The following is presented in an effort to highlight hospital “best practice” around the region. CareFirst BlueCross BlueShield (CareFirst) wants to share with you the innovative ways in which D.C., Maryland and Virginia hospitals are improving quality of care while controlling the rising cost of health care. Look for additional “best practice” features in future issues of HealthInk.

As one of Maryland’s most highly regarded orthopedic hospitals, St. Joseph Medical Center has created a niche for itself as the highest-rated knee and hip replacement program in the Baltimore area¹ and the second-most sought after program in the state.

When St. Joseph put its case management program in place more than eight years ago, pathways for total hip and knee joint replacements were the first care management pathways to be designed and implemented. Because the total hip and knee replacement population generally has a high volume of diagnostically related groups (DRGs), St. Joseph decided that these patients presented the best chance of benefiting from care pathways. With the input of a multidisciplinary team, pathways for both knee and hip replacements were developed. At that time, the target length of stay was five days.

In 1998, St. Joseph, seeing a need to create efficiencies, put together a clinical resource team for each of its service lines. Each team identified its service line’s top five DRGs based on high volume, high cost and high risk. The surgical clinical resource team reviewed hospital data along with current literature to identify joint replacement best practice. The knee and hip replacement pathways were revised based on the team’s findings and have been in use since April 1999. The target length of stay is now three days.

The main goals of the St. Joseph total hip and knee replacement pathways are:

• To educate the patient with knowledge and understanding of the procedure and what to expect.
• To manage pain. St. Joseph recognizes how pain and discomfort can affect a patient’s progress during their procedure and recovery.
• To facilitate mobility on the first post-operative day. The day after their surgery, joint replacement patients at St. Joseph are out of bed and going to physical therapy (located on the same floor).
• To discharge the patient on the third post-operative day. The appropriate next level of care is determined for each patient. This might be a stay in the transitional care unit within the hospital, a transfer to another rehab facility or home care.

To help meet these goals, St. Joseph has instituted interdisciplinary rounds for the knee and hip pathways, as well as all others. Team rounds help identify the full spectrum of a patient’s needs and facilitate a multidisciplinary discussion on how those needs can be met. The team meets three more times a week to focus on clinical, psychosocial and educational issues that may delay progress.

“At St. Joseph, we believe that all disciplines must come to the table to identify appropriate changes in a patient’s plan of care,” says Teresa Kessell, Outcomes Management Coordinator. “We apply this thinking to our ongoing efforts to cut costs and improve quality of care. Most of all, we believe that to be a center of excellence, we must monitor patient outcomes. Our pathways help us do this by setting a standard to measure against.”

St. Joseph pathway teams often step back for an overall perspective to ensure that each patient is legitimately “on a pathway.” For example, physician order sets are monitored to make sure they match pathway design.

The multidisciplinary pathway team continuously reviews data to monitor trends, supply costs, system barriers, etc.

Utilization has been reduced in many areas thanks to the time and resources St. Joseph Medical Center invests in monitoring and trending resource utilization and outcomes. As the team reviews overall practice, it examines antibiotics utilization, operating room supplies, prosthesis costs, utilization of continuous passive motion machines, availability of physical therapy and other aspects of care.

“The physical therapy (PT) unit is a good example of the dividends that come from collecting and analyzing data,” Ms. Kessell says. “Through data review, the team discovered that it would be very cost-effective to have a satellite PT area close to the orthopedic unit and that it should have improved weekend access. This has decreased missed and delayed treatments.”

In the year and a half since the implementation of new total knee and hip replacement pathways, the length of stay for these procedures at St. Joseph has been reduced from five days to 3.2 days.

Ms. Kessell relates another perspective on how using pathways improves patient care at St. Joseph. “Besides being a means of educating new staff about how to care for a particular population, standard care pathways establish an expectation of excellence for all St. Joseph caregivers.”

¹ As rated by Healthcare Report Cards

If you consider it important to affiliate with only the best health plans in the area, consider this: FreeState Health Plan has been awarded the National Committee for Quality Assurance’s (NCQA) highest accreditation status.

FreeState Health Plan earned NCQA’s "Excellent" accreditation status following a rigorous and voluntary review process. This status is granted for a period of three years to those plans that have excellent programs for continuous quality improvement and meet or exceed NCQA’s exacting standards.

FreeState would like to thank the physicians’ offices that participated in NCQA’s medical record reviews, quality studies and interviews for sharing our commitment to quality care.

NCQA is an independent, not-for-profit organization dedicated to assessing and reporting on the quality of managed care plans. Its mission is to provide information that enables purchasers and consumers of managed health care to make informed decisions based on objective quality data. The various standards and performance measures that make up NCQA’s Accreditation program fall into the following six categories:

• Quality Improvement
• Utilization Management
• Physician Credentialing
• Members’ Rights and Responsibilities
• Preventive Health Services
• Medical Records

FreeState’s recognition isn’t new. In 1998, FreeState Health plan achieved Full Accreditation status under NCQA’s then newly implemented stricter guidelines.

By Simeon Margolis, M.D., Professor of Medicine and Biological Chemistry, Johns Hopkins University School of Medicine

Overwhelming evidence has shown that improved control of blood glucose can prevent or delay the development of diabetic retinopathy, nephropathy and peripheral neuropathy in both type 1 and type 2 diabetes. Yet blood glucose levels (as determined by measurements of glycohemoglobin) remain unacceptably high in many patients treated for diabetes. This situation is particularly discouraging now that we have so many effective agents to treat diabetes.

I vividly remember a self-referred, 69-year-old man with a nine-year history of diabetes whose hemoglobin A1c was 10.9 despite taking a total of 50 units of insulin. He had been well-controlled on small doses of glyburide and metformin (Glucophage) until he had an injection of triamcinolone for a herniated disk several months earlier. He was started on insulin, but his diabetes remained poorly controlled. He was not overweight, followed a good diet and had no evident late complications of diabetes.

Because he was eager to go back to oral agents, I started him on glyburide, 10 mg daily, and metformin, 500 mg with breakfast and dinner. He was instructed to increase the metformin dose to 1 g twice daily if he had no side effects from the drug. He responded well, and during four years of follow-up, his hemoglobin A1c has never exceeded 7.6. His urinary microalbumin, which had not been tested previously, was elevated and he was started on an ACE inhibitor.

It is not clear whether a residual effect of the steroid injection caused the deterioration of his glucose control, or why he responded so poorly to insulin. He does illustrate, however, that most patients with type 2 diabetes can be controlled with oral agents — at least initially — unless their fasting glucose is extremely high, say, greater than 300 mg/dL. Even then, a short period on insulin may lower blood glucose enough to overcome glucose toxicity (poor release of insulin by beta cells due to the high glucose values) and to allow patients to be controlled with oral agents.

Most newly diagnosed type 2 diabetics should be started on an oral agent. My first choice now is metformin, especially in obese patients, unless they are at increased risk for lactic acidosis due to renal or liver disease, congestive heart failure or severe peripheral vascular disease, or unless they drink alcohol heavily. Liver function and creatinine should be checked first.

Metformin’s advantages over sulfonylureas include less weight gain and fewer instances of hypoglycemia. Should full doses of metformin fail to achieve adequate results, or if intestinal side effects are intolerable, I would then add or substitute a sulfonylurea. It is important to remember how often the sulfonylureas cause hypoglycemia and that switching from metformin to a sulfonylurea, or vice versa, is unlikely to improve glucose control. Instead, either a sulfonylurea or metformin must be added to the other agent.

The Food and Drug Administration recently approved Glucovance tablets, which contain a combination of glyburide and metformin. Glucovance is less expensive and more convenient than taking metformin and a sulfonylurea separately. When a patient presently on both a sulfonylurea and metformin is switched to Glucovance, the starting dose should not exceed the daily dose of metformin and the equivalent dose of the sulfonylurea already being taken.

If hemoglobin A1c levels remain high despite acceptable fasting glucose levels, the patient may have large postprandial increases in glucose that might be improved with repaglinide (Prandin) or acarbose (Precose) with meals. Repaglinide is generally well tolerated; it stimulates insulin release for a short period and is less likely than sulfonylureas to cause hypoglycemia. Acarbose also is an effective drug worth trying, but many patients discontinue it because of flatulence.

The two newest agents for the treatment of type 2 diabetes are rosiglitazone (Avandia) and pioglitazone (Actos). Rosiglitazone is approved as a monotherapy or in combination with metformin; pioglitazone is approved as a monotherapy or in combination with metformin, a sulfonylurea or insulin. Liver function tests must be done before starting either drug and then periodically during follow-up. Since type 2 diabetes gets worse over time, it is often necessary to increase the dose of a single drug, add a second or third oral agent, or begin treatment with insulin, even in patients initially controlled with a single medication.

Medications are by no means the only way to treat type 2 diabetes. Effort must be made by the patient to lose or control weight by combining dietary measures with exercise. The recommended diet, by the way, is the same as the one recommended by the American Heart Association — low in total and saturated fat and cholesterol — to lessen the risk of cardiovascular disease. Instructions should be given for meticulous foot care, and feet should be examined on every visit. Persons with type 2 diabetes should see an ophthalmologist upon diagnosis and at least once annually thereafter. Microalbumin should be tested and an ACE inhibitor started when levels exceed the upper limits of normal.

The Diabetes Disease Management Program

Our diabetes disease management program is available to FreeState Health Plan, CapitalCare and Maryland region indemnity members. Members who have diabetes receive regular bulletins on diabetes control that contain useful tips and promote self-care. Call or have your patients call the Health Education Department at 410-528-7997 or 800-323-4472 to ensure they they are on our mailing list.

Diabetes patients who need intense services and coordination of care may be eligible for case management. These services are available to FreeState, CapitalCare and Maryland indemnity members (barring contract exclusions). Call 410-605-2413 or 888-264-8648 to arrange case management for Maryland region and FreeState members; call the number for precertification on the back of the member’s ID card to refer CapitalCare members.

Managing diabetes requires a team approach. You, the practitioner, are central to helping patients control their diabetes and preventing long-term complications. Have you thought about teaming up with a Certified Diabetes Educator (CDE)? These health care professionals work with individuals with diabetes to develop self-management guidelines based on the plan of care outlined by you. Because their clinical knowledge about diabetes includes areas such as medications, psychosocial issues, nutrition, educational principles, pathophysiology, exercise and glucose pattern management, they can facilitate an individualized approach for your patients that will help them develop the skills and attitudes they need to lead independent and fulfilling lives.

CDEs are nurses, dietitians and other health care professionals who have met rigorous requirements to take a special certification examination given by the National Certification Board of Diabetes Educators. Preparation constitutes both academic and clinical experience. In order to maintain CDE status, a diabetes professional must retake the examination every five years.

CDEs can be found in many communities throughout the United States. The American Association of Diabetes Educators maintains a listing of CDEs on its Web site at www.aadenet.org. To obtain a list of diabetes self-management education programs recognized by the American Diabetes Association, log on to www.diabetes.org. Contact your provider representative or team for more information on how to set up CDE services for your CareFirst, FreeState or CapitalCare patients.

By Kevin Scott Ferentz, M.D., Associate Professor, The University of Maryland School of Medicine and Residency Director, Department of Family Medicine

Major depression is the single most prevalent psychiatric diagnosis seen by the primary care physician. Approximately 10 percent of the population meet criteria for major depression each year, and almost one in five people will experience clinical depression at some point in their lives. Every primary care physician must be skilled in its recognition and treatment. It also is important for physicians to have appropriate references to help them in this area. I strongly suggest that physicians obtain a copy of the Primary Care Version of the DSM-IV to help them in making accurate diagnoses of psychiatric illness.

Despite its prevalence, depression remains underdiagnosed and undertreated. One reason for this is that patients often do not complain of depressed mood, nor is depressed mood a requirement to make the diagnosis (see chart, above right, for diagnostic criteria for major depression). Depression occurs in all age groups and in both sexes but is seen twice as often in women, especially those in their child-bearing years (18–44). A family history of depression doubles the risk in the individual.

A mnemonic device that can help remind a clinician to use the criteria is SIG.E.CAPS. You can remember the mnemonic by thinking that when you see a patient that looks depressed you might want to give them “energy capsules” — your “sig” for a prescription.

In primary care practice, patients with depression often present with somatic complaints as their “ticket” into our offices. Patients who present with issues like chronic pain (headaches, backache, chronic abdominal or pelvic pain), sleep disturbance or vague symptoms should trigger a high index of suspicion in the primary care physician. Patients with depression will often complain of anxiety as their chief psychiatric symptom. When you hear “anxiety,” think depression and ask about anhedonia (loss of pleasure), suicidal ideation and other common symptoms of depression (see criteria above). One also should consider depression and anxiety disorders in patients that are abusing drugs and alcohol. They may be using these substances to self-medicate their psychiatric problem.

There is a short list of differential diagnoses to consider when seeing a patient with depressive symptoms.

• Hypothyroidism can mimic some of the symptoms of depression, but depression does not usually cause constipation, hair and skin changes, etc. If these and other stigmata of hypothyroidism are present, a screening TSH (thyrotropin) may be advisable.
• Certain medications, such as Aldomet, propranolol and other antihypertensives, can cause depressive symptoms.
• Bereavement is a mood disturbance that occurs when symptoms of depression begin after the death of a loved one. In these patients, major depression usually should not be diagnosed unless the symptoms persist beyond two months after the death.
• Patients also may experience mild symptoms of depression after a major life event — so-called “adjustment disorder.”

Bereavement and adjustment disorder are not treated with antidepressants but rather with supportive psychotherapy.

Depression usually develops over days to weeks. Left untreated, an episode of depression lasts approximately six months, with the majority of patients having their symptoms remit spontaneously. Approximately 20 percent to 30 percent of patients will experience only partial remission, and some 5 percent to 10 percent will not improve at all without treatment. A “wait and see” attitude is never advocated for patients with depression, as untreated patients are at greatly increased risk of suicide — not to mention that they feel terrible. In addition, depression must be considered a recurring disorder. One-half of patients will have another episode after their first, and usually within five years. After three episodes, the risk of recurrence is greater than 90 percent.

The cornerstone of depression treatment is antidepressant medication. While all antidepressants are equally effective, each drug has certain advantages and disadvantages (see table on page 8). Approximately 70 percent of patients will respond to the first antidepressant selected. Physicians should therefore select an antidepressant based on side-effect profiles. It also is reasonable to select an antidepressant based on how the patient or a family member has responded to it in the past. The following is a brief synopsis of the various antidepressants available.

Selective Serotonin Reuptake Inhibitors (SSRIs)

There are currently four SSRIs indicated for depression: citalopram (Celexa), fluoxetine (Prozac), paroxetine (Paxil) and sertraline (Zoloft). They also are effective anxiolytics, although they are indicated for different anxiety disorders. All have nuisance side effects, such as nausea and headache, which dissipate quickly and rarely cause patients to stop taking the medication. They all cause sexual side effects in approximately 40 percent of patients, particularly difficulty obtaining orgasm. While beneficial in patients with premature ejaculation, this side effect is troublesome in most patients. Adding bupropion (Wellbutrin) to the SSRI can often reverse the sexual difficulty. Other agents also have been used with varying success, including yohimbine, methylphenidate (Ritalin), buspirone (Buspar) and cyproheptadine (Periactin).

Bupropion (Wellbutrin)

Many physicians have had experience with this drug as the smoking cessation aid Zyban. Bupropion has several unique qualities, including a total lack of sedative effect. Some patients may actually have difficulty sleeping using this product, although it is usually not a problem when the second dose is taken at least 4–5 hours before sleep. Bupropion does not cause sexual side effects and can even reverse SSRI-induced orgasmic dysfunction (refer to section on SSRIs). One should not use this drug in patients with seizure disorder or those with a history of eating disorders who seem to be at increased risk for seizures while on bupropion.

Tricyclic antidepressants (TCAs)

Tricyclics were once the mainstay of treatment. Given their poor side-effect profile and the potential for lethality, they should now be reserved for patients that do not respond to any of the newer medications. Only 10 days’ worth of a therapeutic dose is enough to cause death. They also cause numerous significant side effects, including dry mouth, sedation, weight gain, constipation, urinary retention and many others. If one must use a TCA, it is preferable to use the secondary amines — nortriptyline (Pamelor) and desipramine (Norpramin) — over the older tertiary amines, such as imipramine (Tofranil) and amitriptyline (Elavil).

Venlafaxine (EffexorXR)

This drug appears to be more serotonergic at lower doses and have more norepinephrine activity at higher doses. GI disturbance and elevated blood pressure are less problematic in the extended release formulation than they were in the immediate release. Patients may respond to doses up to 375 mg per day.

Trazodone (Desyrel)

Sedative effects limit the usefulness of trazodone as a treatment for depression. It can be used in small doses (50-100 mg) as a hypnotic agent at bedtime. Priapism is a rare side effect.

Nefazodone (Serzone)

Nefazodone is not nearly as sedating as trazodone. When given in higher doses it may be beneficial to splint the dose unevenly, i.e., give the larger portion at bedtime. Nefazodone does not cause sexual dysfunction. It is the one antidepressant that is metabolized extensively throughout the cytochrome P450 3A4 system. When given with another 3A4 drug it may precipitate torsades de pointes, a rare form of ventricular arrhythmia which can result in cardiac arrest and death.

Mirtazapine (Remeron)

This agent causes significant sedation and weight gain. It is an effective anxiolytic.

Patient follow-up

Patients in the Acute Phase of treatment should be seen within a few weeks of starting an antidepressant to assess side effects and efficacy. If there is no response at all by four weeks, the dose of the medication should be increased.

If there is no improvement by six weeks, the medication generally should be changed. At each visit, patients should be asked about the symptoms they initially presented with. The dosage of medication should be increased until the symptoms have completely resolved. Once the patient feels “back to normal,” they enter the Continuation Phase of treatment and should remain on medication for another six to nine months. Some patients, especially those that have experienced three or more depressive episodes, require Maintenance treatment to prevent future episodes of depression. Antidepressant medication should be continued until the patient wishes to stop. At that time it should be slowly tapered. Patients with recurring episodes of depression will almost always benefit from psychotherapy as well.

*Consult the appropriate formulary before prescribing any of these drugs to your CareFirst, FreeState or CapitalCare patients. The generic and brand name drugs included on these formularies carry lower member copayments than do non-formulary brand name drugs. The drugs that appear in red are non-formulary.

CareFirst recently made a grant in the amount of $100,000 to help establish a dental clinic on Maryland’s Eastern Shore in Federalsburg. The grant will be administered through the Maryland Health Care Foundation and is designated for the Choptank Community Health System, which is building the dental facility as part of a primary health care center.

This center will serve thousands of adults and children on the mid- and upper-Eastern Shore who have inadequate access to oral health care. Since dental decay is the most prevalent chronic disease in children, Choptank Community Health System has prioritized improving dental care access to children in its service area.

Persons over 65 are considered at high risk for influenza and have been given priority consideration status for the flu vaccine by the Advisory Committee on Immunization Practices for the 2000-2001 season.

Some patients harbor fears and misconceptions about the vaccine’s potential to cause the flu. To help put these concerns in check, FreeState Health Plan has mailed members 65 and older a Shots Aren’t Just for Kids postcard that offers educational information on the vaccine. It reinforces that they can’t get the flu from the vaccine and reminds members to tell their doctor if they’ve obtained a flu shot elsewhere so their medical record can be updated.

Be sure to recommend a flu shot for your patients over 65. A good overview of the flu vaccine’s recommendations, efficacy and side effects is available at www.cdc.gov/ncidod/diseases/flu/fluvac.htm.

• Do your patients know how to use their medicines for a flare-up?
• Do they really know the difference between their inhalers and what they are for?
• Do you ask them to bring in all their medication containers for their office visits?
• Do they have an asthma action plan you’ve helped them fill out?
• Are those patients who need them on anti-inflammatory medication?
• Have you watched your patients use an inhaler to see if they use them correctly?
• Do they know that they should be using their controller medications every day?
• Do they check their peak flows and know how to use them to guide their home treatment?
• Do you really know if they have made an effort to modify those environmental triggers that can be changed?
• Do they want and need more education?
• Do you have enough time to explain as well as you would like?
• Are your patients enrolled in CareFirst’s asthma disease management program? (To enroll your patients, call CareFirst Health Education at 410-528-7997 or 800-323-4472.)

We’d like to hear from you on your practice tips for treating patients with asthma so that we can share them with your colleagues. Please send them to:

CareFirst Health Education, BALT-74
100 South Charles Street, Tower II
Baltimore, MD 21201

The Maryland Health Care Commission (MHCC) recently released its annual guide for consumers on the performance of 15 Maryland HMOs. The MHCC report card rates each Maryland HMO on how frequently members obtain preventive and wellness services, whether members are satisfied with the health care they receive and how customers feel about their health plan.

Report card results are based on the Consumer Assessment of Health Plans Survey (CAHPS) and clinical data from Health Plan Employer Data Information Set (HEDIS) audits. Results for FreeState Health Plan and CapitalCare, CareFirst’s subsidiary HMOs, are shown here. The entire report card is published by the MHCC in Comparing the Quality of Maryland HMOs 2000: A Guide for Consumers (available at www.mhcc.state.md.us or by calling the Commission at 877-245-1762).

Overall, the results reflect that members continue to be satisfied with the services provided by FreeState Health Plan and CapitalCare. FreeState Health Plan demonstrated above average performance in categories charting childhood immunizations, comprehensive diabetes care and antidepressant medication management. CapitalCare’s performance was rated above average in member complaints, well-child visits for infants and children, and prenatal care for pregnant women.

FreeState Health Plan was named “Star Performer” in the MHCC’s 2000 report for better-than-average performance over several years in delivery of childhood immunizations. FreeState’s immunization rate for 2-year-olds in its commercial population increased by almost 40 percent to 77 percent of these children receiving recommended vaccines (second place among the Maryland HMOs rated), and FreeState’s commercial adolescent immunization rate increased dramatically to reach 17 percent. The adolescent immunization rate among FreeState’s Medicaid population also has risen considerably to more than 14 percent of Medicaid adolescents receiving recommended vaccines. These significant improvements are attributable to FreeState’s successful childhood and adolescent immunization tracking system and your attention to this aspect of preventive care.

CapitalCare continues to demonstrate steady improvement in the area of childhood and adolescent immunizations. CapitalCare’s childhood immunization rate improved by close to 30 percent to more than 50 percent of children receiving recommended vaccines, and adolescent immunizations rose 86 percent to reach 13.5 percent.

The National Committee for Quality Assurance (NCQA) also publishes HEDIS results and compares many HMOs on a national and regional basis in The State of Managed Care Quality 2000, available at www.ncqa.org.

2000 MHCC Report Card
Measures of Clinical Performance	CapitalCare	FreeState
Childhood immunizations
Adolescent immunizations
Well-child visits for infants/children		-----
Well-care visits for adolescents
Prenatal care for pregnant women
Check-ups for new moms after delivery
Screening for breast cancer
Screening for cervical cancer
Comprehensive diabetes care — blood glucose testing
Comprehensive diabetes care — eye exam
Comprehensive diabetes care — lipid profile
Screening for high cholesterol	------
Beta blocker treatment after a heart attack	------
Controlling high blood pressure
Use of appropriate medications for asthmatics
Antidepressant medication management
Follow-up after mental health hospitalization
Measures of Customer Satisfaction	CapitalCare	FreeState
Overall satisfaction with health plan
Overall satisfaction with health care
Getting needed care was not a problem
Getting care quickly was not a problem
How often doctors communicated well
Satisfaction with health plan customer service
Helpfulness of coverage information
Few customer complaints
Above Average Average Below Average — Indicates data was unavailable or not reported

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 quality of their services and the satisfaction of their patients. 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 comprehensive care for acute and chronic illness, as well as preventive care — in the hospital, at the doctor’s office and at home.

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 health status, medical conditions and treatment options.

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 comprehensive care, reducing the risks of illness and helping to treat small problems before they can become more severe.

We believe that access to affordable, comprehensive care gives consumers the value they expect and contributes to the peace of mind that is essential to good health.

Adapted from the American Association of Health Plans.

CareFirst’s Mission

CareFirst shall be the leading regional health care company recognized for a comprehensive portfolio of high-quality, innovative products and administrative services. Our purpose is to provide the best value to our customers in partnership with the health care community and in an environment that promotes respect, fairness and opportunity for our associates.

Reducing or eliminating heartburn symptoms, including breakthrough symptoms, is a key factor in improving the quality of life for patients with GERD (gastroesophageal reflux disease). Although proton pump inhibitors (PPIs) provide effective relief for many patients with GERD, some patients find they experience what has become known as “nocturnal acid breakthrough” or “occasional acid breakthrough” (OAB).

Current information indicates that many providers are not aware of this phenomenon. A recent survey of 543 adults currently taking a prescription antisecretory medication found that 52 percent used OTC acid relief products as rescue medication for OAB. Of the patients who supplemented their prescription regimen:

• 85 percent had used both a prescription and an OTC medication within the past four weeks.
• 61 percent stated they wake up with heartburn or stomach symptoms.
• 43 percent associated their symptoms with the ingestion of food and beverages.

So while it’s evident that OAB is a common occurrence, even in patients receiving PPI, many patients don’t tell their physician about the problem — and their physician may not be asking.

Once aware of a patient’s breakthrough symptoms, some physicians opt to prescribe the PPI twice a day or double the dose. Both of these approaches double the cost of the patient’s medication. Other physicians switch the patient from one PPI to another. This strategy imparts only a class effect and often results in the patient having to pay an additional drug and/or office visit copayment and wastes the remainder of the previous prescription.

Several strategies can reduce the symptoms of OAB. As a first approach, it is important to reinforce the value of lifestyle modifications (very often GERD can be controlled this way). Although not as immediately effective as acid-suppressing drug treatment, lifestyle changes can make an important contribution to symptomatic relief and have been shown to enhance the benefit of drug therapy.

Recommended lifestyle changes include not eating three hours prior to bed (particularly fatty foods and alcohol); avoiding foods that decrease lower esophageal sphincter pressure (e.g., chocolate and carminatives such as peppermint and spearmint); avoiding foods that are direct mucosal irritants (such as orange juice, tomato juice and coffee); quitting smoking; reducing bodyweight to normal; and raising the head of one’s bed with eight-inch blocks. These changes cost nothing but can improve a patient’s quality of life.

Advise your patients to use antacids for immediate relief (but not with their PPI). Don’t double the dose or frequency of PPI dosing, which is expensive and unnecessary. Instead, advise patients to use OTC H2-blockers HS, which are effective and cost-efficient as well. Several studies have compared various strategies in patients taking once-daily and twice-daily PPIs. In patients taking a once-daily PPI, adding an OTC H2-receptor at night has been shown to be as effective as adding a second evening dose of the PPI. Addition of an OTC H2-receptor antagonist should be considered a cost-effective adjunctive therapy for patients who develop OAB on once- or twice-daily PPI therapy. With their faster onset of action, PRN OTC H2-receptor antagonists may be particularly appropriate in patients who experience only episodic symptoms.