(Embargoed Until: 3 P.M. (CT), Monday, November 8, 2004)
(Embargoed Until: 3 P.M. (CT), November 8, 2004)
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EMBARGOED FOR RELEASE UNTIL 3 P.M. (CT), MONDAY, November 8, 2004
To contact Eric G. Poon, M.D., M.P.H., call Amy Dayton at 617/534-1603.
DELAYS IN TEST RESULT REVIEWING COMMON
CHICAGO—Delays in reviewing test results are common, and many physicians are not satisfied with how they are able to manage test results, according to an article in the November 8 issue of the Archives of Internal Medicine, one of the JAMA/Archives journals.
According to the article, failure to follow up with patients about their test results is a patient safety and malpractice concern, and lack of timely follow-up can jeopardize patient safety and satisfaction.
Eric G. Poon, M.D., M.P.H., of Brigham and Women's Hospital, Boston, and colleagues attempted to identify problems in current test result management systems and developed possible alternatives for improving these systems.
The researchers surveyed 262 physicians (64 percent response rate) working in 15 internal medicine practices affiliated with two large, urban teaching hospitals. Physicians were asked about specific systems they used to manage test results and how much time they spent managing test results.
Of the physicians who completed the surveys, 83 percent reported at least one delay in reviewing test results during the previous two months. "Despite reporting that they spent on average 74 minutes per clinical day managing test results, only 41 percent of physicians reported being satisfied with how they managed test results," the article states. The features physicians most wanted to help with test result management were tools to help them generate result letters to patients, prioritize their workflow and track test orders through to completion.
"Our survey findings suggest that significant problems exist with test result management systems in primary care physicians' offices," the authors write. "The high frequency of reported delays is important since self-reporting typically significantly underestimates the true incidence of errors. The relationship between self-reported delays and dissatisfaction suggests that physicians also recognized delays in test result review as a significant problem affecting quality of care and patient safety. While our survey did not directly characterize the clinical importance of these delays, the fact that physicians 'wished they had known about' these results earlier strongly suggests that many of these results might have changed patient management."
(Arch Intern Med. 2004;164:2223-2228. Available post-embargo at archinternmed.com)
Editor's Note: This work was funded in part by a grant from the Agency for Healthcare Research and Quality, Rockville, Md.
For more information, contact JAMA/Archives media relations at 312/464-JAMA (5262) or e-mail mediarelations{at}jama-archives.org.
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EMBARGOED FOR RELEASE UNTIL 3 P.M. (CT), MONDAY, November 8, 2004
To contact Robert G. Brooks, M.D., call Nancy Kinnally at 850/644-7824. To contact editorialist James Schroeder, M.D., call Elizabeth Crown at 312/503-8928.
RURAL FLORIDA SEVERELY AFFECTED BY STEEPLY RISING MEDICAL PROFESSIONAL LIABILITY INSURANCE COSTS
CHICAGO—Rising professional liability insurance costs in Florida have had a major impact on the availability of health care services in rural areas, according to an article in the November 8 issue of the Archives of Internal Medicine, one of the JAMA/Archives journals.
According to the article, almost half of the states, including Florida, face serious problems with professional liability insurance (PLI). In these states, huge increases in insurance premiums, physicians leaving these states, and the closing of health care facilities including emergency departments, are reported frequently. Particularly vulnerable to these changes are the 60 million people who live in rural America, the article states.
Robert G. Brooks, M.D., of Florida State University, Tallahassee, and colleagues surveyed physicians practicing in rural Florida in 2003. Physicians were asked about changes in health care delivery by service type and specialty, and about changes in PLI premiums and the effect of these changes on delivery of services and their own satisfaction in their practice.
Of the 781 physicians surveyed, 411 (52.6 percent) decreased or eliminated health care services during the past year. The researchers found that overall:
- 73 (61.3 percent) of 119 decreased or eliminated vaginal deliveries
- 60 (52.6 percent) of 114 eliminated cesarean sections
- 186 (51.7 percent) of 360 eliminated hospital-based surgical procedures
- 209 (46.4 percent) of 450 eliminated emergency department coverage
- 103 (41.7 percent) of 247 eliminated endoscopic procedures
- 187 (40.9 percent) of 457 eliminated office-based surgical procedures
- 105 (34.5 percent) of 304 eliminated mental health services
Elimination of procedures and/or services was found to be highest among general surgeons (78.4 percent), surgical specialists (73.6 percent), and obstetricians/gynecologists (70.2 percent).
The researchers also found that premiums for PLI in Florida rose an average of 93.5 percent, and they write, "Difficulty finding or paying for PLI was listed as an important factor by those reducing or eliminating services and by those planning to leave the community within the next two years."
The authors state that, "The current crisis in medical PLI in Florida has a major impact on the availability and delivery of health care services to rural areas. Given the number of states that are experiencing similar insurance market upheavals, adverse effects on access to care are likely occurring nationwide."
"One of the most concerning findings in this study is the decrease and elimination of vaginal deliveries and cesarean sections by obstetricians/gynecologists and family physicians. Rural women have traditionally been shown to have increased rates of infant mortality and maternal complications, problems that may be accentuated by the decreasing availability of local delivery and cesarean section services," the authors write.
(Arch Intern Med. 2004;164:2217-2222. Available post-embargo at archinternmed.com)
Editor's Note: This study was supported in part by a grant from the Florida Department of Health, Office of Rural Health, Tallahassee.
EDITORIAL: CANARIES IN THE COAL MINE: THE NOXIOUS EFFECT OF THE LIABILITY CRISIS ON RURAL HEALTH CARE
In an accompanying editorial, James Schroeder, M.D., of the Northwestern Medical Faculty Foundation, Chicago, writes, "Brooks and colleagues make clear that, as a result of the liability crisis, access to care is declining significantly, and that effect is marked, especially in vulnerable populations where access is already problematic."
"Identifying a solution to the crisis is not difficult, because we have states in which PLI costs are not excessive. The common factor in states in crisis is the failure to cap noneconomic damages. Overall, states that cap noneconomic damages have lower PLI premiums than those that do not have caps," Dr. Schroeder writes.
"Beginning with the capping of noneconomic damage awards is critical to stabilize the system, but ultimately other reforms are needed if we are to 'bridge the quality chasm,' as the Institute of Medicine proposed," writes Dr. Schroeder.
Among Dr. Schroeder's recommendations are the following:
- cap all noneconomic damages (pain and suffering, mental anguish) at $250,000
- eliminate the rule that prohibits juries from knowing about payments that plaintiffs already received from other sources
- require a reasonable statute of limitations on claims
- establish a sliding scale for attorney's fees
- limit punitive damages to $250,000 or twice compensatory damages (the total of economic damages plus noneconomic losses), whichever is greater
- Make grants available to states to develop Alternative Dispute Resolution programs
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EMBARGOED FOR RELEASE UNTIL 3 P.M. (CT), MONDAY, November 8, 2004
To contact Allan V. Prochazka, M.D., M.Sc., call Dana Berry at 303/315-5571.
ANTIDEPRESSANT MAY HELP PEOPLE STOP SMOKING WHEN USED WITH NICOTINE PATCH
CHICAGO—When used with a transdermal nicotine patch, nortriptyline-an antidepressant medication-may aid in smoking cessation, according to an article in the November 8 issue of the Archives of Internal Medicine, one of the JAMA/Archives journals.
According to background information in the article, smoking is an important preventable cause of death. However, current cessation methods are only partially successful. Several different types of antidepressant medications have been effective in helping people quit smoking.
Allan V. Prochazka, M.D., M.Sc., from the University of Colorado Health Sciences Center, Denver, and colleagues tested the efficacy of nortriptyline in helping people quit smoking cigarettes. Study participants, aged 18 to 65 years, were randomly assigned to one of two groups: one group received nortriptyline (n = 79) and one group received placebo (n = 79). Researchers started both groups with 25 milligrams per day of either nortriptyline or placebo 14 days before the set quit date, and then increased dosage to 75 milligrams per day, as tolerated. A transdermal nicotine patch was administered to all study participants on the determined quit day and was worn for eight weeks.
The researchers found that at six months, cessation rates were 23 percent for those taking nortriptyline and 10 percent for those taking placebo. Neither group experienced a reduction in withdrawal symptoms. However, the nortriptyline group had a significantly higher rate of adverse effects than the placebo group, with 38 percent of participants experiencing dry mouth and 20 percent experiencing drowsiness. Nortriptyline was discontinued in 13 percent of participants due to adverse effects.
The authors write, "...there are several possible mechanisms of action for nortriptyline's effect in enhancing smoking cessation. Nortriptyline may reduce depressive symptoms and the need for 'negative affect reduction smoking.' Other antidepressant agents are also effective in smoking cessation, suggesting that the antidepressant effect may be the common mechanism."
The researchers conclude: "It is also clear from our data that subjects treated with nortriptyline require close monitoring for adverse events...However nortriptyline combined with transdermal nicotine may prove to be a useful alternative for smokers in whom first-line smoking cessation therapies have failed."
(Arch Intern Med. 2004;164:2229-2233. Available post-embargo at archinternmed.com)
Editor's Note: This study was supported by a grant from the Department of Veterans Affairs, Washington, DC.
For more information, contact JAMA/Archives media relations at 312/464-JAMA (5262) or e-mail mediarelations{at}jama-archives.org.
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EMBARGOED FOR RELEASE UNTIL 3 P.M. (CT), MONDAY, November 8, 2004
To contact David R. Matthews, F.R.C.P., e-mail: david.matthews{at}ocdem.ox.ac.uk. To contact editorialist Ronald Klein, M.D., M.P.H., call Lisa Brunette at 608/263-5830.
CLOSE CONTROL OF BLOOD PRESSURE ASSOCIATED WITH FEWER EYE PROBLEMS IN PATIENTS WITH TYPE 2 DIABETES
CHICAGO—Patients with type 2 diabetes and hypertension who kept their blood pressure very tightly controlled had fewer eye disorders caused by their diabetes, according to an article in the November issue of the Archives of Ophthalmology, one of the JAMA/Archives journals.
According to the article, type 2 diabetes and hypertension are often associated. At age 40, approximately 32 percent of patients with type 2 diabetes are also hypertensive, and that proportion increases to 47 percent by age 60, the article states. Hypertension also increases the risk of microvascular disease (including diseases of the eye like retinopathy, which can affect vision), and reducing blood pressure has been known to reduce the risk of microvascular disease.
David R. Matthews, F.R.C.P., of the Oxford Centre for Diabetes, Endocrinology, and Metabolism, Churchill Hospital, England, and colleagues investigated the relationship between tight blood pressure (BP) control and diabetic retinopathy (a type of eye disorder associated with diabetes) in patients with type 2 diabetes mellitus (DM).
The researchers studied 1,148 hypertensive patients (average age, 56) who had DM for an average duration of 2.6 years at the beginning of the study. Participants had an average BP of 160/94 millimeters of mercury (mm Hg). Seven hundred fifty eight patients were randomly assigned to the tight BP control group (aiming for a BP of less than 150/85 mm Hg), and 390 were assigned to a less stringent BP control policy (aiming for a BP of less than 180/105 mm Hg).
The researchers found that 4.5 years after the beginning of the study, 23.3 percent of participants in the tight BP control group experienced five or more microaneurysms (tiny dilated areas in the walls of the blood vessels of the eye) compared to 33.5 percent of the less tight BP control group. Additionally, there was an elevated risk of blindness in the less strict BP control group, although no participant went blind in both eyes over the study period.
"High BP is detrimental to each aspect of diabetic retinopathy and a tight BP control policy reduces the risk of clinical complications from diabetic eye disease," the authors write.
(Arch Ophthalmol. 2004;122:1631-1640. Available post-embargo at archophthalmol.com)
Editor's Note: This study was supported in part by major grants from the United Kingdom (UK) Medical Research Council, London, England; British Diabetic Association; the UK Department of Health, London; National Eye Institute, National Institute of Digestive, Diabetes, and Kidney Disease in the National Institutes of Health, Bethesda, Md.; the British Heart Foundation, London; Novo-Nordisk A/S, Copenhagen, Denmark; Bayer (Schweiz) AG, Zurich, Switzerland; Bristol-Myers Squibb, New York, N.Y.; Hoechst AG, Kehl, Germany; Eli Lilly & Co., Indianapolis, Ind.; Lipha and Farmitalia Carlo Erba, Milan, Italy.
EDITORIAL: IS INTENSIVE MANAGEMENT OF BLOOD PRESSURE TO PREVENT VISUAL LOSS IN PERSONS WITH TYPE 2 DIABETES INDICATED?
In an accompanying editorial, Ronald Klein, M.D., M.P.H., of the University of Wisconsin-Madison, writes, "The report in this month's issue describes the effect of blood pressure control on the incidence of specific retinal lesions, the need for photocoagulation [treatment for ocular microaneurysms], and visual outcomes. The new data show a highly significant reduction in incidence of [several eye disorders associated with diabetes] at 7.5 years of follow up. Loss of three lines of vision or more at nine years of follow-up was reduced by 47 percent in the tight control group compared to the less tight control group."
Dr. Klein writes that, "These findings clearly demonstrate the importance of lowering blood pressure to reduce the progression of retinopathy, incidence of macular edema, and loss of vision in persons with relatively short duration of type 2 diabetes and moderate to severe hypertension."
He concludes: "Ophthalmologists should tell their diabetic patients about the benefits of blood pressure control in reducing loss of vision from diabetic retinopathy and emphasize the need for routine monitoring of blood pressure (including measurements at each eye examination)."
(Arch Ophthalmol. 2004;122:1707-1709. Available post-embargo at archophthalmol.com)
For more information, contact JAMA/Archives media relations at 312/464-JAMA (5262) or e-mail mediarelations{at}jama-archives.org.
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