Magnetic resonance angiography of the circle of Willis in patients with symptomatic intracranial neuropathology: medicare LCD L25367(R4).

Patients with symptomatic intracranial neuropathology such as atherosclerotic occlusive disease or unruptured aneurysms face high risks for morbidity and mortality. Magnetic resonance angiography of the circle of Willis is an important tool used to detect and diagnose intracranial neuropathology; however, recent changes to the Medicare local coverage determinations for this procedure threaten to compromise the physician's ability to deliver this current standard of care. Physicians can assume an important role in advocating for this lifesaving procedure on behalf of this vulnerable patient population.

Guidance of magnetic resonance imaging and placement of skin-marker localization devices.

AIM: A variety of magnetic resonance imaging (MRI)-compatible skin-marker localization devices are available on the market. MRI protocols call for the liberal use of the skin markers over the specific site of symptoms or over any palpable mass. This study investigates the usefulness of patient-assisted placement of 1 000-mg fish oil capsules as skin markers over the area of maximum localized pain, signs, or symptoms and correlates this placement with any potential underlying neuropathology or potential pain generator. METHODS: One-hundred symptomatic patients undergoing MRI were assessed for focal or localized signs or symptoms. Under the direction of a physician and with guidance from the patient, the MRI technician placed a 1 000-mg fish-oil capsule over the area of maximum pain or signs and symptoms. Patients with poorly localized, diffuse symptoms or an area of maximal signs and symptoms outside the field of view of the MRI were not included in this study. All MRI exams were reviewed by clinical physicians and radiologists or neuroimaging physicians. RESULTS: In all 100 cases, the images show clearly visible MRI-compatible skin-surface markers that correlate with potential underlying neuropathology. CONCLUSION: Our results show that 1 000-mg fish-oil capsules can be used as MRI localization devices as a cost-effective alternative to more expensive commercially available devices.

Urine drug testing in the treatment of chronic noncancer pain in a Kentucky private neuroscience practice: the potential effect of Medicare benefit changes in Kentucky.

BACKGROUND: Because the symptoms of drug misuse are nonspecific and difficult to detect, pain physicians have relied heavily on the results of urine drug tests to diagnose and treat chronic noncancer pain in patients who are prescribed controlled substances. However, changes in Medicare local carrier determinations for Medicare Part B providers in Connecticut, Indiana, Kentucky, and New York went into effect on July 1, 2009, whereby qualitative drug screening was no longer recognized as medically reasonable and necessary in the treatment of patients with chronic noncancer pain unless the patient presents with suspected drug overdose. STUDY DESIGN: A retrospective review of urine drug testing services. OBJECTIVE: To determine the extent of urine drug testing in patients with chronic noncancer pain in a large, Kentucky neuroscience practice offering pain management services combined with neurologic and neurosurgical services to better understand the potential effects of recent changes to Medicare benefits. METHODS: An audit of services provided during 2007 was conducted using computer software. OUTCOME MEASURES: Outcome measures included the number of practice services, number of urine drug tests by payor, and the number of noncompliant patients by payor who self-released from care. RESULTS: Urine drug tests represented approximately 18.2% of professional medical services rendered in 2007 to patients with a diagnosis of chronic noncancer pain. Of these, UDTs represented approximately 22.2% of services provided to Medicare patients and 24.6% of services provided to Medicaid patients. In 2007, 2,081 patients with noncompliant UDTs self released from the practice against medical advice. Of these, 23.1% were enrolled in Medicare and 47.5% were enrolled in Medicaid. Approximately 40% of patients were referred to the CARE Clinic on the basis of noncompliance as indicated by UDT and/or behavioral health issues. Of these, approximately 50% remained in treatment. Urine drug tests were also instrumental in revealing that 19.6% of patients showed signs of drug abuse or addiction. Of these patients, approximately 60% were government insured. LIMITATIONS: Not a prospective, double-blinded study. We approximated the proportion of patients potentially affected by drug abuse or addiction as the percentage of patients self releasing from medical care. CONCLUSION: In 2007, UDTs were used as an effective tool in adherence monitoring in a private neuroscience practice in Kentucky that offers pain management services combined with neurologic and neurosurgical services. UDTs were instrumental in referring 40% of patients for evaluation and treatment by behavioral health and addiction medicine specialists. UDTs were also instrumental in discovering signs of drug abuse or addiction in 19.6% of patients. Of these patients, approximately 60% were government insured. Should the objective and reliable sign offered by UDTs be eliminated from the physician's toolbox, the physician's ability to accurately diagnose and treat these patients could be impaired.

Importance of urine drug testing in the treatment of chronic noncancer pain: implications of recent medicare policy changes in kentucky.

BACKGROUND: Urine drug testing has become a widely used tool in American society for deterring illicit drug use. In the practice of medicine, urine drug testing is commonly used to help diagnose substance misuse, abuse, or addiction. OBJECTIVE: This narrative review provides an informed perspective on the importance of urine drug testing in the medical treatment of chronic noncancer pain. The history and current uses of urine drug tests in the United States are reviewed, the prevalence and nature of prescription drug misuse is described as is related to chronic noncancer pain, and implications and considerations for practitioners are presented related to the noncancer pain diagnosis and treatment. DISCUSSION: Practitioners are confronted with the ethical and legal dilemma of being called to adequately treat chronic pain in a culture with a high prevalence of prescription drug abuse. Yet the symptoms of drug abuse are nonspecific and therefore of limited value to the practitioner in determining patient compliance to drug treatment regimens. In contrast, urine drug testing has a reliable history, both in and out of medicine, as an independent sign of drug misuse. This sign can be used to aid in the diagnosis and treatment of drug misuse and underlying addictions to improve patient outcomes. CONCLUSION: Regular urine drug testing should be a part of acute and chronic pain management whether or not the patient has any signs or symptoms of drug misuse.

Screening events to reduce farmers' hazardous exposures.

Dairy farmers may be exposed to high levels of noise and dust. Protections against these hazards exist, but many farmers do not use them. An intervention consisting of hearing and respiratory screenings combined with personalized education was implemented. This study evaluates the impact of this intervention on farmers' self-reported use of personal protective equipment (PPE) and implementation of noise and dust abatement. Participants were screened as to noise (n=209) or dust (n=392) hazards and use of PPE. Following this, they were counseled on PPE use, and identification and reduction of noise or dust hazards. Counselors sought a pledge from the farmers to eliminate hazards and increase PPE use. Farmers were subsequently surveyed and asked whether they had implemented the changes. At baseline, 70% (146/209) of farmers exposed to high levels of noise reported poor use ("sometimes", "rarely", or "never") of hearing protection. Results indicated that two months after intervention, 25.2% (28/111) of these subjects had successfully improved their PPE use. At baseline, 79% (311/392) offarmers reported poor use of respiratory protection, with 27.3% (41/150) showing improvement in PPE use within the same time. Strategies to reduce noise hazards were identified by 92.8% (194/209) of hearing screening attendees; 13.2% (18/136) successfully reduced or removed exposure. These values for dust screening attendees were 98.2% (385/392) and 30.7% (54/176), respectively. Use of this intervention appears to be an effective method for increasing PPE use on the farm. However, it is not effective for reducing noise hazards.

Rollover protection on New York tractors and farmers' readiness for change.

Tractor overturns contribute significantly to fatalities in New York State agriculture. On-site inspections a decade ago indicated that approximately 60% of tractors were without effective rollover protection. Our objectives were: to describe the current prevalence and distribution of rollover protective structures (ROPS) on New York farm tractors, to identify characteristics associated with the absence of ROPS, to explore segmenting the New York farm community on readiness for ROPS retrofitting, and to identify demographic characteristics that might assist in this segmenting. A random selection of 644 livestock, dairy, fruit, cash crop, vegetable, and organic farms were contacted for a telephone survey. Of 562 farms (87%) participating, 102 (18.1%) had all tractors equipped with ROPS and 138 (24.6%) had none. A disproportionate number of livestock, cash crop, and organic operations had no ROPS. Rates of ROPS-equipped tractors correlated directly with farm size and annual hours of tractor operation. Older farmers had a lower proportion of ROPS tractors. The presence of a child operator did not affect the proportion of ROPS tractors. After weighting the sample, the total number of non-ROPS tractors in New York is estimated at more than 80,000. In addition to providing key farm demographics, the survey enabled placement of farmers on a "stage of change" continuum related to readiness for retrofitting. Three-quarters of New York farmers are in the "precontemplation" stage of change relative to ROPS retrofitting, and this varies little by size of operation, age of farmer, or the presence of child tractor operators. Stage of change may relate to hours of tractor operation (p = 0.05) and does relate to commodity (p = 0.003) due primarily to the higher proportion of crop farmers in the earliest stage of change. The goal of retrofitting all New York farm tractors with ROPS appears nearly as daunting as it did a decade ago.

Risk perceptions, barriers, and motivators to tractor ROPS retrofitting in the New York state farm community.

The prevalence of tractor rollovers among agricultural workers has made the retrofitting of tractors with rollover protective structures (ROPS) and seat belts a public health priority for agricultural health and safety specialists. To address this concern, the New York Center for Agricultural Medicine and Health (NYCAMH) developed a seven-question survey, designed to assess perceptions of risk as well as potential motivators and barriers to retrofitting. Data from 465 phone surveys were gathered from New York State farmers representing various commodities and farm sizes. Analysis of responses to three qualitative questions contained in the survey indicated that most farmers in New York understand the importance of ROPS but lack the proper motivation to consider retrofitting. It appears that more convenient safety strategies, cost, and age of the tractor compete with a farmer's initiative to retrofit. In addition, survey responses illustrate that although many farmers believe ROPS are important in a general sense, many believe that this safety measure is not necessary for them in particular. Frequent motivators to retrofitting are concerns about safety, although the authors conclude that a more thorough analysis of these "general safety concerns" in qualitative interviews is important.

Commentary from the front lines: improving the National Health Service Corps' use of nonphysician medical providers.

Migrant and community health centers, funded by the Bureau of Primary Health Care (BPHC), provide a vital service to rural communities by ensuring accessible and affordable medical care. One way the BPHC helps communities staff these centers is through the National Health Service Corps (NHSC). In this program, medical professionals receive scholarships or educational loan repayment in return for practicing in medically underserved regions where migrant and community health centers are located. Nurse practitioners, physician assistants, and nurse midwives (nonphysician providers) are a recent addition to the NHSC, and they offer the advantages of reduced cost and a strong primary care orientation. In this commentary, the authors recount their own experiences as a nonphysician provider NHSC scholarship recipient and spouse, and they identify five underlying problems with the current system, which lead to poor nonphysician provider retention. (1) Too few potential placement sites are made available from the outset. (2) NHSC placement deadlines do not allow enough time for making the best possible placement. (3) Many community health centers are not highly supportive of or invested in the program. (4) NHSC efforts to support the development of local medical providers from within underserved regions are inadequate. (5) NHSC officers working with nonphysician providers do not demonstrate a high degree of commitment to achieving an optimal provider-site match. Changes in the NHSC program based on these five problems are recommended to improve the retention of nonphysician providers in this important program.