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Am Fam Physician. 2001;63(4):721-722

Vaccine Program Reduces Referral Rate of Uninsured Children

(52nd Annual Scientific Assembly of the American Academy of Family Physicians) According to results of a survey, physicians were less likely to refer Medicaid-insured or uninsured children from their practice to public vaccine clinics since the introduction of the Vaccines for Children (VFC) entitlement program in 1994. Seventy-two percent of primary care physicians (281 of 388) who received the survey in Minnesota and Pennsylvania responded. Results showed that, on a scale of zero to 10, physician likelihood to refer an uninsured child decreased by a mean of 1.4 from pre-VFC to post-VFC. Forty-one percent of physicians reported that the VFC program decreased the number of referrals from their practice to public vaccine clinics and 54 percent gave intermediate responses. Only 8 percent of physicians participating in the VFC program were likely to refer a Medicaid-insured or uninsured child compared with 34 percent of physicians not participating in the VFC program. Physicians from Pennsylvania reported a mean difference of 11.5 in the percentage of children for whom costs hindered vaccinations.—richard k. zimmerman, m.d., m.p.h., University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania.

Inpatient Tobacco Cessation Programs Can Be Effective

(22nd Annual Conference on Patient Education) Cardiovascular patients, particularly open-heart surgery patients, can benefit significantly from inpatient tobacco counseling programs administered during the acute phase of illness, according to a study on the efficacy of such a program. From June 1998 through January 1999, patients admitted with positive tobacco use and a diagnosis of congestive heart failure, chest pain syndrome, stent/cardiac intervention and open-heart surgery received tobacco cessation counseling at WellSpan Health York Hospital, York, Pa. Counseling was individualized and personal; a physician order was not required. The patients were assessed for stage of preparedness following the Transtheoretical model of change. The counseling was a team effort including physicians, nursing staff and other health care professionals. Follow-up telephone calls were made for those patients striving to remain tobacco-free at two weeks, three, six, nine and 12 months. Of 316 patients (88 of whom were open-heart surgery patients), 187 received follow-up at one year; 67 percent (47 patients) of these were open-heart surgery patients. The investigators believe that the timing of inpatient counseling during the acute phase of illness more successfully prepares patients to make behavioral changes and provides opportunity to consider pharmacologic support options prior to discharge from the hospital. They also believe that successful tobacco cessation appears to be directly related to the intensity of counseling.—vickie l. zeiler, a.s., r.c.p., et al., WellSpan Health York Hospital, York, Pennsylvania.

Interdisciplinary Approach Helps Patients Lower Cholesterol Levels

(Patient Education) An interdisciplinary lipid management program in the family practice setting can be successful in helping most patients reach their goal for low-density lipoprotein (LDL) levels defined by the National Cholesterol Education Program guidelines. This was the conclusion of a study of 50 patients who were enrolled in the Total Lipid Care (TLC) program provided by a family practice residency in Columbus, Ohio. The program is provided by a clinical pharmacist who is also a faculty member in the residency program. The TLC program supports physicians in lipid management and documentation of clinical outcomes. Twenty-six of the patients in the study were men and 24 were women. The age range was 34 to 83 years. Twelve patients were already receiving lipid-lowering therapy, and 38 were beginning therapy. Patients were identified and enrolled in the TLC program by their family physician. Patient disease knowledge and information retention was measured by a quiz at baseline and at each telephone follow-up interview. Additional information collected from patients included medication adherence, exercise and diet evaluation and a satisfaction survey for the TLC program. The program included one-on-one teaching; provision of written materials, cholesterol log and videotape; telephone follow-up every three months for one year; and dietitian referral when applicable. Thirty-nine patients received medication therapy for at least 90 days. These patients were assessed for achievement of target LDL levels. Twenty-four (62 percent) of these patients achieved their LDL target; 15 patients (38 percent) did not reach their LDL target, but nine of these 15 patients did reduce their LDL levels. The investigators also noted that patient knowledge of hyperlipidemia improved after enrollment in the program and the number of patients who exercised increased.—miriam m. chan, pharm.d., and susanna e. johnson, m.d., Riverside Family Practice Residency, Columbus, Ohio.

Leflunomide Is Effective in the Treatment of Rheumatoid Arthritis

(64th Annual Meeting of the American College of Rheumatology) Results of a randomized, placebo-controlled, multicenter study showed that twice as many patients receiving both leflunomide and methotrexate for treatment of rheumatoid arthritis demonstrated significant therapeutic benefits compared with a control group receiving a placebo and methotrexate. The 24-week, multicenter trial included 263 patients with active rheumatoid arthritis who were unresponsive to treatment with methotrexate alone. Patients were randomized to receive 10 mg per day of leflunomide with methotrexate (130 patients; mean dose of 16.7 mg per week) or placebo with methotrexate (133 patients; mean dose of 16.2 mg per week). Dose adjustments were made depending on tolerability and efficacy. Forty-six percent of patients in the leflunomide group responded to the therapy while only 20 percent of patients in the control group responded to therapy. The researchers used the American College or Rheumatology's (ACR) 20 percent response rate to assess the efficacy of the treatment at 24 weeks. The ACR criteria for response includes: (1) at least a 20 percent improvement in both tender and swollen joint count and (2) at least a 20 percent improvement in three of the following five criteria: patient's assessment of disease activity, investigator's assessment of disease activity, pain intensity, functional/disability measur, and acute phase reactants. The combination therapy was well tolerated; minor adverse effects included diarrhea, nausea and dizziness.—joel m. kremer, Center for Rheumatology, Albany, New York.

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