Coverage inequalities of new therapies for rheumatoid arthritis in a managed care setting.

Rheumatoid arthritis (RA) is a progressive disease that leads to functional disability and substantial medical costs. Early treatment with disease-modifying antirheumatic drugs (DMARDs) has been shown to inhibit the progression of RA, with accompanying improvements in functional outcome and long-term medical costs. Biologic response modifiers (BRMs) are a new class of therapeutic agents for RA that offer a more favorable side-effect profile than traditional DMARDs. One BRM, the self-injectable medication etanercept, has demonstrated great potential for improving the long-term prognosis of patients with RA. Unfortunately, patients' access to treatment with etanercept is sometimes limited because of the structure of health-care coverage for self-injectable drugs.

New pharmacological agents under clinical investigation for treating disorders of lipoprotein regulation leading to atherosclerosis.

Coronary heart disease (CHD), whose primary aetiology is atherosclerosis, is the leading cause of mortality and a major cause of morbidity in the industrialised world [1]. Serum lipoprotein levels are aetiologically related to the risk of atherosclerosis and CHD [2]. The liver and the gastrointestinal system are the major protagonists involved in regulation of lipoprotein biochemical-physiological mechanisms and the development of hypercholesterolaemia. Furthermore, specific lipoprotein receptors are being discovered as targets for pharmacological intervention to correct lipoprotein disorders. Agents that target lipoprotein regulation in the liver, gastrointestinal-biliary and atherosclerotic tissues resulting in improved serum lipoprotein levels and/or control of primary and secondary dyslipidaemic disorders including diabetes, are currently undergoing clinical trials. The most novel promising compounds, after the greatly effective newest HMG-CoA reductase inhibitors, are drugs that affect peroxisome proliferator-activated receptors, PPARalpha and PPARgamma receptors, bile acid transport mechanisms, cholesterol absorption and cholesterol acyltransferase and other biochemical targets of lipoprotein regulation. Current knowledge and ongoing trials with these agents are described here within the boundaries of investigator confidentiality agreements.

The medical director as educator: an interview with Elizabeth M. Gallup, MD, JD, MBA. Interview by Richard L. Reece.

Richard L. Reece, MD, interviewed Elizabeth M. Gallup, MD, JD, MBA, on July 9, 1999, to talk about the evolving role of the physician executive. Dr. Gallup discusses how medical directors have evolved from a purely clinical role to participating in the business side of medicine as well. The traditional medical director, a Dr. No who denies treatment and watches clinical performance, is now becoming an educator helping physicians to manage their behavior and change their practices based on comparative data. Her book, How Physicians Can Avoid Surrender and Lead Change: Gaining Real Influence in Your Own Health Care Organization Before It's Too Late, (American College of Physician Executives, 1996) promotes acting together as a group if physicians want to stay independent and not become employed. Independent physicians can form IPAs and act together as a group, avoiding some antitrust laws. Unless physicians get together and act as a group, she says, they are doomed to further and further erosion of their economic interests as well as their clinical autonomy.

Forming physician organizations. Part 2: The underlying reason a PO succeeds: an offense, not defense.

How has Community Health Partners been able to move the ball down the field toward the goal of a preferred network in its community? What are the specific offensive strategies CHP has implemented to bring about its vision? Part 1 of this series explored five reasons for CHP's progress: (1) A working, knowledgeable board of respected physicians, (2) A board that moves ahead on simultaneous tracks, (3) a willingness to affiliate with any hospital or payer that really knows how to partner with physicians, (4) developing quick wins and communicating the progress, and (5) educating physicians about the new ground rules for capitation. Here are six more reasons for CHP's success in forming a PO.

Physician organizations. Part 1: A report from the trenches of a start-up PO.

How has Community Health Partners, a physician organization based in Kansas City, turned the corner as it rolls into the second year of operation? The biggest indicator is that CHP hammered out the city's first professional risk contracts and the PO has grown from 23 to more than 50 physician member/owners. Looking back, there are at least 10 reasons why CHP made it this far. These are not reasons you learn about in medical school or an MBA program. There is no one-size-fits-all template for building POs. No fixed organizational chart. No neon signs pointing to the best capital partner. Part I explores five reasons for success, such as having a strong board and physician leadership, as well as educating participating physicians about capitation and affiliating with any hospital or payer that really knows how to partner with physicians. Part 2 will focus on five more lessons learned from the trenches of a start up PO.

Identification of patient-controlled analgesia overdoses in hospitalized patients: a computerized method of monitoring adverse events.

OBJECTIVE: To describe and validate a computer-based quality assurance method that detects narcotic overdoses associated with patient-controlled analgesia (PCA) use. SETTING: Two acute care teaching hospitals. PATIENTS: 4669 patients who received PCA. INTERVENTIONS: The following patient lists were obtained during a two-year period from both hospital information systems: those who received PCA and (1) received naloxone, a narcotic antagonist, (2) were transferred to an intensive care unit, (3) had a cardiac or respiratory arrest, or (4) died. Possible overdoses were defined as patients who appeared on the PCA list and one of the other lists. Charts were reviewed if the patient's name appeared on the PCA and one of the other lists. Patients were judged to have experienced a narcotic overdose if there was an immediate improvement in blood pressure, respiratory rate, or mental status after the administration of naloxone. RESULTS: The search strategy identified 294 possible overdoses in 1499 patients who received PCA. Ten charts were unavailable for review. An actual overdose occurred in 11 patients. The accuracy of the new method was compared with that of the hospitals' present reporting methods. Eleven overdoses were identified by the computer search, but only 6 overdoses were identified in incident and adverse drug reaction reports. CONCLUSIONS: The systematic computer search identified almost twice as many adverse incidents than were reported by the traditional hospital methods.

Liability insurance for moonlighting by family practice residents.

BACKGROUND: Moonlighting is a widespread practice among residents in family practice programs. It is thought that many residents fail to appreciate the problems that moonlighting may pose with respect to liability insurance. METHODS: A survey regarding liability insurance instruction and moonlighting insurance was sent to the chief resident of each family practice residency program (380) in the United States. An overall response rate of 78.7% was achieved. RESULTS: Chief residents appear to have limited knowledge about liability insurance, believe that education about liability insurance in the residency program is inadequate, and are not well informed regarding liability insurance issues related to moonlighting. CONCLUSIONS: Information regarding professional liability insurance and its implications for the resident who chooses to moonlight should be a part of the practice management curriculum of every residency program.

Benign parotid enlargement in bulimia.

Bulimia is an episodic compulsive urge to overeat often followed by recurrent attempts to lose weight by self-induced vomiting. Seven young women with this eating disorder and associated benign bilateral painless parotid enlargement are described. The glandular swelling was generally intermittent, with parotid enlargement usually developing 2 to 6 days after a binge overeating episode had stopped. Several had hypokalemic alkalosis and a moderate elevation in serum amylase levels. None had clinical evidence of pancreatitis, and a parotid gland biopsy in one patient was normal. The clinician should be alerted to the association of benign parotid enlargement with this syndrome.