QD: News Every Day

ACP Internist's daily digest of primary care in the news continues with sudden coherence on Obamacare, prescription med fatalities and the trend of falling patient volume and procedures during the recession.

Health care reform
Overnight, Democrats and moderates in the Senate Finance Committee agreed to $400 billion in federal subsidies to defray premium costs for lower-income families and help small businesses offer coverage to their workers. Amendments will seek to let the states form their own public options and make health care affordable. But the compromise doesn't offer a permanent fix for the Sustainable Growth Rate. It could hurt physicians who are the biggest users and discourage them from taking on patients. And it still needs to merge with other bills.

If you're unclear which health care reform bill is which, the San Francisco Chronicle explains them.

In case you missed it:
Drug overdoses, mostly from prescription meds, overtook traffic accidents as the leading cause of death in some states.

The Robert Wood Johnson Foundation warns that not passing health care reform could hurt the states most of all.

Revenue in medical practices declined in 2008, possibly tied to smaller patient volumes and increasing bad debt due to patient financial hardship.

According to the "MGMA Cost Survey: 2009 Reports Based on 2008 Data," multispecialty group practices saw a 1.9% decrease in total medical revenue in 2008. (MGMA captures data on both multispecialty groups and single-specialty practices, but uses multispecialty data as a proxy for overall trends.)

Procedure volume fell 9.9% and patient volume shrunk 11.3% from 2006 to 2008. And bad debt in multispecialty group practices from fee-for-service charges increased 13% from 2006 to 2008, suggesting that patients may be having a harder time paying their medical bills.

In 2008, multispecialty practices cut overhead expenses 1.4%, largely by cutting support staff costs by 1.5%--the first decline in several years. Support staff make up 32% of medical practice expenses. While medical groups reduced support staff costs, their total worker count remained constant, indicating that employees may have gone without raises and bonuses or perhaps even suffered pay cuts.

Revenue by specialty:

Labels: drugs, health care reform, practice management, QD, recession

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posted by Ryan DuBosar at 12:29 PM   0 Comments

'Robo-pills' boost Rx compliance

Novartis is testing microchips embedded in prescription drugs to remind patients to take their medicines.

A receiver on the patient's shoulder picks up the signal. If the patient forgets, the chips sends patients a text message.

20 patients using valsartan (Diovan) increased compliance from 30% to 80% after six months, reported the Financial Times.

It adds new meaning to the term "telemedicine."

Labels: drug companies, drugs, medication, medication adherence

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posted by Ryan DuBosar at 12:01 PM   0 Comments

What did Obama mean?

Obama's nod to malpractice reform got Republicans on their feet the other night, but he was wisely vague about his specific intentions. A Washington Post article helpfully explains what the administration's approach to malpractice reform would likely really entail. As with the whole overall, the current plan sounds like it's along the lines of what he talked about during the campaign. Gets points for consistency, at the very least.

And, to compensate, some light reading for a gloomy (at least here in Philly) Friday afternoon--a CDC report of preschool teachers accidentally eating brownies spiked with pot. A couple of notes: First, California's medicinal marijuana laws must have made the drug awfully easy to come by that magic brownies are now selling on the street for $1.50. Second, one of the teachers went to the hospital and was treated with antibiotics. I'm no doctor but I'm pretty sure "being sky high" is an off-label use for any antibiotic.

Labels: drugs, health care reform, malpractice

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posted by Stacey Butterfield at 2:23 PM   1 Comments

Paging Dr. Big Brother

Patients who fail to take their medications properly suffer unnecessary complications, raise health care costs and drive their physicians nuts. We've written articles suggesting potential solutions to this problem, like motivational interviewing. But now those clever R&D guys have come up with an answer that will avoid the effort of patients and doctors actually talking to each other.

"Proteus Biomedical Inc., is testing a miniature digestible chip that can be attached to conventional medication, sending a signal that confirms whether patients are taking their prescribed pills. A sensing device worn on the skin uses wireless technology to relay that information to doctors," report the Wall Street Journal.

Yes, that's right. No longer will you have to ask patients whether they've been compliant with their prescriptions. Just plant a bug in their drugs and wait for the transmissions. And we thought the replacement of internists with computers was just fiction.

Labels: drugs, patient communication

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posted by Stacey Butterfield at 12:15 PM   0 Comments

Superbug threat lurks in sewer

The threat of antibiotic resistance is attributed mainly to the overprescribing and overuse of antibiotics, but a new study explores a new, often-overlooked, danger: sewage sludge.

The study, by the Swedish National Veterinary Institute and the Finnish Food Safety Authority and published in the journal Acta Veterinaria Scandinavica, analyzes vancomycin-resistant enterococci (VRE) found in sewage sludge from a waste-water treatment plan. Researchers performed the unenviable task of collecting sludge from the plant weekly for four months and found that 79% of the 77 samples tested positive for drug-resistant superbugs. The danger, the researchers noted, is that VRE may pass on resistant genes to other bacteria.

Since sewage sludge is often used as fertilizer, its use threatens to spread antimicrobial resistance throughout the animal and human food chains, researchers warned. More efficient hygienic treatment of sewage sludge, they concluded, must become another weapon in the public health arsenal against superbugs.

Labels: drug resistance, drugs, superbugs

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posted by Janet Colwell at 8:00 AM   0 Comments

Best drug info doesn't come over free lunch

It's tempting to embrace newer generation drugs that are either more effective or cause fewer side effects than older drugs, but there's also wisdom in waiting for the dust to settle, if the current controversy over the atypical antipsychotic quetiapine (Seroquel) is any indication.

Quetiapine made the news again recently in connection with a federal court case during which manufacturer AstraZeneca PLC revealed a previously undisclosed analysis of studies showing that the newer drug was less effective than the conventional antipsychotic haloperidol, which it was supposed to improve upon, according to the Wall Street Journal.

Court papers have produced other unsettling revelations, including that AstraZeneca apparently told its sales reps to downplay a possible connection between quetiapine and diabetes, even though its own physician had once stated that a link was probable, the Wall Street Journal also reported. The company now faces more than 9,000 lawsuits from people alleging that they developed diabetes after taking quetiapine.

Those reports come after a study published last month in the New England Journal of Medicine concluded that patients taking atypical antipsychotic drugs (clozapine, quetiapine, olanzapine, and risperidone) faced a higher risk than non-users of sudden cardiac failure.

The reports seem like a good reason not to rely on the sales rep for information about new drugs, and to turn to unbiased sources such as Rxfacts, a project initated by Jerry Avorn, MD, and colleagues at Harvard. (See a related ACP Internist article on the project.)

Labels: antipsychotics, drugs

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posted by Janet Colwell at 11:51 AM   1 Comments

TB and drugs: A double whammy

Nearly one-fifth of U.S. tuberculosis patients abuse drugs or alcohol, which is a problem in and of itself. But the substance abuse also makes it harder to treat the TB, according to a release from a new study in Archives of Internal Medicine.

TB patients are more likely to be substance abusers than to be recent immigrants, infected with HIV, homeless or working at a high-risk job, the study found. Substance abusers with TB, but without HIV, were almost twice as likely to have a contagious form of TV than non-abusers, and women substance abusers were more than twice as likely to fail treatment.

Why is this? Substance abusers may not get routine medical treatment, so they are less likely to be detected early. Since TB often spreads faster as the disease progresses, these undetected substance abusers would be more contagious, study authors said. And they may be harder to treat because of weakened immune systems.

Labels: drugs, infectious disease, TB, tuberculosis

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posted by Jessica Berthold at 3:12 PM   0 Comments

Don't drink the water

ACP Internist's latest cover article describes the potential environmental impact of disposing of drugs down the drain and into the water supply. I ran into this problem after getting a bad series of eye, ear and sinus infections over the holidays.

I worked my way through all the antibiotics as prescribed, but those aren't the problem anyway, said Christian Daughton, PhD, Chief of the Environmental Chemistry Branch at the EPA's National Exposure Research Laboratory in Las Vegas. He told ACP Internist that antibiotics in drinking water occur only at parts-per-trillion range, which is probably a moot concern for creating bacterial resistance.

My main problem is all that leftover pseudoephedrine. I didn't mix well with the pills and didn't finish them. And, while I was looking through my medicine cabinet to throw them out, I found a family's worth of expired prescriptions and over-the-counter meds so old that I can't even remember buying them. If I dispose of them improperly, I'm making sure my neighbors don't get headaches, fevers, sore throats, cramps, coughs, stuffiness, gas, bloating or warts.

I'm supposed to mix it all with kitty litter, but I don't have a cat. If I did, I'd probably need more pseudoephedrine. I drink coffee and thought I'd found a conscience-free way of throwing them out with used grounds, but Dr. Daughton said, "The recommendation to mix drugs with kitty litter or coffee is not without controversy."

To top it all off, only one of the pill bottles is recyclable in my borough. It's not just me getting sick, it's the planet.

Labels: drugs, environment, infectious disease

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posted by Ryan DuBosar at 11:35 AM   0 Comments

Meet the new drug...same as the old drug.

The NEJM has an article out today which dispels the notion that atypical antipsychotics have a lower cardiac risk than typical antipsychotics. Traditionally, the atypicals have been considered safer.

The rate of sudden cardiac death for people taking atypical antipsychotics was more than twice that of non-users-- actually a little higher than the rate for those taking typical antipsychotics. And the greater the dose, the greater the risk.

I'm wondering how relevant this study is to primary care internists. I know that, in addition to being used for schizophrenia, antipsychotics are often prescribed as adjunct therapy to offset the side effects of other psychiatric drugs, but I don't know if this is mostly a practice of psychiatrists, or if primary care doctors do this as well. Anyone care to weigh in on how this information about antipsychotics might be useful to internists?

Labels: antipsychotics, drugs

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posted by Jessica Berthold at 10:13 AM   0 Comments

Ritalin for everyone

This Nature article, in which a group of scientists and ethicists come out in favor of allowing healthy people to take cognitive-enhancing drugs, has gotten a lot of news coverage, but it's definitely still worthwhile to read it for yourself.

The authors go pretty far out on some theoretical limbs--making the case that brain-stimulating drugs are no different than sleep or education and suggesting that someday it could be mandatory for surgeons to take the pills if they were proven to improve outcomes. But they build a compelling argument (and a lot of curiousity--would this blog post be vastly more intelligent if I had popped an Adderall beforehand?).

The article also puts a lot of responsibility on physicians, noting that they are already pushed by some healthy patients to prescribe the drugs (anyone want to comment on their experiences with that?). And, in the end, the experts want docs, or their representative organizations, to decide this tricky issue:

"It would therefore be helpful if physicians as a profession gave serious consideration to the ethics of appropriate prescribing of cognitive enhancers, and consulted widely as to how to strike the balance of limits for patient benefit and protection in a liberal democracy."

Labels: drugs, ethics

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posted by Stacey Butterfield at 12:21 PM   0 Comments

Tell me about your extra drugs!

Earlier this year, the Associated Press did a big investigation of the levels of pharmaceuticals in our drinking and ground water. A lot of the drugs get into the water after passing through people's bodies, but some end up there because patients are following the traditional instructions for disposal of unused medications--flush 'em.

I'm working on a story, as part of our Medicine and the Environment series, about what physicians can do to help fix this problem. Obviously, if you have a drug takeback program in your area, that's great. But if you don't, what should you be telling patients to do with their leftover meds?

I found one article that details the laborious process (involving kitty litter and unmarked containers) recommended by the federal government, but I highly doubt that's getting a lot of play in offices or homes around the country. So, has anyone ever asked you what to do with their unused medications? What do you tell them? If it were a relatively simple process, would you be willing to collect the meds?

Labels: drugs, environment

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posted by Stacey Butterfield at 3:26 PM   4 Comments

Drugs to keep an eye on

As we reported in ACP Internist Weekly today, a record number of deaths and serious injuries from prescription drugs were reported to the FDA in the first quarter of 2008, according to the non-profit Institute for Safe Medication Practices (ISMP).

I thought it might be interesting to show the ISMP's chart of the top ten drugs in terms of adverse events and deaths. So here we go:

Drugs, ranked by reported # of serious adverse events:

VARENICLINE: 1001 events
HEPARIN: 779
FENTANYL: 631
INTERFERON BETA: 582
INFLIXIMAB: 463
ETANERCEPT: 401
CLOPIDOGREL: 297
PREGABALIN: 280
ACETAMINOPHEN: 273
OXYCODONE: 272

Drugs, ranked by reported # of deaths:

OXYCODONE: 185 deaths
ALPRAZOLAM: 163
ACETAMINOPHEN: 160
ACETAMINOPHEN; BUTALBITAL; CAFFEINE (combo drug): 156
FENTANYL: 131
MORPHINE: 115
IBUPROFEN: 114
METHADONE: 111
ACETAMINOPHEN; HYDROCODONE (combo): 111
HEPARIN: 102

Labels: drugs

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posted by Jessica Berthold at 12:01 AM   0 Comments

New uses for old drugs

There's something pleasingly efficient about research that finds new applications for existing therapies. A few such studies were presented today at the ACR meeting.

Hydroxychloroquine, an antimalaria medication, appears to be an effective treatment for both lupus and rheumatoid arthritis. In the lupus study, the drug protected against kidney damage, a common complication of lupus. The arthritis study, an observational trial, added to the evidence base for hydroxycloroquine by finding that it reduced the likelihood that RA patients would develop diabetes. Researchers suggested the drug--which is generic and costs less than $60 a month--might also be good for lipids and platelets.

Finally, a new study found that Cialis can increase blood flow to other parts of the body besides the one for which it was intended. In a trial of 25 patients (mostly women), the drug effectively treated secondary Raynaud's phenomenon, a condition which causes fingers to turn white and blue when exposed to cold. Guess now you can "be ready" to go build a snowman.

Labels: drugs, rheumatology

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posted by Stacey Butterfield at 6:22 PM   0 Comments

Drugs, drugs, and...tai chi?

At most conferences, a press badge causes other attendees to avoid you if anything. But here at the American College of Rheumatology meeting, drug reps are drawn to my press ribbon like flies to honey. And they were in full swarm at a press conference this afternoon.

Early data on several experimental rheumatologic therapies was presented, including an injection for treatment-resistant gout and a new painkiller for knee osteoarthritis, as well as two potential competitors to Fosamax (in case Sally Field's commercials haven't already made it clear, there seems to be some money to made here). One of the drugs is a twice-yearly biologic and the other reduces glucocorticoid-induced fracture risk.

None of the drugs have been FDA-approved yet, though, so it should be a while before the drug reps are chasing you down the hall to discuss them.

The press conference did offer one non-drug therapy for knee osteoarthrtis--the ancient Chinese art of tai chi. Patients who did tai chi for 12 weeks had better function, balance and quality of life scores than those who did conventional stretching and wellness education. The researcher did warn that the tai chi exercises should be modified for OA patients because as typically done, tai chi can actually cause a lot of knee injuries. There's always a catch.

Labels: drugs, rheumatology

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posted by Stacey Butterfield at 7:01 PM   0 Comments

Saying no to generic doughnuts

A new study by Medco reveals some interesting data about how seniors work around the Part D doughnut hole.

It's no big surprise that a chunk of them stop taking their statins once they have to pay for them. But did you know that--among those who stay on their meds--many seniors switch from brand-names to generics while they're paying out of pocket, and then switch back again when they reach the other side of the gap?

In an ACP Internist discussion of these stats, one staffer attributed the finding to the penny-saving, coupon-clipping habits of the Greatest Generation. But, as it turns out, these thrifty seniors may actually be costing themselves (as well as all of us taxpayers) in the long run, because if the patients used generics while they were covered by Part D, they would delay, or even avoid, arrival at the doughnut hole.

According to the Medco press release, the company deals with the problem by offering their members forms to talk to their docs about prescribing generics. But if they're already switching back and forth, it doesn't seem like these patients are scared to ask for the drugs they want. The real issue seems to be how do you convince them that generics are just as good as brand names? Any strategies out there?

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posted by Stacey Butterfield at 1:45 PM   0 Comments

Americans taking fewer drugs

According to stats from IMS Health Inc., prescriptions dropped almost 2% in the second quarter of this year compared to the year before. The lede of this Philly Inquirer article attributes the drop to economic problems, but also cites several other potential causes of the first drop in drug sales since 1996:

• fewer new drugs being introduced
• heavy publicity for some nasty side effects (e.g. rosiglitazone)
• a slowdown in FDA approvals

Physician visits were also down 1.2%. But medical workers shouldn't worry about unemployment quite yet, experts said. The American population is still expected to get older and sicker in the future, so we can expect business to pick back up. What a relief.

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posted by Stacey Butterfield at 3:21 PM   0 Comments

Drugs going to the dogs

Drug sales are down. People are opting for generics over more pricey brand names and the FDA approval process has gotten tougher. So what are ailing drug companies to do? According to a cover feature in last weekend's New York Times magazine, pets are the next frontier.

Does Fido stare miserably out the window when you leave for work? Does Spot, like the dog featured in the article, obsessively chase his tail? A dose of Clomicalm, drugmaker Novartis' canine version of Anafranil, a tricyclic antidepressant, may calm his nerves. Eli Lilly's Reconcile, (Prozac for dogs), is also being billed as a remedy for separation anxiety while Pfizer's Anipryl may help absent-minded dogs remember important facts such as the location of their food dish.

Nice to know but I'll pass on the drugs for my excitable, emotional, run-around-like-crazy (but endearing) spaniel.

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posted by Janet Colwell at 9:10 AM   0 Comments

Get drug alerts, warnings and recalls fast

More than 100,000 doctors have registered to receive emails about safety alerts and drug recalls. Are you one of them?

The service is provided for free by the nonprofit iHealth Alliance, and you can sign up here.

The alerts are tailored to your specialty, and are limited mostly to the "Dear Doctor" letters that drug manufacturers send out about label changes, recalls and warnings.

According to the Wall Street Journal:

"After receiving email notifications, doctors will get updates by going to a Web site called the Health Care Notification Network, which will archive alerts for a year, and will record that the doctors have gone to the site to see the notices. The network will provide suggested language that doctors can forward to their patients....The network may also be used to send doctors information on major public-health emergencies or bioterrorism alerts. "

If you haven't already, you can also sign up for the FDA's MedWatch safety alert and recall emails. It's always good to cover your bases.

Also, your patients can be sent alerts about drugs they are taking by setting up an online personal-health record here.

Labels: drugs, FDA

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posted by Jessica Berthold at 2:59 PM   0 Comments