May 2001 • Volume 7 • Number 5
Convocation builds on excitement for practice-based research
BY SHARON DICKINSON DENT
These family physicians and about 45 others swapped research ideas at the first meeting of the AAFP national research network.One hundred thirteen people participated in the first convocation of the AAFP's National Network for Family Practice and Primary Care Research March 21 - 24 in Colorado Springs, Colo.
The convocation took place in the tradition of the national network's predecessor, the Ambulatory Sentinel Practice Network, which closed in 1999. If energy and enthusiasm at the 2001 convocation are any indication, the transition went smoothly. Former ASPN participants -- joined by those new to research -- expressed zeal to launch research projects that would address questions of importance to the discipline of family medicine and lead to improved patient care.
John Hickner, M.D., M.S., national network director, aims to get at least 10 percent of AAFP active members -- or about 6,000 practicing physicians -- involved in research. He guessed that up to 2,000 FPs currently participate in some way.
"There are lots of levels of participation," said Hickner. "It doesn't mean that the doctor has to become a researcher; that doctor can simply open his or her office to a research study and allow others to come in and collect data on the office practice. Or a doctor can choose to participate in gathering data or have his staff involved in gathering data. And then there's a need for doctors to go up to the next step and be clinical advisers to the research process, so although they might not be an investigator, they're providing advice and helping to shape the study, providing the input to get the questions right. Some actually like it so much, they go on to become investigators. We need all of those levels." (See the story "Practicing FPs form backbone of research team.")
For more information on participating in practice-based research, contact Tom Stewart, AAFP research network coordinator, by e-mail at tstewart@aafp.org or by phone at (800) 274-2237, Ext. 3172.
Your turn
Tell Congress why Medicare rules are a hassle
Here's your chance to let members of Congress hear how Medicare regulations complicate your practice. The House Committee on Energy and Commerce is reviewing the Medicare program and wants your input.
You can go online and answer the committee's questions, including:
- What rules do you consider the most burdensome? Give examples.
- Have you ever received inconsistent information from a Medicare carrier? Give examples.
- Do the carriers provide adequate educational materials on coding and billing?
- Have you limited the number of Medicare, Medicaid or State Children's Health Insurance Program beneficiaries you provide care to because of the rules and regulations?
The committee is working with HCFA to eliminate waste, mismanagement and bureaucratic delays. Staff members in AAFP's Washington office say replies to the survey could help convince Congress to pass laws such as the Medicare Education and Regulatory Fairness Act. (See the story, "Law could wipe out some burdensome Medicare regulations.")
So take a few minutes to explain the problems Medicare has posed for your practice. Go to http://www.house.gov/commerce/hcfasurvey.htm and answer the survey online or mail your response to the address provided.
Strange bedfellows, same goal: health care coverage for all
BY PAULA BINDER
Rep. Jim McCrery, R-La.Examine their voting records and you'd think they had nothing in common, other than their first name, serving in the House since '88 and serving on the Ways and Means health subcommittee.
Republican Rep. Jim McCrery of Louisiana scored 83 percent "conservative" in rankings compiled by the National Journal -- and he abhors the idea of a government-controlled single-payer health system, in part because it would stifle innovation and development. "Dumbing down" the system, he calls it.
Democratic Rep. Jim McDermott, M.D., of Washington state, a psychiatrist, scored 85 percent "liberal" in the same rankings and for many years advocated the very system McCrery abhors.
And yet they've found common ground and are forging a plan to reform the health system and provide health insurance for all.
The congressmen spoke about reform at an April 4 primary care forum sponsored by the Robert Graham Center in Washington.
Why now?
Back in 1993 - 94, McDermott said, when the Clinton health plan died aborning, about 35 million Americans were uninsured. Since then, he said, "We've had another 10 million people appear on the uninsured rolls, in the midst of a booming economy. It doesn't make any difference where you are on the political spectrum -- you look at it and say, 'Something ought to be done about this.'"
"My passion emanates from a slightly different angle," said McCrery. "It's well-established that a person with health insurance is more likely to seek primary care, preventive care and care at an earlier stage of disease or illness, and therefore be generally healthier than a person without health insurance. So if we're concerned about health care in our country, we would want everybody to have health insurance."
No more patchwork
Rep. Jim McDermott, M.D., D-Wash.But McCrery doesn't want just a tax credit to help the uninsured buy insurance. That would be one more patch on the patchwork that's already there. "What I'd like to do -- and I think Jim shares this -- we want to put everybody into the same system," he said. "But I want everyone in the same system that is managed by the private sector, not the public sector."
McDermott and McCrery first sat down to explore possible points of agreement at the request of a journalist from The Atlantic Monthly (http://www.theatlantic.com/issues/2000/10/miller.htm). "Since we have a basic respect for one another -- though we think the other is totally wrong on politics -- we agreed to do this," McDermott said of the request. As they discussed the options with the journalist, they found a degree of agreement on some basic concepts -- including a move away from employer-based health insurance. (See the story "Key points the lawmakers have been discussing.")
Where there's a will
Of course, galvanizing the political will to create such a system is another question entirely. Some major hurdles would have to be overcome. For example, many people -- both Democrat and Republican -- would resist giving up employer-based health insurance, said McCrery. They'd see it as a "take-away" since the value of employer-based insurance is not taxed.
"We both have huge hurdles to get over in our respective caucuses before we can pass anything like that," McCrery said. "If in fact we are concerned about health care in this country, and if those on my side don't want single payer (or) government control, and those on Jim's side want everybody to be covered and to have some semblance of reasonable health care, seems to me there is common ground that we might build on."
"It's not going to be done by one side or the other," agreed McDermott. "It's going to be done on a bipartisan basis in spite of our hating to be bipartisan, our enjoyment of fisticuffs and throwing bombs and everything else."
This time, that won't work, he added. "This is too big an issue to be solved by one side or the other. Nobody can ram through just what they want. That's why this is an important discussion to have."
Key points the two lawmakers have been discussing
Republican Rep. Jim McCrery of Louisiana and Democratic Rep. Jim McDermott, M.D., of Washington have been discussing a plan for health reform that includes these ideas:
- The government should establish a relatively generous basic benefits package, perhaps using the Federal Employees Health Benefits Plan as a model.
- The insurance system should move from the current employer-based model to one based on individuals. Employers should pay employees additional wages with funds that previously had been spent on health insurance premiums.
- The government should mandate that everyone buy health insurance for his or her family in the private market. Individuals should use the additional wages left after taxes to purchase the insurance.
- Insurers should underwrite individuals using a community rating for everyone in the United States. "Today's insurance market is a mess: large-group coverage, small-group coverage, individual coverage, club plans -- it's nuts," said McCrery. "We ought to try to put some order in the insurance market, and community rating is the key to doing that. Yes, it's hard to convince other Republicans that it's something the government should mandate. But I'm willing to do that in order to create this private sector-managed universal system."
- The purchase of health insurance could be reported on the federal income tax return, and an income tax credit would be available to everyone who purchased insurance. The question is -- what credit is big enough to encourage employers to "cash out" employees so they can buy insurance individually? McCrery also goes a step further: He advocates redistributing the federal tax credit to give lower-income workers more incentive to purchase insurance."I can't figure out any reason why the government should subsidize my health insurance," he said. "I make enough money to go out and buy health insurance for my family."
- Some mechanism should be established to get funds to people who can't afford to pay for insurance and then wait for the tax credit.
- Finally, a default system should cover individuals who defy the mandate to purchase but then require care. They might be held responsible for paying back premiums, McCrery said.
Practicing FPs form backbone of research team
BY SHARON DICKINSON DENT
Family medicine is experiencing a cultural revolution, according to John Hickner, M.D., M.S., director of the AAFP National Network for Family Practice and Primary Care Research. The AAFP and medical practice are moving toward a more evidence-based approach, and the practice-based research network is part of that evolution.
"The old culture was 'We do practice,'" Hickner said. "The immediate past culture was 'We do practice, and we teach medical students in our offices.' The new culture is 'We do practice, we teach and we are involved in generating new knowledge.'"
Hickner pointed out that practice-based research networks involve three key participants: the family physician, the principal investigator and the network director. Three attendees at the national network's convocation March 21 - 24 in Colorado Springs, Colo., explained their roles in the process.
Practicing FP
As a solo family physician in Baton Rouge, La., Linda Stewart, M.D., sees about 35 patients each day and serves as a preceptor for medical students and family practice residents. But she also finds time to take part in office-based research studies, including research projects of the AAFP national network.
"I've always been interested in the research end, but I am not in a huge research hospital. I'm out in the trenches by myself," said Stewart. "I can't go hire a staff and writers and statisticians. But I can participate at this level. I can help with creating ideas; I can be a research tool. One of the big perks for me is it keeps me stimulated and it helps answer the questions that come up in my mind."
Although her practice may have two or three studies under way at any given time, most projects ask for short-term involvement, she said. "For example, you have 10 patients to recruit to do a diabetic questionnaire. It's a no-brainer. It's not a big invasion in my practice."
Family physicians provide an important reality check for researchers, Stewart said. "We can try to help them understand that if they modify how they're representing the material, the time constraints or the paperwork involved, then they'll get a better result."
Patients are surprisingly positive about participating in office-based research studies, she said. "I can't say they're always enthusiastic about everything we do, but we gave our diabetic patients a 10-page questionnaire, and they were filling it out saying, 'Gee, Doc, I'm so glad someone's interested in what I think.' That's the response we get."
Linda Stewart, M.D.:
"I've always been interested in the research end, but I am not in a huge research hospital. I'm out in the trenches by myself.'"
Linda Stewart, M.D.,
practicing FP
Principal investigator
FP Dan Vinson, M.D., M.S.P.H., from the family and community medicine department at the University of Missouri in Columbia, caught the research bug about 12 years ago while working with a group of family practice residents. They were trying to decide how to treat a patient who was experiencing alcohol withdrawal.
After looking into the options, "I began to realize that there was a lot that wasn't known," Vinson recalled. "I had an idea for a little alcohol research project, just chart review, but it worked. One thing led to another, and I began to think more philosophically about what was important to study about alcohol and problem drinking in primary care."
At the convocation, Vinson presented details about his current study, "Comfortably Engaging: Which Approach to Screening for Problem Drinking Is More Effective?"
Doctors in the AAFP's national network will enroll patients in the study later this spring to compare the use of a four-question approach with the use of a single question.
"Problem drinking is very common," said Vinson, noting that 15 percent of U.S. adults have at least one episode of binge drinking per month, and 7.4 percent meet the criteria for alcohol abuse or dependence. "There is a lot that primary care clinicians can do to help patients identify the risks, think about them and begin to change. And we don't do that for a lot of reasons. To try to find a way to make those alcohol-related discussions more effective, part of it has to be with an eye toward making it better for the clinician."
Dan Vinson, M.D., M.S.P.S.:
"I had an idea for a little alcohol research project, just chart review, but it worked. One thing led to another.'"
Dan Vinson, M.D., M.S.P.H.,
principal investigator
Network director
With new practice-based networks springing up around the country, many new network directors at the convocation sought advice from seasoned veterans such as Kevin Peterson, M.D., M.P.H., of Lake Elmo, Minn., the Minnesota AFP Research Network director.
Peterson, whose network includes about 200 members, said a network director wears many hats in a largely administrative role. "The network director needs to protect the interests of the family physician in the community," he explained. "He needs to ensure that research that's brought in won't negatively affect the physician's bottom line, that it doesn't encumber his practice or disillusion him as a researcher. On the other hand, he needs to ensure -- from a primary investigator's standpoint -- that a project is done in a fashion that is consistent with the protocol, that is scientifically sound and rigorous, and that eliminates as much bias as possible."
In his network, a steering committee evaluates each potential research project and determines issues such as its practice-friendly factor and the time required to conduct the study. Committee members then determine whether to support the project.
At the convocation, Peterson was elected to wear yet another hat: chairman of the Federation of Practice-Based Research Networks steering committee. The FPBRN includes 33 networks representing more than 7,000 members. The AAFP national research network is a network member of the FPBRN and helps coordinate and facilitate its activities.
Kevin Peterson, M.D., M.P.H.:
"The network director needs to protect the interests of the family physician in the community."
Kevin Peterson M.D., M.P.H.,
network director
You can help asthma patients adhere to their therapy regimens
BY DENNIS CONNAUGHTON
Artwork from AAFp Video CME program, "Allergic Rhinitis and Asthma: A Clinical Practice Update"Studies show that a scant 50 percent of asthma patients adhere to the daily therapy regimens their doctors prescribe. The rest fail to follow through for a variety of social, economic and psychological reasons.
But physicians can play a big role in turning those statistics around and improving patient outcomes, said speakers at the annual meeting of the American Academy of Allergy, Asthma and Immunology held this March in New Orleans.
"If you want to improve patient adherence to taking asthma medication, you as physicians must make the patient the only thing you are interested in when you see the patient in your office." This was the advice of FP Stuart Stoloff, M.D., clinical associate professor of family and community medicine at the University of Nevada School of Medicine in Reno.
Stoloff dramatized his point, putting on a skit with Carol Jones, R.N., an asthma nurse clinician at Rush-Presbyterian-St. Luke's Medical Center in Chicago. In their dialogue, the patient gave vague answers to general questions from the physician, and the physician seemed bent on getting the conversation over with and the patient out the door.
"We have really good medications for asthma, but they won't do any good unless the physician connects with the patient," Stoloff said. "Just giving people medicine is not enough. You have to develop and strengthen a positive relationship that fosters trust."
Predicting adherence
Various factors may help physicians predict which patients are likely to adhere to a prescribed medication regimen, said Cynthia Rand, Ph.D., associate professor of medicine at Johns Hopkins University School of Medicine in Baltimore.
Among those factors are the characteristics of the therapy itself, such as the dosing frequency, side effects, cost and route of administration. There is usually a decline in adherence with a dosing frequency of more than twice a day, she said.
"Is there something unique about asthma that makes adherence a problem?" asked Frederick Leickly, M.D., clinical associate professor of pediatrics at Indiana University in Indianapolis. "Yes, probably," was Leickly's own answer. He cited the nature of the disease and its therapy as key factors. Leickly reviewed ways to monitor adherence, including self-reporting, physician estimates, prescription filling, pill counting, body-fluid analysis and electronic monitors.
Educating, motivating
If a physician suspects the patient is not adhering to a treatment regimen, the physician should provide ongoing asthma education to the patient, bring the patient back in the near future for follow-up care, simplify the treatment plan and provide motivation to stick to the regimen. So said Bruce Bender, Ph.D., head of pediatric behavioral health at the National Jewish Medical and Research Center in Denver.
"It takes a lot of energy on your part to improve your patient's adherence to therapy," added Don Bukstein, M.D., assistant clinical professor of pediatrics and family practice at the University of Wisconsin in Madison. "But if you educate and motivate your patient, you can change his or her behavior."
Pharmacogenetics should help clinicians individualize drug therapies
BY DENNIS CONNAUGHTON
P harmacogenetics promises this: Using what scientists know from the Human Genome Project, clinicians should be able to tailor drug therapy to the individual, based on the individual's genetic makeup, to avoid drug toxicity and maximize therapeutic benefits.
However, according to speakers at the annual meeting of the American Academy of Allergy, Asthma and Immunology here in March, that promise may take five years or more to become reality.
"Pharmacogenetics is going to be one of the very important applications of the Human Genome Project," said Jeffrey Drazen, M.D., editor-in-chief of the New England Journal of Medicine and a professor of medicine at Harvard University in Cambridge, Mass. "Pharmacogenetics is defined as the use of genetic information to ascertain who will respond favorably or unfavorably to a given type of treatment."
The way an individual metabolizes drugs is based on his or her phenotype, Drazen said. The result: different outcomes in different individuals treated under the same therapeutic regimen. "The idea is that some people may be undertreated or overtreated, given their genetic makeup," he said.
Drazen predicted that within five years, clinicians will be able to order a drug-response phenotype profile for an individual, just as they order a complete blood count today. That profile will help physicians individualize drug therapies.
Another speaker on pharmacogenetics was Richard Weinshilboum, M.D., professor of molecular pharmacology and experimental therapeutics and medicine at Mayo Clinic in Rochester, Minn. He described studies of immunosuppressive drugs, such as the anti-leukemia drug 6-mercaptopurine, that show differences in drug metabolism associated with individual phenotypes.
"Most people metabolize 6-mercaptopurine quickly, and so their dosage must be high enough to treat leukemia and prevent relapses," Weinshilboum said. "Others metabolize the drug slowly and need lower doses to avoid toxic side effects. A small portion of people metabolize the drug so poorly that its effects can be fatal. This diversity in responses is due to variations in the gene for an enzyme called TPMT, or thiopurine methyltransferase."
Want info on new research?
Go to http://www.aafp.org/fpr/20010500/asthma.html to read another article, "New Research in Immunotherapy for Asthma and Allergy May Bear Clinical Fruit."
Elliot Israel, M.D., acting chief of the pulmonary division at Brigham and Women's Hospital in Boston, discussed a study he and others did. They examined the effects of genetics on how asthmatic patients respond to regular use of albuterol.
Inhaled beta2-agonists are the most commonly prescribed asthma medications in the world, Israel said. Controversy exists over whether regular use of beta-agonists has a deleterious effect on the control of asthma. Israel's study found that asthmatics with a homozygous arginine genotype at position 16 of the beta2-adrenergic receptor had a decline in airway function with regular use of a beta-agonist.
"If corroborated, our findings suggest that these individuals may benefit by avoiding regularly scheduled beta-agonists and might be candidates for earlier intervention with anti-inflammatory agents," Israel said.
Lanny Rosenwasser, M.D., head of the allergy department at the National Jewish Medical and Research Center in Denver, has reviewed studies of how genetics may affect resistance to steroid medications among asthmatics. He concluded that the task of applying genetic research to clinical treatment may be a daunting one.
Rosenwasser said there are some four million small variations, known as single nucleotide polymorphisms (SNPs), in genetic sequences. "SNP biology is becoming the major driving force for understanding the genetic variations seen in complex disease states such as asthma," he said. "Interventions related to SNP biology and variations in SNP biology will probably have the greatest clinical impact in the future."
New research in immunotherapy for asthma and allergy may bear clinical fruit
BY DENNIS CONNAUGHTON
The discovery of new drugs is like planting an orchard. It takes a long time to bear fruit.
So said the opening speaker at the session "New Developments in Pharmacotherapeutics" during the annual meeting of the American Academy of Allergy, Asthma and Immunology in March.
Among the immunologic discoveries related to asthma and allergy now beginning to bear fruit in the research orchard are new asthma mediators, cytokines that help regulate immunoglobulin E (IgE), the pleiotropic actions of interleukin-4 and interleukin-13, and the critical effect of interleukin-5 on eosinophils, said Anthony Frew, M.D. He heads the department of medical specialties at the University of Southampton in England.
Frew introduced five researchers who presented findings from their recent studies of the latest immunotherapies for asthma and allergies. In time, if the work is confirmed in other research, these new and emerging treatments will reach clinical practice.
William Busse, M.D., head of allergy/clinical immunology at the University of Wisconsin Hospitals and Clinics in Madison, studied the effects of omalizumab (Xolair), a recombinant humanized monoclonal anti-IgE antibody, on perennial allergic rhinitis (PAR) in patients who were unresponsive to previous treatment with nasal steroids or immunotherapy.
He and his colleagues around the world found that omalizumab significantly reduced nasal symptoms in PAR patients unresponsive to other therapies. The medication was both effective and well tolerated, Busse said.
Another study of omalizumab was reported by Jonathan Corren, M.D., associate clinical professor of medicine at UCLA and medical director of the Allergy Research Center in Los Angeles. Corren and coworkers looked at omalizumab's effect on serious asthma exacerbations requiring hospitalization in patients with moderate to severe allergic asthma.
They found that treatment with this drug reduces the risk of serious flareups of asthma in both children and adults with allergic asthma. The treated patients had an 83 percent reduction in hospitalizations for asthma exacerbations.
In an initial phase II clinical trial of immunotherapy using specific immunostimulatory sequences of DNA linked to amb a 1 (the immunodominant allergen in ragweed pollen) for patients with ragweed allergies, Joseph Eiden, Jr., M.D., from Dynavax Technologies Corp. in Berkeley, Calif., and colleagues found that this therapy increases the immunoglobulin G response.
"Since allergen-specific increases in IgG are often associated with successful immunotherapy with conventional vaccines," Eiden said, "these study results indicate the potential utility of the amb a 1 allergen-specific immunotherapy for treatment of ragweed rhinitis."
Theresa Michelle, M.D., from Bio-Technology General Corp. in Iselin, N.J., and others studied the use of an antioxidant enzyme, recombinant human copper/zinc superoxide dismutase (rhSOD), to prevent chronic lung disease in infants born prematurely with respiratory distress syndrome.
At one-year follow-up, the researchers found that rhSOD significantly reduced the need for asthma medication among the treated infants. They concluded that this therapy could provide long-term pulmonary benefits by preventing oxidative injury in the lungs of these babies.
In a study of a computer-based mathematical model of chronic asthma known as Entelos Asthma PhysioLab, Cynthia Stokes, Ph.D., from Entelos, Inc., in Menlo Park, Calif., and coworkers looked at it's the model's application to research into the treatment of exercise-induced asthma.
The computer model was able to predict the efficacy of treatments with luekotriene-receptor antagonists or long-acting beta-agonists in protecting against exercised-induced asthma, Stokes reported. The study also demonstrated the model's ability to show the complex biological mechanisms underlying the clinical results.
Battling a growing dilemma
AAFP joins in developing new antibiotic use guidelines
BY CINDY McCANSE
You've heard it before, and you'll hear it again: It's just not smart medicine to routinely prescribe antibiotics for every child's acute otitis media or every adult's acute pharyngitis.
The fallout from overuse and inappropriate use of antibiotics is the emergence of scores of antibiotic-resistant pathogens.
Witness the virulence of Streptococcus pneumoniae, the leading cause of community-acquired bacterial pneumonia, bacterial meningitis, bacterial sinusitis and otitis media in the United States. Penicillin-resistant strains of this ornery little critter now abound, and resistance to doxycycline, macrolides, second- and third-generation cephalosporins and trimethoprim-sulfamethoxazole is on the rise.
In response, the Academy recently teamed up with the CDC, the American College of Physicians-American Society of Internal Medicine and the Infectious Diseases Society of America to create a set of evidence-based clinical practice guidelines on evaluating and treating adults with acute respiratory tract infections. The guidelines appeared in the March 20 Annals of Internal Medicine and will also be published in a series in American Family Physician. Currently, you can access them online by going to http://www.annals.org/issues/v134n6/toc.html and scrolling through the table of contents.
The guidelines present practical strategies for limiting antibiotic use to patients most likely to benefit from it. Specifically considered are acute sinusitis, acute pharyngitis, acute bronchitis and nonspecific upper respiratory tract infections. The majority of such infections, the guidelines conclude, are of viral origin and, therefore, warrant symptomatic rather than antibiotic treatment.
What's the reality?
But how do these recommendations translate into hands-on patient care? What do you tell a busy father who pleads with you to give him something -- anything -- that'll clear up a three-day-old sinus infection and get him back to work?
"We do respond to pressure from patients," says family physician Susan Hawn, M.D., of Jefferson, Ga.
Many patients don't want to be educated, says Hawn. "Some of them get hostile about it. I have patients who come in and say, 'I have a green nasal discharge' or 'I'm coughing up green mucus.' They've been told for 50 years, 'Oh, you need an antibiotic.' Who do you think they're going to believe?"
Lee Green, M.D., M.P.H., of Ann Arbor, Mich., a member of the Academy's Commission on Clinical Policies and Research, agrees it's a problem that physicians have largely brought on themselves.
"What was it Pogo said?" he muses. "'We have met the enemy and he is us.' There is a widespread perception on the part of doctors that patients demand antibiotics and can't be dissuaded, or that explaining the new thinking takes more time than we already-overburdened docs have."
But in truth, Green notes, that may not be the case. According to a recent study conducted by researchers at the University of California, Los Angeles, most parents who had been informed about the downside of the routine use of antibiotics in their children accepted their physician's explanation. Better yet, it added an average of only 31 seconds to the patient encounter.
Getting the word out
Granted, some patients already avoid taking antibiotics. They've read about the resistance problem and want reassurance that the drugs are necessary.
But those folks are in the minority, Hawn says. "Most people's concept of biology comes from shows like ER, where everybody who doesn't get the 'right treatment' is dead in three hours."
"They do try to make us earn our pay," agrees Theodore Ganiats, M.D., of La Jolla, Calif., chair of the AAFP commission. "But I've been shocked by the number of times that I've started trying to talk a patient out of antibiotics, and they've stopped me and said, 'No, I'm not asking for them. I'm just asking if I need them.' So the message is getting out to patients."
Help in delivering that message is on the way. HHS has already initiated a four-pronged attack on antimicrobial resistance; increasing patient awareness plays a major role (see the story "Feds, insurers step into the fray.")
Such a plan can create a culture in which patients don't expect an antibiotic prescription for every cold or sore throat, Ganiats believes. But then, he adds, it's up to physicians to enforce that culture.
Feds, insurers step into the fray
"We're from the government, and we're here to help -- really."
That was the message HHS conveyed in January when it released an action plan to fight the proliferation of antimicrobial resistance in the United States.
The Public Health Action Plan to Combat Antimicrobial Resistance (http://www.cdc.gov/drugresistance) includes these components: surveillance, prevention and control, research and product development.
In addition, a consortium of 25 health plans and insurers held a news conference in Washington April 17 to launch a public health initiative about the hazards of overprescribing antibiotics. "There is a mindset that antibiotics are a cure-all for 'what ails ya.' But in many cases, the patient just needs to take an over-the-counter cold or flu medicine to feel better," said AAFP President Richard Roberts, M.D., J.D., of Madison, Wis., at the news conference.
Through the initiative, posters and pamphlets will soon be showing up in doctors' offices and workplaces, and free samples of over-the-counter cold and flu remedies will be sent to supplant the antibiotic samples handed out by pharmaceutical reps.
Ah, spring! Ahhhhh-choo!
May is Clean Air Month. It's Asthma and Allergy Awareness Month. It's a month when patients might be firing questions at you, between sneezes and wheezes, about their airways and the pollen count.
To help with answers, this month the Academy is mailing you easy-to-read materials you can copy as patient education handouts. They're part of the Annual Clinical Focus 2001: Asthma, Allergy and Respiratory Infections.
The handouts cover topics such as allergic conjunctivitis, acute bronchitis, antibiotics (when they can and can't help), asthma flare-ups, dust mites, ear infections, flu and colds, sinusitis and sore throat.
Next month, you will receive the new American Family Physician monograph, Management of Acute Sinusitis and Acute Otitis Media.
ACF 2001 is a program of the AAFP developed in cooperation with the National Heart, Lung, and Blood Institute; American Lung Association; National Institute of Allergy and Infectious Diseases; and American Thoracic Society.
Jobe to be dean at Mercer University medical school
Family physician Ann Jobe, M.D., M.S.N., plans to continue her family practice activism as a new dean. She takes that post July 1 at Mercer University School of Medicine in Macon, Ga.
Family practice, this March, had its fourth straight decrease in medical students matching into the specialty's residencies. "To be a family medicine dean within the Association of American Medical Colleges, to me this brings the challenge of telling the others in the AAMC Council of Deans that this erosion of interest in primary care by medical students is something we all have to solve," says Jobe.
The AAMC has predominantly focused on funding for research through the National Institutes of Health, says Jobe. NIH funding, mainly for subspecialist research, is $20.36 billion for 2001, and the Bush administration proposes $23.11 billion for NIH in 2002, a 13 percent increase.
Jobe compares the AAMC's success in promoting the NIH with the importance of fostering primary care. "I need to make the AAMC aware it should rethink how it can support primary care, including family medicine, and do the same thing to enhance that across the nation," says Jobe.
"The AAMC is advocating meeting the needs of the underserved, covering the care of all people, improving their care. They (the AAMC) cannot do that with just an NIH budget," she says. "They've got to do it in partnership with primary care, with family physicians." Jobe has been assistant vice chancellor during the last three years for the medical school at East Carolina University in Greenville, N.C.
Jobe, 55, began participating in the Academy and the AAMC as a medical student. She led AAFP's congress of residents and served on two committees. She was a student representative within AAMC and chairs its MedCAREERS Advisory Committee, working to improve counseling programs and online information on career options. Jobe expects to be one of only five or six women among some 125 deans on the AAMC Council of Deans.
Scherger named dean at Florida State
News flash: Ann Jobe, M.D., M.S.N., will not be alone as a family practice activitist within the AAMC Council of Deans. Joseph Scherger, M.D., M.P.H., was chosen as dean of the Florida State University College of Medicine in Tallahassee April 23. He begins serving as the college's founding dean July 1. Scherger, past president of the Society of Teachers of Family Medicine and past director on the AAFP Board, is currently associate dean of the University of California, Irvine, College of Medicine.
New preventive services recommendations hit the streets
Choosing which clinical preventive services to offer your patients isn't always an exact science. Should all men age 35 or older be screened for lipid disorders? What about routinely screening young, sexually active women for chlamydial infection?
If you're uncertain about the benefit of these and other clinical interventions, new recommendations recently released by the third U.S. Preventive Services Task Force can help in the decision-making process.
The April supplement to the American Journal of Preventive Medicine carries the first four of numerous new USPSTF recommendations to be published over the next few years. You can also go to http://www.ahrq.gov/clinic/prevnew.htm to view them.
These initial recommendations cover skin cancer screening, screening pregnant women for bacterial vaginosis, screening for lipid disorders in adults and screening for chlamydial infection. The recommendations are based on systematic reviews of the available clinical evidence conducted by investigators at two evidence-based practice centers sponsored by the Agency for Healthcare Research and Quality. In addition, the scope of work of this third task force was expanded to include cost-benefit analyses for selected interventions.
The AAFP provided peer review for the recommendations and maintains a liaison to the task force. The AAFP Commission on Clinical Policies and Research will review the USPSTF evidence reports and recommendations to see what changes it might recommend in AAFP policy. The USPSTF is chaired by FP Alfred Berg, M.D., M.P.H., of Seattle. Other Academy members on the task force are Steven Woolf, M.D., M.P.H., of Fairfax, Va., and Paul Frame, M.D., of Cohocton, N.Y.
Medicare drug coverage
To the editor:
Here's a better idea than giving all Medicare recipients drug coverage: The government should increase the proportion of Medicare costs that are paid by seniors based on an accurate means test and have all seniors eligible for benefits with a sliding scale approach to payment/coverage. Those with more resources would help pay into a pool of money that would be available for less fortunate patients to access. Patients and their physicians would have a set amount of money each year to utilize for Rx coverage, and beyond that amount the patient would be responsible for either paying cash or independently providing Rx coverage insurance.
Therefore, this system would encourage communication and joint decision making between the patient and physician regarding the patient's medication choices and prioritization each year.
Jon Parham, D.O., M.P.H.
Knoxville, Tenn.Members oppose sexual orientation coverage
To the editor:
I wanted to respond to the March FP Report special section on sexual orientation issues. The AAFP has done well in allowing for a great deal of diversity. I appreciate this and know that this is part of the culture in a group as large and influential as our Academy is. I do, however, take exception to the notion that a "gay/lesbian/bisexual/transgender-friendly office" is a desirable thing for family physicians. We are able to treat and maintain all individuals without needing to enter into a politically motivated and very divisive stance.
When step one to engineering a GLBT-friendly office is the exorcising of my own "demons" in regard to my personal view about homosexuality I find tremendous fault with the process being promoted. I would suggest giving fair time to a group that has had success in helping people escape homosexuality. I have maintained a professional relationship with those who have come out of the homosexual lifestyle and have been overwhelmed with joy in the relief they have found. I would refer the AAFP to The National Association for Research and Therapy of Homosexuality, 16542 Ventura Blvd., Suite 416, Encino, CA 91436, (818) 789-4440, narth3@earthlink.net.
Bruce Young, M.D.
Olathe, Kan.The choice to publish this, while many worthwhile subjects beg for publication, casts serious doubt on the moral integrity of those at the helm of FP Report. It is evidence of detachment from that which is real, enduring and important in our lives and the lives of our patients. Editors, please acknowledge that this set of articles was a worthless pursuit, and aim for subjects that will edify and transform.
John Humiston, M.D., Lt., U.S.N.R.
Keflavik, IcelandMy practice is very diverse, and I care for all my patients with the same care, skill and compassion. To suggest that I have to take special steps or precautions to make GLBT patients welcome is absurd; I take the same extra care with everyone. That I should put up special signs or should respond in some special way to some symbol (be it a rainbow or a star of David) is totally unnecessary. The tone of these articles was condescending and offensive.
Ron Stephans, M.D.
Tampa, Fla.Aren't there many more minority groups that comprise far larger segments of the population, and have serious issues in their lives which were not brought about by choices but by tragic illnesses or accident, to whom we could give the attention?
Paul Reay, D.O.,
Wichita, Kan.Reasonable compensation
To the editor:
It's impressive that the March 4 New York Times printed the AAFP's letter about health care coverage for all. But now that we have the public ear, perhaps we should say some other things. For example, are we insisting that doctors get a reasonable compensation for their work? Are we assuming that Medicaid is charity, and we are the donors? Have we taken a position on the onerous government regulation package that comes with accepting Medicaid patients? One of my local reps for a program, when confronted with the regulations holding doctors responsible for the behavior of parents of children on Medicaid, glibly told me not to worry, "we're not prosecuting doctors for that" -- of course, with the implication that they could if they wanted to.
I am not a malcontent. I have weathered 22 years in various compensation climates. I feel the nonfinancial rewards of long-term relationships with patients and staff have made my life full and rich. However, when I see local groups successfully recruiting primary care docs at $80,000 a year, I fear the decline of family practice will sadly accelerate.
Dennis Novak, M.D.
Forked River, N.J.Down with referrals!
To the editor:
I am trying to get managed care organizations to abandon the practice of requiring referrals. The referral system serves no real medical purpose -- but it is quite effective in driving a wedge between physicians and their patients and between primary care doctors and specialists. The system also is useful to MCOs in their campaign to deny or delay payments for services.
Today's average primary care office is processing so many referrals that it needs a special phone line and an employee dedicated to this process. We must create these referrals on a credit card type of machine, entering detailed CPT codes for the services the specialist may perform. Should these codes be incorrect, a denial of payment to the specialist occurs. The specialist and the patient call and gripe to the primary care office, which must intercede on their behalf and beg the MCO to pay, despite the "error."
If referrals were eliminated, the MCOs could use the positive press coverage that would result. The millions of dollars saved could be spent on patient care or quality assurance. Physicians should unite to dismantle the nightmare of referrals.
Roger Thompson, M.D.
Middletown, N.J.Kudos to the Academy
To the editor:
I think the Academy is on a roll! The Web site familydoctor.org has been extremely well received by my patients. I've also directed friends in other specialties to it, as an alternative to wacko chat rooms that permeate the Web.
American Family Physician continues to be of great help. I forwarded recent articles on end-of-life care to our social service department, and the patient handouts are being given to families faced with these decisions. Also, when students, NPs and PAs have rotated through our family medicine department, they are very impressed with AFP's content, mentioning how useful it was during their various rotations.
The Home Study program is more relevant than ever. Family Practice Management is filling a long-standing void. FP Report is better and more useful than ever, and the new AAFP This Week by e-mail is equally good.
I am sure that these things will show students how the Academy and family medicine have developed, and will counter some of the academic folks who continue to downgrade our specialty. I think that, apart from trying to make sense of billing and attempting to change the adversarial relationship between medicine and HCFA, my practice is satisfying -- and fun.
D.E. Peterson, M.D.
Inverness, Fla.Editor's note: We appreciate hearing from readers, even when they're not happy with coverage in FP Report. We believe, and we hope, the AAFP is seen as a place where all family physicians can come together to share their common concerns, learn from each other's special perspectives and respect each other's differences.
To the reader: Write us letters of 200 words or fewer (subject to editing), using the FP Report address pbinder@aafp.org or FP Report, 11400 Tomahawk Creek Parkway, Leawood, KS 66211-2672.
Law could wipe out some burdensome Medicare regulations
A true story: A Medicare carrier audited a sample of 80 claims, looking for overpayments to the physician. The physician had to supply supporting records and documentation within 45 days.
Discrepancies and mistakes were found in some claims. The carrier estimated that the same proportion of errors occurred in all the physician's Medicare claims for a certain period. The physician therefore owed Medicare between $99,000 and $285,000 in overpayments, and the carrier demanded $99,000 within 30 days.
Tell your lawmakers why MERFA would make more physicians willing to care for Medicare patients.
The physician sought an extension. The carrier asked for letters denying loan applications, within 30 days. The physician's practice could not apply for loans and obtain responses by the deadline, so it paid the $99,000.
The physician appealed the audit findings. Three years later, a judge ruled there'd been no overpayment and refunded the $99,000.
That's the end of the story. But it's just the start of a new effort to make Medicare rules less burdensome. The Academy and 48 other medical groups sent the story April 3 in a letter to all members of Congress, asking them to cosponsor the bipartisan Medicare Education and Regulatory Fairness Act, H.R. 868 and S. 452.
MERFA would, for one thing, ensure that the physician in the case study above could go through an appeals process before being forced to repay the alleged overpayments, if the audit followed Medicare's first discovery of an error by the physician. MERFA also would:
- require HCFA and the carriers to construct effective, responsive education programs for physicians concerning Medicare regulations,
- stop carriers from demanding documentation on claims without cause, and
- allow physicians to waive a copayment when a Medicare patient cannot afford to pay.
Tell your lawmakers why MERFA would make more physicians willing to care for Medicare patients. See http://www.aafp.org/gov/fed/factsheets/merfa.html.
Order from AAFP at (800) 944-0000 unless otherwise noted.
Want to open your own practice? On Your Own: Starting a Medical Practice from the Ground Up (#R749, $50) has comprehensive information about starting a business, plus physician practice information on financing options, personnel issues, fees and contracting, medical records, office design and more. Go to https://secure.aafp.org/cgi-bin/catalog.pl?uid=cat100975 to order it online.
Proven value: Qualified practice advisers are at your fingertips -- just visit FP Assist. This online clearinghouse has information on consulting firms and law firms that can meet your needs. There's even advice on how to get the most benefit from the client-advisor relationship. Visit http://www.aafp.org/fpassist, e-mail fpassist@aafp.org or call (800) 274-2237, Ext. 4148.
Proven value: Check your mailbox this month for the registration brochure describing the best CME value for family physicians, the AAFP Scientific Assembly Oct. 3 - 7 in Atlanta. Register by July 11 for the best choice of courses and to save $80 on your general registration fee.
A shipping fee may apply; Kansas residents pay a 7 percent tax.
Correction
A phone number that appeared in the story "Taking the Mystery out of Loan Repayment" in the April FP Report was incorrect. To contact Paul Garrard at the Association of American Medical Colleges about debt management services, call (202) 828-0511.
FP Report is published by the AAFP News Department.
Copyright © 2001 by American Academy of Family Physicians.
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