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Wednesday, January 14, 2004

Drug Rep Tales #2 

The rep from AstraZeneca was in yesterday.
She said "the FDA allows me to say Atacand is superior to Cozaar".
Wow, it's not every day that drugs are compared to each other.
Apparently, it requires the submission of two articles before such statements are allowed. She tells me the "CLAIM Studies" prove this. I say "what is the primary endpoint"?

She says, "I don't know".

Later, the study (J Clin Hypertens. 2001;3:16-21) gets dropped off at my office.
It is called: Antihypertensive Efficacy of Candesartan in Comparison to Losartan: The CLAIM Study.

I read the article for validity:
1. Double-blind, randomized, parallel-group, forced titration. So far so good.
2. Used intent to treat. Another plus.
3. The sponsors are reputable medical programs but include the drug company. Not automatically bad but does raise suspicion.
4. Patients matched? Seems OK to me.
5. The outcomes are mean trough BP, mean peak BP, and mean 48 hours after last dose at 8 weeks.
6. Adverse effects are noted and similar.

The absolute BP differences are:
1. Trough systolic 3 mm and diastolic 2 mm
2. Peak systolic 2 mm and diastolic 1 mm
3. Post 48 hour dose systolic 5 mm and diastolic 3 mm

This is an example where the p values are significant but the effect isn't important.
Also, the outcome has the typical POEM vs. DOE problem.

Give the People What They Want 

The American Academy of Family Physicians this week e-mail newsletter has this link Health Affairs -- Abstracts: Levit et al. 23 (1): 147.
They say: "U.S. health care spending climbed to $1.6 trillion in 2002, or $5,440 per person. Health spending rose 8.5 percent in 2001 and 9.3 percent in 2002...".
The abstract points out hospital costs account for 1/3 of the rise. Also, the rise is due to consumers desire for "more loosely managed care".

Doctors and patients need to share in the blame.

Tuesday, January 13, 2004

Survey Says 

Got the results of my HMO access audit.
I passed. No surprise here since I'm on Same-Day Appointments.

The HMO Appointment Standards are (my italics for examples):
1. Emergency ("life or limb") = immediate
2. Urgent ("sick people") = same day or < 24 hours
3. Routine ("chronic illness") = within 7 calendar days
4. Preventive ("wellness") = within 42 calendar days

What I struggle with is:
1. Specialty care access is listed only under item #3. The HMO's own definition of Routine Care = "symptomatic condition that is medically stable. Yet, specialists get a lower standard = within 14 calendar days. Is there no other kind of specialty care? Many of my in network options can't even meet a one month standard.
2. Their examples of Preventive are well-woman exams and well-baby exams. In spite of the generous access standard here, many of my patients describe Pap smear waits of 3 months (never mind that I can do those here, that's another post). In addition, consider newborns at 0, 2, 4, and 6 months. Hmmm, four office visits within six months. As they say..."do the math".
3. For non-well-woman and non-well-baby care I can meet the Clinical Preventive Services for Normal-Risk Adults Recommended by the U.S. Preventive Services Task Force expectations in the context of other visits, making the dedicated appointment for a "physical" moot. On days I'm running on time or early, I often capture the wellness items even if that isn't why they came in.

A Modest Proposal #1 

Recall the English physician guilty of murdering patients CNN.com - Britain's 'Dr. Death' found hanged - Jan. 13, 2004.

The story goes on to say:
LONDON, England (CNN) -- Serial killer Harold Shipman, known as "Dr. Death," has been found dead in his prison cell in northern England, officials say...In July 2003, an inquiry found that Shipman murdered at least 215 patients, mainly elderly women.

But the part I noticed was:
Although his motive for the killings was not entirely clear, the report concluded that Shipman began ending the lives of terminally ill patients and then moved on to patients that he found annoying or uncooperative.

I wonder if this information would enhance patient compliance?

Monday, January 12, 2004

The Placebo Effect 

A fascinating link LRB | Carl Elliott : Scrivener's Palsy got me thinking a lot. I plan to read some of the books and post later.

Stupid Specialist Tricks # 1 

I was covering for an associate. His medical assistant told me their patient needed medical clearance before an elective surgery the next day.
I found out after 1 PM and was already seeing patients.
We told the surgeon's office I would be happy to review the record and make a decision at the end of the day.
The surgeon instead called me during a busy time and I was pulled from a room to review everything and clear the patient.
Even that wasn't good enough because he also needed a letter that day faxed over.

Recall the saying "a lack of planning on your part does not make it an emergency on my part".
The patient didn't do anything wrong so I did it.

My associate uses that surgeon more than I do.
I plan to use him less.
I doubt he will figure it out.

Friday, January 09, 2004

Medical Meme #3 Continued 

Not satisfied with yesterday's post, I was able to find an even better answer.
Body weight and risk of oral contraceptive failure makes more sense to me than antibiotic use.

Thursday, January 08, 2004

Medical Meme #3 Antibiotics and Oral Contraceptives 

This comes up a lot and I've often wondered about the evidence.
I was reading the Dec 24, 2003 post from code blog: tales of a nurse and saw the issue again.

Turns out, this is an example of using surrogate markers instead of clinical outcomes.
While antibiotics can alter hormone levels the rate of unintended pregnancy isn't influenced according to Arch Fam Med -- Burroughs and Chambliss 9 (1): 81.

Since the effectiveness of the birth control pill isn't 100%, the apparent antibiotic caused pregnancies are more likely the combination of low but predictable failure and our "six degrees of separation".

Monday, January 05, 2004

The Mail Bag 

I get a lot of mail. Most of it is unsolicited. I got to wondering how much are we really talking about? So, I saved one month's (December 2003) worth.

Here are the totals:
1. Throwaway journals = 18 pounds
2. Drug company ads = 8 pounds
3. Disease management/practice guidelines = 4 pounds
4. Real journals = 5 pounds
5. Surveys = 2 1/2 pounds
6. CME invitations that were not overtly drug company sponsored = 1 pound.

Total (not including time sensitive stuff like consult letters, etc.) = 38.5 pounds.

Interestingly, the top two categories are the least important to me and make up 68% of the total.


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