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| CLINICAL NEWS FOR OUR PARTICIPATING HEALTH CARE PRACTITIONERS |
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Best Practice: Peninsula Regional Medical Center’s Automated Pharmacy System
New and Emerging Technologies
CareFirst Commitment
Embracing a Diverse Patient Population
Recent Literature on: CareFirst and CareFirst BlueChoice Disease Management Initiatives
QI Program: Setting Goals for Improved Care and Service
Be Sure Your Practice is Teen-Friendly
New CDC Treatment Guidelines on STDs Now Available
Talk to Authors of Peer-Reviewed Articles
Best Practice: Peninsula Regional Medical Center’s Automated Pharmacy System
The following is presented in an effort to highlight hospital “best practices” in the CareFirst BlueCross BlueShield (CareFirst) and CareFirst BlueChoice, Inc. (CareFirst BlueChoice) service area and to share with medical professionals throughout the region the innovative approaches hospitals are adopting in Maryland, Washington, DC and Northern Virginia. Their “best practice” approach to patient care is not only improving the quality of care, but also helps contain the rising cost of care.
Medical mistakes go down hard — sometimes fatally. No individual, no institution in the role of healer can easily tolerate a mistake that, at best, fails to improve a patient’s condition, and at worst, results in a patient’s death. Among the most common of all medical mistakes, and a problem of increasing concern in recent years, is the miss-filled prescription. Miracle drugs, one of the nation’s most impressive contributions to modern medicine, provide little benefit, and in fact can be seriously harmful, when improperly administered.
In recent years, due to a shortage of qualified pharmacists and a steady increase in the use of prescription medications, the rate of death and medical complications attributed to miss-filled prescriptions has risen sharply, according to the National Association of Boards of Pharmacy. The association estimates that as many as 5 percent of the 3 billion prescriptions filled each year in the United States are incorrect and may be contributing to as many as 7,000 deaths a year.
The challenge to accurately prepare and deliver proper medication is of particular concern in hospitals where the medical staff is routinely responsible for getting hundreds of dosages correctly dispensed to dozens of patients around the clock, every day. A contributing circumstance, often cited as an underlying cause for mistakes in filling prescriptions, is the pressure to meet a complex set of patient needs in a stressful environment of distractions and interruptions — the hospital environment.
The challenge of properly administering every medical prescription to every patient, every time, is fundamental to patient safety. And nowhere in the Mid-Atlantic region is the goal of error-free patient care more consistently achieved than at Peninsula Regional Medical Center (Peninsula Regional) in Salisbury, Maryland.
Alan Newberry, the center’s president and chief executive officer, says the formula for medication safety lies in new technology and the vision to use it effectively. He says, “Technology in a hospital is like putting seat belts in a car. Once it’s proven — and it has been proven that robotics, computerized physician order entry and bar-coding all reduce errors and save lives — then it’s obvious that we need to make that investment.”
Peninsula Regional started on the path of new technology in the early 1990s. Today, it stands on the threshold of “closing the loop” on an automated, integrated, patient-safe, pharmacy system that over the past two years has administered more than two million doses without a single administrative error.
Peninsula Regional is a 106-year-old tertiary care facility that features a wide array of specialty and sub-specialty services on Maryland’s lower Eastern Shore. As a regional facility, it draws patients from Maryland, Delaware and a small portion of Virginia. The center serves more than 500,000 patients a year, including inpatient, outpatient, diagnostic, sub-acute and emergency-trauma cases. Peninsula Regional has 322 acute care and 30 sub-acute care beds.
Peninsula Regional took the first step toward improving patient safety in the early 1990s when the medical center, under the leadership of Newberry, made a multi-million dollar commitment to patient safety through the use of emerging digital technology. Creating the medical center’s “automated pharmacy” did not occur overnight, but rather through a series of calculated steps over a number of years.
The initial step was to identify and develop a relationship with a corporate partner who understood hospitals and could provide the information technology required to fulfill Peninsula Regional’s commitment to patient safety. That partner turned out to be the McKesson Corporation, a leading provider of medical supplies, information and care management products and services designed to reduce costs and improve the quality of health care.
In 1994, McKesson installed its Electronic Medical Record (EMR) technology at Peninsula Regional as the foundation for its patient care information system. The EMR replaced the familiar large brown envelopes that for many years were the common repository of a patient’s health history at Peninsula Regional and other hospitals. These envelopes would physically go with the patient, point-to-point, throughout the hospital. The Electronic Medical Record put patient information in front of a doctor or nurse instantly — and made it possible to share the information with a patient’s private physician across town, or across the country.
It also meant that a pharmacist filling a prescription for a patient at the hospital had more precise and accurate information.
In 1998, Peninsula Regional enhanced its EMR by adding further capability — McKesson’s Admin-RxTM system — that bar-coded medications dispensed at the hospital and reduced the potential for error by integrating compliance monitoring, drug dose checking, patient consultations, allergy screening, drug-interaction screening, therapeutic duplication and drug-disease interactions.
By adding these capabilities to its core system, Peninsula Regional improved the efficiency of its pharmacists by freeing them of clerical tasks and enabling their greater participation in medication management.
In 1999, as individual medications administered annually approached the million mark, the hospital again improved its process for managing and dispensing medicine with patient safety as the foremost criteria. It again called on McKesson which provided a robotic solution officially known as ROBOT-Rx (and unofficially named “Rosie the Robot” by Peninsula Regional’s staff). Using the bar-code technology already present in the system, the robot selects a patient’s drug as ordered by the physician and entered by the pharmacist. “Rosie” then sorts or prepares the required dosage for delivery. The robot is at work, 24 hours a day, 365 days a year – filling about 2,800 doses daily from the pharmacy. The accuracy rate to date is a commendable 100 percent.
This system was further enhanced when the hospital added other McKesson-designed capabilities to streamline the pharmacy workload, screen for drug interactions, review lab tests and complete orders more efficiently.
Director of Pharmacy Services at Peninsula Regional Morrell C. Delcher says the system has delivered impressive benefits, “Rosie has reduced the possibilities for medication errors and allowed us to expand the pharmacist practice into a more clinical and therapeutic advisory role. This improves overall patient outcomes.”
By 2001, the quantities of medications dispensed at Peninsula Regional had increased the need for improved methods for storing and securing drugs. This issue was resolved with AcuDose-Rx, a high-tech McKesson cabinet that makes it possible to decentralize the pharmacy process and automate the storing, dispensing and tracking of narcotics, floor stock and other select medications in patient care areas.
A year later, 2002, Peninsula Regional added the keystone piece to its impressive array of new technology designed to achieve the highest possible degree of patient safety. Combining its basic electronic medical record system with other McKesson technologies, Peninsula Regional became one of the first hospitals in the United States to introduce bedside scanning of medications and patients as a final safety check. The procedures adopted remove virtually all margins for error in providing medication to patients.
At the bedside, the nursing staff uses a cart-mounted notebook computer, equipped with bar-code scanners and technology. The nurse scans the patient’s barcoded arm-band to bring up his or her medical profile.
Then the medication is scanned to verify that the medication being delivered is intended for the patient who is about to get it. If an incorrect dosage is detected, the system immediately warns the nurse before the drug is administered. The system may also be used to ensure that nurses have properly programmed bedside I.V. pumps.
Looking back on more than a dozen years of progressive improvement in a patient safety approach to hospital medication, John Hammergren, McKesson’s chairman and chief executive officer, said recently, “Peninsula Regional had the foresight to invest in patient safety before it became part of the public consciousness. We commend them for their vision and are proud to partner with them to make health care safer.”
This year, Peninsula Regional will take yet another step to extend further its patient safety procedures with the introduction of McKesson’s Horizon Expert OrdersTM. The technology will provide physicians with real-time clinical feedback about their medication orders. Doctors can make more informed decisions about medications at the point of decision when information is delivered in a way consistent with their particular practice of medicine. Doing so will help reduce errors at the beginning of the medication management process — prescribing the medication.
By bringing best practices to the point of ordering, The Expert Orders system helps reduce variations in the quality and the cost of care. At the same time, it sets up a closed-loop medication safety strategy by helping doctors avoid medication errors at the starting point of medication management.
Jeffrey Turner, chairman of Peninsula Regional board of directors, says of the hospital’s fully integrated patient safety strategy, “This is a Medical Center that is growing and a team that is constantly seeking out opportunities to remain one of the safest in America.”
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New and Emerging Technologies
CareFirst and CareFirst BlueChoice's Technology Assessment Committee — which includes CareFirst and CareFirst BlueChoice physicians and 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'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. Click here to find the review criteria by clicking on Medical Policies . The Technology Assessment Committee recently made the following determinations.
| Carotid angioplasty and stenting (CAS), with distal embolic protection |
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This has been developed as a result of the success of coronary angioplasty and stent placement technique, as an alternative to carotid endarterectomy (CEA) in patients with carotid stenosis.
CareFirst and CareFirst BlueChoice determination
Early studies show a high rate of complications related to showering of emboli during the procedure, so distal embolic protection devices were developed. Since then, results of clinical studies suggest a reduced rate of complications and favorable short-term outcomes. However, these studies are limited by small sample sizes, lack of randomization and/or blinding, poorly defined study populations and lack of statistical analysis. A less limited study by Yadav et. al. reported CAS was no less effective than CEA in patients with severe stenosis and at least one risk factor for complications from CEA. This non-inferiority study led to expert opinions that CAS could be considered an alternative to CEA in those patients who require intervention and are considered high risk for CEA. On the contrary, other authors have stated that even patients with significant risk factors can be operated on with an acceptable level of complications and desired outcomes. Expert opinions on the evidence are cautious and conservative, as clinical trials are continuing, and questions remain as to whether CAS is a viable alternative to CEA, and if so, what patients should be considered for CAS. Long-term durability remains to be determined, as the studies to date have not adequately addressed whether the stents now available in the U.S. will eventually re-stenose. In the U.S., the Carotid Revascularization Endarderectomy versus Stent Trial is in progress, and in Europe the Carotid and Vertebral Artery Transluminal Angioplasty Study is in its early stages. Based on the limited evidence, we consider carotid angioplasty and stenting to be experimental/investigational.
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| Home unattended sleep studies for the diagnosis of sleep-related breathing disorders |
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A number of devices that record the patient’s breathing characteristics during sleep are intended to be worn overnight by the patient at home. The information is analyzed to determine whether the patient has a sleep-related breathing disorder, like obstructive sleep apnea (OSA).
CareFirst and CareFirst BlueChoice determination
The current gold-standard diagnostic test for OSA and other sleep-related breathing disorders is the multi-channel polysomnogram performed in a sleep laboratory setting. A number of simpler, more limited devices are claimed to be effective for diagnosing a disorder, but do not require the presence of a professional technician or a sleep laboratory. Such devices lack scientific validation, according to evidence-based reviews published within the past two years, cooperative efforts of expert panels with representatives of the American Academy of Sleep Medicine, the American Thoracic Society and the American College of Chest Physicians. The American Academy of Sleep Medicine recommends that home-based studies be reserved for patients who would otherwise be unable to undergo a conventional (Type I) polysomnography in a sleep lab. The SNAP® system, a limited home device, provides some data on the patient’s breathing characteristics, but not enough data on the sleep architecture to be meaningful. This would be considered a Type IV test, which is generally not recommended by the expert panels.
Although unattended sleep studies continue to show potential value in the diagnosis of sleep disorders in adults and children, the equipment has not been proven equal or superior to the current standard.Home, unattended equipment yields higher test failure rates and are limited as to the parameters they measure, which yields limited information on the characterization of the sleep pattern of patients suspected of having a sleep disorder. For these reasons, we continue to regard home-based, unattended sleep studies as experimental/investigational.
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| 24-hour ambulatory blood pressure monitoring (ABPM) |
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ABPM has been in use since the early 1990’s mainly to identify patients with office hypertension (i.e., “white coat” hypertension) who are otherwise normotensive. There has been a great deal of study documented in the literature on this topic, and which has been reviewed by expert panels of several professional societies.
CareFirst and CareFirst BlueChoice determination
Although the technology has been available for many years and has been promoted by some specialty medical organizations, the evidence lacked clarity as to whether patients with office-based hypertension were at any greater risk for end organ damage than normotensive patients. Further, there was insufficient evidence as to what constituted a “positive” value for 24-hour ABPM that would lead the physician to recommend treatment.
Finally, there was insufficient outcomes data on overall patient outcomes; whether ABPM contributed to improved patient outcomes in the form of control of end organ damage over time.
More recent studies have directly and indirectly addressed some of these concerns. For instance, it is now known that blood pressure readings tend to be higher in the doctor’s office, whether the patient is actually hypertensive or not. Also, blood pressure readings taken in the office by people other than the physician, such as a nurse or technician, tend to be lower. The trend in the studies published over the past two years points toward using ABPM as a tool to determine if a patient, whose blood pressure, when measured in the office, suggests borderline hypertension, white-coat hypertension, is a “non-dipper” over a 24-hour period, or to monitor the patterns of individuals who remain hypertensive despite the use of medications. However, the evidence in such cases is not robust. Published consensus panel statements and clinical practice opinions tend to be vague when referring to the clinical utility of ABPM.
Based on the most current evidence, 24-hour ambulatory blood pressure monitoring is not experimental or investigational, but there is insufficient data to establish medical necessity as an alternative to other means, like re-checking the patient’s blood pressure in the doctor’s office or in the home with a conventional blood pressure cuff. As a result, 24-hour ambulatory blood pressure monitoring is considered not medically necessary.
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| Human growth hormone (HGH) treatment for children with idiopathic short stature |
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The FDA has allowed labeling of recombinant HGH preparations for this indication, defined as a height for a given age that is two or more standard deviations below normal, in the absence of evidence of growth hormone deficiency, for unknown or hereditary reasons.
CareFirst and CareFirst BlueChoice determination
Although administration of HGH to children with idiopathic short stature can increase the near-final growth height, there is insufficient evidence that doing so translates into improved health outcomes. Furthermore, there is insufficient evidence that children with idiopathic short stature suffer adverse outcomes in terms of normal achievement and social development in the absence of treatment. Therefore, we determined that human growth hormone treatment for idiopathic short stature is considered not medically necessary, as no endocrine system dysfunction or disease state has been established.
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| Low-level laser therapy (LLLT) for musculoskeletal and neuromuscular conditions |
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LLLT, also known as cold laser or soft laser therapy, involves the use of light-emitting diodes with a wavelength in the range of approximately 860-890 nm. This wavelength of light supposedly penetrates the skin to the muscle level and the nerves without causing a warm sensation, or thermal damage to the tissues. Two such devices have received clearance from the FDA for marketing under 510(k) provisions.
CareFirst and CareFirst BlueChoice determination
Studies in peer-reviewed literature report outcomes for LLLT used to treat patients with conditions, like carpal tunnel syndrome, osteoarthritis, rheumatoid arthritis, fibromyalgia, tendonitis and low back pain. Results reported have either been conflicting or have involved small study groups and limited study designs, from which reliable conclusions regarding health outcomes are not possible. For this reason, we consider LLLT to be experimental/investigational.
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| MRI guided focused ultrasound destruction of fibroid tumors (ExAblate 2000® system) |
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This is a recently FDA-approved device for non-invasive treatment of symptomatic uterine fibroids (leiomyomata). The PMA approval letter stipulates that the company must conduct a post-approval study to evaluate the long term safety and effectiveness of the ExAblate 2000 system. The focused ultrasound impulse is centered on the tumor, which is located by MRI scanner as the patient lies face-down on the device, which causes internal thermal destruction of the tumor tissue.
CareFirst and CareFirst BlueChoice determination
Evidence regarding outcomes of the treatment in published literature is rare. The largest study involved only 109 patients and reports a reduction in fibroid volume and improvement in symptoms. Follow-up periods were short, so there remain questions about whether the treatment is durable. There is also insufficient information to determine patient selection criteria based on size, type and location of the fibroid, and, therefore, which patients may benefit from this non-invasive approach, as opposed to alternative interventions. Some early published expert opinions suggest that focused ultrasound is suitable only for small (<5cm) tumors. Focused ultrasound is only recommended for patients who wish to have a non-surgical treatment where continued fertility is required, as it is unknown whether patients may be able to sustain a pregnancy after treatment. Surgical myomectomy and hysterectomy are well-established surgical alternatives to ultrasound treatment. Myomectomy is used for patients who wish to retain fertility. No studies directly compare outcomes of myomectomy to the ultrasound treatment. Uterine artery embolization (UAE) is another technique that has been in use for about a decade and has recently become regarded as a mature technology. Although it cannot be used in patients who wish to remain fertile, it is widely regarded as safe and effective, and may be used successfully on larger tumors. No studies compare UAE with ultrasound, so it is not known whether ultrasound is as effective. Therefore, based on the scarcity of evidence of patient outcomes and evidence that focused ultrasound is at least as effective as currently accepted alternatives, we consider the treatment to be experimental/investigational.
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CareFirst Commitment
CareFirst and CareFirst BlueChoice have launched CareFirst Commitment, a new initiative designed to improve health care accessibility, quality and safety and address emerging cultural diversity needs and racial and ethnic disparities in health care outcomes. The components are:
Bridges to Excellence
To support high quality care, we will provide recognition and financial rewards to primary care physicians who take concrete steps that encourage and support optimum care and better outcomes. By partnering with Bridges to Excellence, a national non-profit organization advancing solutions that help provide patient care, we hope to promote the delivery of safe, timely, effective, efficient, equitable and patient-centered care. Click here for more information.
Health Information Technology (HIT)
We are working with physician-led collaborative that involves hospitals, health systems and other stakeholders, including payers to improve quality of care, patient safety and efficiency through technology.
Patient Safety Centers
We are working with The Maryland Patient Safety Center, a non-regulatory collaboration of the Maryland Hospital Association and the Delmarva Foundation to create programs promoting safety in area health care facilities. The Center’s current strategies include:
- Error Prevention - implement mandatory reporting of serious adverse events.
- Collaboration and Education - facilitate training to share information, best practices and lessons learned.
- Voluntary Reporting - providers may report errors to the Center using a confidential form.
Hospital Safety
We will work with health care systems to improve patient safety, quality of care and efficiency. Through partnerships with area hospitals, we will establish an Intensive Care Initiative that will ensure that patients receive state-of-theart intensive care unit (ICU) care.
Responding to Increasing Diversity
We will also help meet the health care needs of the increasingly diverse communities we serve and help eliminate health care disparities by funding initiatives to:
- Develop products that meet the cost and benefit needs of our diverse population.
- Address cardiovascular disease in African Americans, diabetes in Latinos and cervical cancer in Asian women.
- Increase cultural sensitivity through translation and cultural outreach to serve diverse communities.
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Embracing a Diverse Patient Population
Racial and ethnic health care disparities are a national problem. One goal of the Department of Health and Human Services’ Healthy People 2010, a set of national disease prevention and health promotion objectives to achieve by 2010, is to eliminate health disparities among different segments of the population.
According to the Agency for Healthcare Research and Quality’s National Healthcare Disparities Report, minorities are less likely to receive cancer screenings, more likely to have late-stage cancer when diagnosed and less likely to receive immunizations for flu and pneumococcal pneumonia. This could be a result of the fact that Asians, Latinos and those with lower incomes have more difficulty accessing health care information, including information about prescriptions.
These groups do not fill 25 percent of their prescriptions. Latinos are twice as likely to have diabetes as Caucasians, but less likely to self monitor blood glucose and have their cholesterol checked. Also, 71% of Latino children compared to 79 percent of Caucasian preschoolers were fully vaccinated by age two.
Visit the Institute of Medicine Web site for more information.
What you can do
We know you recognize the challenge of caring for and communicating with patients from diverse backgrounds. Here are some suggestions of how you can help:
Strengthen relationships with patients
Patients who speak other languages may not be able to understand your instructions or questions. Patients may also have difficulty accurately communicating their symptoms and complaints. These patients may also have difficulty following a treatment plan. Educating providers and patients about health care disparities is an important initial strategy to eliminate health care disparities and to provide quality care for all patients.
Acknowledge different cultures
In cross-cultural patient/provider relationships, both parties must acknowledge, respect and ask about perceptions and practices different from their own. When you are open-minded when caring for patients with different cultural backgrounds, they may be more receptive to your treatment plan.
What CareFirst is doing
CareFirst is working to better meet and respond to the health care needs of the increasingly diverse communities the company serves. Recognizing that racial and ethnic health disparities are becoming more prevalent, CareFirst’s initiatives will include medical strategies to address the higher prevalence of cardiovascular disease in African Americans, diabetes among Latinos and cervical cancer in Asian women. Other initiatives include translation and cultural outreach to serve diverse communities, development of products that meet specific community needs, and participation in a variety of existing public health programs.
We recently launched a Spanish version of our My Care First, our health and wellness Web site. Have your Spanish-speaking patients visit www.carefirst.com/salud.
What Inova Health System is doing
Interpreter Services
Inova Health System’s (Inova) patient-provider communication program, Hablamos Juntos (We Speak Together), is entering its third year. Because language barriers can hinder quality health care, Inova’s medical interpreters in the emergency department (ED) also serve as “patient navigators” by helping patients admitted through the ED get the language services they need in other parts of the facility. If trained bilingual staff is not available to help these patients, phone interpreters are available 24 hours a day, seven days a week.
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Recent Literature on: CareFirst and CareFirst BlueChoice Disease Management Initiatives
By Robert M. Thomas, MD, Medical Director, Clinical Affairs
CareEssentials: Disease Mangement
As part of the Disease Management component of CareEssentials, our care management program that provides you with essential tools for patient care, this article is intended to call your attention to recent information that may be of interest to you.
| Diabetes |
| What's Available |
Where to Find It |
Risk Factors Associated with Acute Pyelonephritis in Healthy Women
This is a useful article because the population under analysis is one very familiar to the practicing physician (a community dwelling/healthy adult pool).Acute pyelonephritis is a severe infection of the upper urinary tract and is thought to account for 250,000 office visits and nearly 200,000 hospital admissions per year in the United States. Most of these infections occur in women and are easily treated in the ambulatory setting. Besides pregnancy and diabetes, the risk factors for acute pyelonephritis in young healthy women go largely unexplored. This study looked at several risk factors: sexual intercourse 30 days prior to the event, new sexual partners, spermicide exposure and Hx of urinary incontinence 30 days prior to the diagnosis along with a history of UTI in the previous 12 months. Family Hx (mother) of UTI is also a risk factor. E. coli, not surprisingly, is the predominate isolate observed. |
Annals of Internal
Medicine. 2005; 142
(Number 1, Jan.) pg. 20-27 |
| Other Items of Interest |
| What's Available |
Where to Find It |
Peginterferon Alfa-2a Plus Ribavirin Vs. Interferon Alfa 2a Plus Ribavirin for Chronic Hepatitis C in HIV Co-Infected Persons
For patients co-infected with HIV and Hepatitis C, a sustained response could be achieved using this combination, which is not surprising since the same scenario exists for patients with Hepatitis C without HIV. Since beginning the aggressive treatment of HIV using HAART therapy, more HIV patients are living longer. Unfortunately, this can mean the later development of end-stage liver disease in persons also infected with Hepatitis C. Overall, peginterferon plus ribavirin may be of benefit in HIV-positive patients who show signs of rapid progression of Hepatitis C. The co-infected patient presents a difficult choice for the clinician:Who to treat with this regimen (the therapy is toxic with the side effects of depression, severe flu-like symptoms, neutropenia and other laboratory abnormalities frequently observed) and when to treat are still not medically standard protocols in the world of HIV/Hepatitis C. |
New England Journal of
Medicine. 2004; pg. 351;
451-459 |
Mainstream and Alternative Medicine: Converging Paths Require Common Standards
Complementary or alternative medicine is not going away. In the United States, patient visits to alternative medical providers outnumber visits to primary care physicians.Which alternative medicine treatments work and which do not? How does the physician identify patients who might benefit from complementary medicine? These questions can only be answered by studies incorporating the same rigorous standards and research methods that mainstream medicine uses to identify the effectiveness of new therapy for disease treatment. This editorial by Dr. George Bondurant of Georgetown University suggests ways that this might be done in a scientific framework. The distrust that many physicians feel in regards to alternative medicine will be alleviated only through evidence analysis. |
Annals of Internal
Medicine. 2005; 142 (No. 2,
Jan. 18) pg. 149-150 |
Effectiveness of Acupuncture as Adjunctive Therapy in Osteoarthritis of the Knee
This article is useful in light of the recent controversy surrounding the market withdrawal of Vioxx. Osteoarthritis of the knee is the most common form of arthritis and a major cause of disability in the United States. Pain and limitation of motion are the most common complaints associated with this disease. Many therapies are available to treat this condition: Physical therapy, education and exercise, weight loss, acetaminophen, NSAIDs, topical (capsaicin), opioids and intraarticular injections are mainstays. Several of these have side-effects; some of which are severe. Complementary/Alternative medicine is another approach that arthritis patients are using with or without their treating physician’s approval. This study provides an evidence-based analysis of acupuncture for this condition. Previous acupuncture studies have had conflicting results. Most were of a small sample size or limited duration. This large, randomized, placebo controlled study of 570 patients compared acupuncture during a 26-week period with sham acupuncture in the treatment of osteoarthritis of the knee. It was observed that pain relief and increased mobility occurred in a statistically significant number of the participants. No side-effects of acupuncture were noted. The description of the devised sham acupuncture procedure is rather ingenious. |
Annals of Internals of
Internal Medicine. 2004;
141 (No. 12, Dec. 21) pg.
901-910
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A Clinical Prediction Rule to Identify Patients with Low Back Pain Most likely to Benefit from Spinal Manipulation: A
Validation Study details a study that tests the usefulness of a clinical predictive model for classifying patients who might respond to spinal manipulation for low back pain. A subgroup of patients with lower back pain was found who responded to manipulation outside of the effects of education and exercise. The criteria for predicting Spinal Manipulation Responders are:
- duration of current episodes of back pain less than 16 days
- no symptoms distal to the knee
- low score on Fear-Avoidance Beliefs Questionnaire (preconceived ideas about back pain and mistaken belief about avoiding activity)
- greater than one hypomobile segment in lumbar spine (corresponds to range of motion of lumbar spine)
- internal range of motion of hip greater than 35 degrees
Patients meeting at least four of the above criteria were more likely to respond to spinal manipulation. Such guidance has been lacking in the past in regards to the identification of patients who might benefit from spinal manipulation.
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Annals of Internals of
Internal Medicine 2004;
141 (No. 12, Dec. 21) pg.
920-928 |
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QI Program: Setting Goals for Improved Care and Service
CareFirst and CareFirst BlueChoice are committed to providing high quality care and service to members. The Quality Improvement (QI) Council works with community physicians to develop and implement the QI Program to help improve the quality and safety of clinical care in all areas of the health care delivery system. As part of this effort, QI supports the six guiding principles identified in the Institute of Medicine 2001 report, “Crossing the Quality Chasm: A New Health System by the 21st Century”:
- Safe: Avoid injuries from care intended to help
- Timely: No unnecessary waits
- Effective: Evidence-based treatments and technology
- Efficient: Not wasteful
- Equitable: Same care for everyone regardless of gender, race, ethnicity, age
- Patient-centered: Responsive to preferences, needs and values
CareFirst and CareFirst BlueChoice annually implement a QI work plan that outlines specific clinical and service-related improvement activities using the National Committee for Quality Assurance (NCQA) Standards and Guidelines as a framework. Data are collected and analyzed for each clinical and service-related improvement activity throughout the year. Work groups then study improvement barriers and develop targeted interventions to help us achieve our established goals. Here are some examples of our interventions:
- To improve childhood immunization rates, we mail a series of age-specific letters to educate parents and remind them about the immunizations due for their child.
- To improve breast and cervical cancer screening in women, we mail age-appropriate birthday cards to women that encourage appropriate screenings for women’s health.
- To promote preventive services among adult male members we mail age-appropriate brochures to men promoting blood pressure testing and control, cholesterol testing and control, colon cancer screening (50 years and older) and pneumonia vaccine (50 years and older).
Categories of measures our quality improvement plan used to analyze data are:
- Use of preventive services
- Compliance with clinical practice guidelines
- Continuity and coordination of care between medical and behavioral health care
- Effectiveness of disease management programs
- Patient safety in all aspects of clinical care
- Response to increasingly diverse populations’ health care needs
- Availability of practitioners and access to care
- Potential over- and under-utilization of care
- Member and provider satisfaction
For more information about the QI Program and how we meet our goals, call 410-528-7997 or 800-323-4472.
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Be Sure Your Practice is Teen-Friendly
Habits formed early in life can lead to good health or to chronic health problems. That’s why it is essential to develop a good relationship with your teen patients. Here are some tips on how to make your practice more teen friendly.
- Stress the importance of preventive care.
- Inform your staff that in Maryland, Virginia and Washington, DC teens are authorized to consent on their own for:
- contraceptive services
- prenatal care
- STI/HIV services
- alcohol and/or drug abuse treatment
- outpatient mental health services, if 16 or older in Maryland
- Encourage teens to involve their families in health decisions, but guarantee confidentiality.
- Maintain information on other health, social and educational programs that meet the physical and mental health needs of teens.
- Have teen magazines and teen-related brochures on display in your waiting room.
- Always look for opportunities to emphasize the need for teens to make healthy choices.
Helping teens become comfortable in your office can reduce risky behaviors and help teens make healthy decisions that help prevent chronic health problems.
CareFirst is providing financial support for a training program to assist your practice in becoming more teen-friendly, being offered by the DC Campaign to Prevent Teen Pregnancy this summer. Call the DC Campaign to Prevent Teen Pregnancy at 202-789-4666 extension 18 for more information about available training.
Source: DC Campaign to Prevent Teen Pregnancy. (July 2003) Not Yet Adults: A Manual of Adolescent Health Care for District of Columbia Providers.
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New CDC Treatment Guidelines on STDs Now Available
The DC Medical Society and the DC Division of Sexually Transmitted Disease (STD) Control Program have made the “Summary of Centers for Disease Control and Prevention 2002 Sexually Transmitted Diseases Treatment Guidelines” available online at www.cdc.gov/STD/treatment/. Call 202-466-1800, ext. 116 to obtain a hard copy of the guidelines. Assembled by a team of professionals knowledgeable in the field of STDs, the report is an update to the 1998 guidelines.
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Talk to Authors of Peer-Reviewed Articles
To help apply the results of published studies into clinical practice, the Journal of the American Medical Association and the Institute for Healthcare Improvement are testing a program in which readers can talk directly to authors of peer-reviewed articles. The program, called Author in the Room, allows readers to participate in a conference call to discuss a selected article and to ask the author questions. Articles containing evidence-based ideas that can be put into practice are selected every month.
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