst Commitment initiative and other public mission activities, CareFirst
BlueCross BlueShield (CareFirst) supports efforts to increase the accessibility,
affordability and quality of health care throughout its market areas.
CareFirst is helping to bridge the gap in health disparities among minority
groups by funding a $360,000 diabetes care management over three years at La
Clinica del Pueblo, a free, nonprofit health clinic in Washington, D.C., that
serves mostly uninsured and underinsured Latinos.
Diabetes affects almost twice as many Latinos as caucasians. Many Latinos can’t
afford the care and don’t have the knowledge required to manage diabetes.
Therefore, they suffer more complications, which leads to lower quality of life
for them and higher health care costs for all of us.
With CareFirst’s support, the program will use national
guidelines to improve the care of persons with diabetes
and make better use of doctors’ time so that more patients
with diabetes can be treated.
The program has three parts:
- CareFirst is funding computer equipment that links the scheduling system
to national guidelines for the treatment of diabetes. Doctors and nurse practitioners
provide health care services while Patient Care Coordinators offer one-on-one
case management and follow-up. The health care teams can track services and
evaluate treatment at all times. This means that patients receive more efficient
care from the moment they enter the clinic.
- A health educator who is sensitive to the Latino culture teaches patients
to manage diabetes. This will take place both in individual and group sessions.
The health educator also informs patients about community resources and outreach
and treatment services.
- The home education visit program is an innovative approach using trained
peer health educators, or promotores. The promotores visit patients in their
homes to teach them to self-manage their diabetes.
CareFirst’s support of La Clinica del Pueblo’s diabetes program
will pave the way for better diabetes care that will meet the needs of our Latino
members.
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Recent Literature Related to CareFirst and CareFirst Disease Management Initiatives
Recent Literature Related to:
CareFirst and CareFirst BlueChoice Disease Management
Initiatives
By Richard S. Safeer, MD, Medical Director, Health Promotion and
Disease Prevention
CareEssentials: Disease Management
As part of the Disease Management component of CareEssentials, CareFirst’s
and CareFirst BlueChoice’s multi-faceted care management program that
provides you with essential tools for patient care, this article is intended
to call your attention to recent literature that may be of interest to you.
For more information on how to enroll your patients in one of our disease management
programs, please call 800-783-4582.
| Congestive
Heart Failure |
| What's Available |
Where to
Find It |
| Vitamin supplementation is a common practice among our
patients. Since vitamin E is an antioxidant, theoretically it can
serve to prevent oxidation of LDL, a step in the process of atherosclerosis.
Some have also touted its potential benefit in preventing cancer.Although
there are epidemiologic studies to support the effect of vitamin E
in preventing cardiovascular disease and a few observational studies
as well, there have been no good randomized controlled trials to state
the same. The authors of Effects of Long-term Vitamin E Supplementation
on Cardiovascular Events and Cancer studied patients over an average
of seven years. “The major finding of the HOPE trial…is
the lack of benefit for vitamin E in preventing cancer or major cardiovascular
events after a prolonged period of treatment and observation. Furthermore,
our study raises concerns about an increased risk of heart failure
related to vitamin E.” In addition, there was no significant
difference between the incidence of cancers between the vitamin E
group and a placebo. This study confirms the earlier findings of the
Heart Protection Study, which failed to show any benefits of vitamin
E after five years, and raises awareness of the potential detrimental
affects of vitamin E on heart health. The CareFirst Congestive Heart
Failure disease management program includes education about a proper
diet. |
Journal of the American Medical Association 2005; 293(11)1338-1347 |
| Coronary
Artery Disease |
| What's Available |
Where to
Find It |
| It’s been more than 15 years since the launch of
the landmark Scandinavian Simvastatin Survival Study. Since then,
physicians have been on steady ground to employ statins as a means
of not only lowering cholesterol levels, but of improving clinical
cardiac outcomes. The medical community is still striving to optimize
the use of statins. Findings from the study, Intensive Lipid Lowering
with Atorvastatin in Patients with Stable Coronary Artery Disease,
continue to push the envelop of LDL-lowering goals. Previously, it
had been shown that lowering LDL goals below 100 mg/dL was clinically
beneficial in patients with acute coronary syndromes. In this study,
patients with LDL less than 130 mg/dL and clinically evident CHD were
randomized between 10 mg or 80 mg of atorvastatin and followed for
almost five years. “As compared with the group given 10 mg of
atorvastatin, the group given 80 mg had a 22 percent relative reduction
in the primary composite efficacy outcome of death from CHD…Patients
given 80 mg of atorvastatin also had significant reductions in the
risk of a major coronary event, any coronary event, a cerebrovascular
event, hospitalization with a primary diagnosis of congestive heart
failure, and any cardiovascular event.” Although these results
are encouraging because they demonstrate the potential to further
reduce our patients’ risk of a poor outcome, the medical community’s
biggest obstacle to maintaining our CHD patients’ health may
in fact be compliance of the medication, not the dose. As many as
50 percent of our patients stop taking their statin medication within
the first year of starting. Our coronary artery disease management
program can work with your patients to improve adherence to medication. |
New England Journal of Medicine 2005; 352:1425- 35 |
| Lower LDL
Goals |
| What's Available |
Where to
Find It |
| There is increasing evidence to support lower LDL goals
in those patients at highest risk for heart disease. In fact, in 2004,
the National Heart, Lung and Blood Institute issued an update to the
National Cholesterol Education Program (NCEP). In this update, they
recommended that those patients at highest risk for heart disease
strive for an LDL level less than 70 mg/dL.You can go to www.nhlbi.nih.gov
for more information. C-reactive protein has also become a frequently
discussed and studied topic since the release of NCEP III occurred
in 2001. The authors of C-Reactive Protein Levels and Outcomes after
Statin Therapy were trying to understand whether lowering C-reactive
protein in patients with acute coronary syndrome altered the clinical
outcome. They found that in this high-risk population, regardless
of the resultant LDL level, those patients with the lowest CRP levels
had better clinical outcomes than those with higher CRP levels. “Given
that the participants had recently had a myocardial infarction or
had high-risk unstable angina and thus had a clear indication for
long-term statin therapy, we believe our findings should not be generalized
beyond situations involving secondary prevention…whether statin
therapy should be used for primary prevention among persons with elevated
levels of CRP who do not have hyperlipidemia remains highly controversial
and is the subject of an ongoing multinational trial.” The NCEP
has not yet made a recommendation to screen risk of heart disease
with CRP levels. |
New England Journal of Medicine 2005; 352:20-8
|
| Coronary
Artery Bypass Grafting VS. Stent Implantation |
| What's Available |
Where to
Find It |
| The researchers of Long-Term Outcomes of Coronary-Artery
Bypass Grafting versus Stent Implantation observed the outcomes of
almost 60,000 patients entered in the New York cardiac registry. They
compared three year survival and revascularization rates of patients
undergoing the aforementioned revascularization procedures. “After
adjustment for severity of illness before revascularization, CABG
was associated with a significantly higher likelihood of survival
in all anatomical groups…” These anatomical groups were
comprised of either two - or three - vessel disease, with or without
an ejection fraction less than 40 percent, and considered the subpopulation
of diabetics. Furthermore, “The overall rates of revascularization
were significantly lower in the CABG group than in the stenting group.”
The accompanying editorial adds “Multiple trials of coronary
revascularization in multivessel disease have suggested that survival
is not compromised by an initial strategy of Percutaneous Coronary
Intervention, except in patients with diabetes. Therefore, the implications
of this study are profound and suggest that things are not as clear-cut
as originally thought.” Still, the decision of which revascularization
procedure to pursue is influenced by “the patient’s and
physician’s appreciation of periprocedural morbidity and mortality,
a realistic perception of the effect of procedural outcomes on the
quality of life, the effect of coexisting conditions, and the magnitude
of the benefit of one procedure over another.” The observed data
occurred between 1997 and 2000 and, since then, there has been an
increased use of drug-eluting stents and off-pump coronary bypass,
just two of the several changes in performing these procedures. The
question of which revascularization procedure is superior must be
continuously reevaluated to keep up with current technology. |
New England Journal of Medicine 2005; 352:2174-83 |
| Diabetes |
| What's Available |
Where to
Find It |
| Diabetes Prevention Program (DPP) compared behavioral
and lifestyle interventions in delaying the onset, or preventing diabetes
in nondiabetic adults with impaired glucose tolerance and fasting
glucose levels between 95mg/dL and 125 mg/dL. It showed that both
lifestyle modification (weight loss and increased physical activity)
and use of metformin delayed the onset and reduced the cumulative
incidence of type 2 diabetes. In The Cost-Effectiveness of Lifestyle
Modification or Metformin in Preventing Type 2 Diabetes in Adults
with Impaired Glucose Tolerance, the authors compare the costs, cost-effectiveness
and quality-adjusted life-years (QALYs) of these two interventions,
versus placebo, over a lifetime. The lifestyle intervention costs
approximately $1,100 per QALY and the metformin intervention costs
$31,300 when compared to placebo. Because of the lower cost and better
outcomes, lifestyle intervention is clearly the preferred option.
“The lifestyle intervention was cost-effective in all age groups.
The metformin intervention did not represent good use of resources
for persons older than 65 years of age.” The DPP shows us that
it is possible to delay the onset of diabetes in some high-risk patients
and prevent the disease in others. For those of your patients who
do develop diabetes, consider enrolling them in our diabetes disease
management program. Our nurses will help your patients adhere to a
healthy lifestyle and improve their medication compliance. |
Annals of Internal Medicine 2005; 1 42:323-332 |
| Other Items
of Interest |
| What's Available |
Where to
Find It |
| It’s fairly common to have a patient ask you about
which type of diet they should start. Although most people in the
medical community believe a balanced diet with the appropriate calorie
intake balanced by exercise is the most favored approach, many patients
want a plan that can ensure quick weight loss. The Comparison of the
Atkins, Ornish,Weight Watchers and Zone Diets for Weight Loss and
Heart Disease Risk Reduction study set out to determine whether any
of these diet plans was superior to the others. The Atkins diet emphasizes
restriction of carbohydrate intake without regard to fat, whereas
the Ornish diet strives for a vegetarian diet, where only about 10
percent of calories come from fat. The Zone diet aims to reduce glycemic
load while balancing macronutrient intake from protein, carbohydrate
and fat. Finally, Weight Watchers emphasizes portion size and calorie
control. Compliance with the diets was poor across the board. Those
who did comply (as self-reported), however, did show a small but significant
weight loss,with all programs producing roughly the same results.
There was a reduction in LDL cholesterol levels seen, but not in blood
pressure or glucose levels. This study assigned individuals to a particular
diet, whereas self selection of the diet plan may increase adherence.
The authors conclude, “Sustained adherence to a diet rather than
diet type was the key predictor of weight loss and cardiac risk factor
reduction in our study.” CareFirst and CareFirst BlueChoice members
are eligible for enrollment in the Weight Watchers program at a reduced
cost.Your CareFirst and CareFirst BlueChoice patients can sign up
through our web site, www.carefirst.com. |
Journal of the American Medical Association 2005; 293:43-53 |
| |
|
| Although uncommon, patients infected by varicella can
die. The varicella vaccine was made available in 1995 and since 1999
mortality rates from varicella infection have declined. The greatest
decline in mortality occurred in the one to four years of age group.
In the Decline in Mortallity Due to Varicella after Implementation
of Varicella Vaccination in the United States, the authors conclude,
“Our analysis clearly documents the dramatic national decline
in varicella-related mortality for all ages, race, and ethnic groups
after the increased use of vaccine.” Please be certain that your
patients who are older than one year have received a varicella vaccine.
Patients who are not immune and older than 13 years need two doses;
at least four weeks apart. |
New England Journal of Medicine 2005; 352:450-8 |
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Influenza Vaccine Reminder
 Last year's influenza season started off with some concern over a projected short supply and finished with excess vaccine being wasted. This year's supply and distribution will hopefully be smoother. The optimal time for administering the vaccine is in October and November, but patients can still yield some benefit if the vaccine is administered later. Remember, patients allergic to eggs should not be given the vaccine and must resort to prophylactic use of antiviral agents.
The following is a list of those patient populations recommended by the Center for Disease Control to be immunized.
- Patients 65 years of age and older
- Children 6 -23 months of age
- Health workers
- House-hold members of persons at high risk
- Residents of nursing homes and chronic care facilities
- Adults and children with asthma and other chronic pulmonary or cardiovascular disorders
- Adults and children with diabetes, renal dysfunction and other disorders which suppress the immune system (such as HIV)
- Pregnant women in their second or third trimester during influenza season
- Persons age 50-65 because of their increased association with chronic illnesses
For more information on influenza and the vaccine to prevent the illness, visit the Center for Disease Control at www.cdc.gov.
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Philosophy of Care and CareFirst's Mission
We represent a philosophy of health care that emphasizes active partnerships between patients and their physicians. We believe that comprehensive health care is best provided by networks of health care professionals who are willing to be held accountable for the satisfaction of their patients and the quality of their services. We are committed to high standards of quality and professional ethics and to the principle that patients come first.
We believe that patients should have the right care, at the right time and in the right setting. This includes preventive care, as well as comprehensive care for acute and chronic illness — at home, at the doctor’s office and in the hospital.
We believe that all health care professionals should be held accountable for the quality of the services they provide and for the satisfaction of their patients.
We believe that patients should have a choice within their health plans of physicians who meet high standards of professional training and experience, and that informed choice and the freedom to change physicians are essential to building active partnerships between patients and doctors.
We believe that health care decisions should be the shared responsibility of patients, their families and health care professionals, and we encourage physicians to share information with patients on their treatment options, medical conditions and health status.
We believe that consumers have a right to information about health plans and how they work.
We believe that working with people to keep them healthy is as important as making them well.
We value prevention as a key component of compre-hensive care, reducing the risks of illness and helping to treat small problems before they can become more severe.
We believe that access to comprehensive, affordable care gives consumers the value they expect and contributes to the peace of mind that is essential to good health.
CareFirst's Mission
The mission of CareFirst BlueCross BlueShield is to provide health benefit services of value to customers across the region comprised of Maryland, Delaware, and the National Capital Area. To fulfill this mission, CareFirst BlueCross BlueShield commits to:
- Offer a broad array of quality, innovative insurance plans and administrative services that are affordable and accessible to our customers
- Fairly address the needs of customers in each jurisdiction in which we operate
- Conduct business responsibly as a non-profit health service plan, to ensure the plan's long-term financial viability and growth
- Collaborate with the community to advance health care effectiveness and quality
- Support public and private efforts to meet needs of persons lacking health insurance
- Foster health systems integration and health care cost containment to benefit the people in areas we serve, and
- Promote respect, fairness and opportunity for our associates.
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