letters

Affordable medications in India

Dr. Richard Sagall's article "Can Your Patients Afford the Medications You Prescribe?" [April 2006] reminded me that the rising cost of medical treatment is an issue with patients and physicians throughout the world. As a family physician working with the urban poor in India, I face this issue every day. I am fortunate to have cheap, reliable generic drugs for many conditions; the cost of 50 mg of atenolol is one cent!

I used to work in a hospital that required the doctors to write the cost of the drugs we prescribed on the side of the prescription for the purpose of easier billing. We knew the cost of all the drugs that we prescribed. Now I work in a hospital that does not require me to do that, but the experience helps me keep tabs on the cost of the drugs I prescribe. We help our patients get their medications in two ways:

1. We refer them to the nearby government hospital for the drugs. These hospitals are terribly overcrowded and understaffed, but the patients manage to get free drugs even though they may not be examined. Then we follow up with the patients in our practice.

2. We write prescriptions for longer periods whenever possible. Most of our patients are laborers who do not have enough money to buy drugs for a long period, but this approach enables them to buy drugs for a short period and then buy more later without seeing the doctor first.

As family physicians, we offer the most cost-effective care to our patients. It is important that the cost is controlled not just by the judicious use of drugs, but also by the practice of clinical medicine that focuses on a good history, physical examination and appropriate use of investigations.

Sunil Abraham, MBBS
Vellore, India

Creating a registry for patients with chronic disease

As a third-year family medicine resident in an academic program, I wondered why many patients with chronic diseases didn't make regular clinic appointments. Instead, many were treated in the university hospital or ER for acute exacerbations. I wanted a way to monitor these patients and remind them to make regularly scheduled appointments without having to create a registry from scratch.

At our large academic medical center with numerous satellite health centers, I discovered that the infrastructure for improved patient communication and monitoring was already in place. I just needed to use the systems more fully.

One solution was to use the centralized university-wide computer database to build registries for patients with various chronic diseases. We asked our information systems department to search for particular patient information stored in the large university database and then transfer it to Excel. The database contained all the information we needed: when the patients were last seen for chronic disease visits; when they last had important blood work and screening tests; and when they were last seen by other specialists or in the hospital. It also contained updated addresses and contact information for every patient at the health center. For example, for our diabetes registry, we obtained a complete list of patients who had an A1C or urine albumin/creatinine ratio drawn within the last 18 months and their corresponding lab values. If Mr. Smith needed to have his A1C and cholesterol checked and also needed a follow-up visit for diabetes maintenance, I would mail him an appointment reminder along with a lab slip and ask him to get his test done a few days before his visit. A few days later I would check our electronic schedule to make sure Mr. Smith had scheduled an appointment.

Another solution was to open a free e-mail account and send myself reminder e-mails about important follow-up testing and appointments. For example, if Mrs. Smith needed a repeat Pap smear in six months, I could generate an e-mail reminder to be sent automatically to my account in six months. I would then follow up with her and the e-mail could be deleted or saved in my account depending on whether a reminder would be needed for a future date.

After six months of using the system, patient visits for chronic disease maintenance rose 40 percent. Our patients' health improved as well. For example, LDL for patients with hypercholesterolemia dropped 20 percent during the first six-month period.

Many providers have a favorite reminder system they use for keeping patients with chronic diseases as healthy as possible. Telephone reminder systems, largely available through companies that supply electronic health records (EHRs), have advantages such as speedy message delivery to patients. EHRs are popular, but the high cost of adapting and maintaining them in a large clinic may prohibit some from using them. Other physicians describe using Excel spreadsheets for tracking visits and test results for patients with chronic diseases (see "Using a Simple Patient Registry to Improve Your Chronic Disease Care," FPM, April 2006). For those providers affiliated with academic centers with a central computer tracking system, fundamental components of a chronic disease registry are already in place and ready for use.

Scott Lee, MD
Worcester, Mass.

Precertification, denials and appeals

Thank you for Dr. Anthony Akosa's article "Precertification, Denials and Appeals: Reducing the Hassles" [June 2006]. It described how to manage insurance company red tape. The real issue, however, is why do we deal with any of it? Ending insurance contracts and dealing only with patient reimbursement is the only way to permanently end the hassles.

Insurance companies created managed care to increase their profit margins. They have succeeded. They deny care to patients who need it and create more work and overhead for physicians. It is unbelievable that physicians and patients have allowed this to happen.

Pay for performance (see the special section in the July/August 2006 issue of FPM) is another manufactured absurdity that no other profession or workplace would tolerate. This emperor has no clothes either!

As physicians, we are supposed to work for patients only, not insurance conglomerates who work for CEOs and stockholders.

Craig M. Wax, DO
Mullica Hill, N.J.

Which drugs to prescribe

I enjoyed Dr. Philip Mohler's article "New Drugs: How to Decide Which Ones to Prescribe" [June 2006]. However, it is missing two key pieces of advice. First, a new drug should not only be at least as effective as the older drug; its efficacy must also be measured using outcomes that actually matter to patients. All too often a drug is promoted because it provides a small benefit as measured by a disease-oriented outcome such as the effect on blood sugar or peak flow. What really matters is patient-oriented outcomes - the effect on morbidity, mortality, symptoms, cost and quality of life.

Second, Dr. Mohler includes colleagues as "unbiased" sources of information. Sadly, given the pervasive reach of pharmaceutical representatives and drug company advertising, they may not be unbiased. Also, the informal and often haphazard observations of an individual physician are fraught with unintentional bias and are no substitute for a careful, well-designed study.

Instead, I encourage readers to read the STEPS (Safety, Tolerability, Efficacy, Price, Simplicity) feature in American Family Physician, where every month we carefully and objectively review a new drug using just the criteria that Dr. Mohler proposes (go to http://www.aafp.org/afp/steps).

Mark Ebell, MD
Deputy Medical Editor, American Family Physician
Athens, Ga.

Author's response:

Dr. Ebell's thoughts are germane and appreciated. Unfortunately, surrogate outcomes and comparisons with only placebo are the (sub)standard mode of bringing drugs to market. As he posits, pharmaceutical marketing often highlights the statistical significance of outcomes that have little, if any, clinical utility.

Dr. Ebell's comments regarding our physician colleagues' lack of unbiased medication knowledge are on target. The pharmaceutical industry, with its glitzy pens, pads and pizza, remains the primary source of drug information for most physicians. Dr. Bob Goodman's Web site, http://www.nofreelunch.org, documents the very powerful bias that physicians expose themselves to when they see drug reps and accept "free" sample medications.

Philip J. Mohler, MD
Grand Junction, Colo.

Correction

Contrary to what is stated in the last paragraph of "The Top PDA Resources for Family Physicians" [July/August 2006], some of the applications described in the article do not run on the PocketPC platform. For example, the StatCoder CPT and ICD-9 applications only run on Palm OS. OB Suite is also Palm OS-compatible only.

Eric Schackow, MD, PhD
Boise, Idaho

Author's response:

I apologize for the errors in my article and regret the disappointment caused to PocketPC users. While Dr. Tim Allen's OB Suite is not available for PocketPC users, he has made OB Wheel for PocketPC devices. This application contains most of the calculator function but leaves out the patient- and procedure-record portion.

As for StatCoder, most of Dr. Andre Chen's applications have been partially tested on the PocketPC platform for use with StyleTap. You can find out more about this software at http://www.statcoder.com/pocket_pc.htm.

Lastly, The Medical Letter is also available for Palm OS only. Many thanks to Dr. Schackow for his attention to detail.

Alvin B. Lin, MD
Las Vegas