Clinical Insights/Professional Update

March 1, 2004



 

NEWS WATCH

CLINICAL INSIGHTS

Jump to:Choose article section... Valacyclovir reduces transmission of genital herpes A new approach to cervical screening Mammography linked to smaller tumors Pelvic arterial embolization for intractable postpartum hemorrhage HT-associated breast cancer has better prognosis Experience says ICSI is safe New tool helps health-care providers ID domestic violence C-sections double risk of stillbirth in subsequent pregnancies PROFESSIONAL UPDATE Meeting the test of character in the courtroom More physicians getting on-call pay Survey says PDAs improve physician practice Case law: Informed consent for abortion does not include value judgment A medical group that works to improve the 'patient service culture' AMA to tackle claim denials based on specialty, audit equity

HT decreases life expectancy, but benefits may exceed risks

Combination hormone replacement therapy (HT) slightly decreases a woman's life expectancy, probably on the order of several days. But, when quality of life without menopausal symptoms is factored into the equation, HT provides an equivalent or greater number of quality-adjusted years of life than no therapy at all.

Using a Markov decision-analysis model, researchers compared the quality-adjusted life expectancy with and without combination HT in three cohorts of women with menopausal symptoms over a 20-year period.

They found that for women who use HT for less than 5 years, symptoms would need to affect a woman's quality of life only slightly—not even as much as seasonal allergies—to make HT use beneficial in terms of quality-adjusted years of life. The authors of the study advise that women and their clinicians considering the use of HT include such information in a complete discussion about the benefits and risks of therapy.

Kim C, Kwok YS. Decision analysis of hormone replacement therapy after the Women's Health Initiative. Am J Obstet Gynecol. 2003;189:1228-1233.

Valacyclovir reduces transmission of genital herpes

Once-daily suppressive therapy with the antiviral valacyclovir not only reduces the frequency of genital herpes outbreaks, but also significantly reduces shedding of the virus, thereby cutting the risk of transmission to half that associated with taking placebo, according to a recently published study.

Researchers from the Valacyclovir Transmission Study Group studied 1,484 immunocompetent, heterosexual, monogamous couples of which one member was herpes simplex virus type-2 (HSV-2)-seropositive and one was seronegative. The positive partners received either 500 mg oral valacyclovir or placebo once daily for 8 months.

Of the 743 couples with a member taking valacyclovir, 14 of the mates acquired the virus (1.9%) versus 27 of the partners of those receiving placebo (3.6%). In addition, about half those taking valacyclovir versus those taking placebo experienced a genital recurrence during the study (39% vs. 77%, respectively), and the time to recurrence was significantly longer in those taking valacyclovir (0.11 vs. 0.4, respectively).

The investigators caution that since the drug does not block viral transmission in all users, HSV-2-positive individuals should still disclose the virus to susceptible partners and continue to use condoms and other safe sex practices.

Corey L, Wald A, Patel R, et al. Once-daily valacyclovir to reduce the risk of transmission of genital herpes. N Engl J Med. 2004;350:11-20.

A new approach to cervical screening

The HART (HPV in Addition to Routine Testing) study suggests that screening women for human papillomavirus and then triaging those who are positive with cytology may improve detection rates of high-grade cervical intraepithelial neoplasia (CIN2+) without increasing the rate of colposcopies.

HART was a British multicenter screening study involving more than 11,000 women between 30 and 60 years of age from 161 family practices. The researchers randomized women with borderline cytology and women positive for high-risk HPV with negative cytology to receive either immediate colposcopy or repeat HPV testing, cytology, and colposcopy in 12 months.

In terms of detecting CIN2+, the authors found HPV testing to be considerably more sensitive than borderline or worse cytology (97.1% vs. 76.6%, respectively), and only slightly less specific (93.3% vs. 95.8%). They also found 12-month surveillance of HPV-positive women with negative or borderline cytology to be as effective as immediate colposcopy.

In addition, they determined that HPV testing is more sensitive than cytology in detecting atypical squamous cells of undetermined significance, and that it has the potential to reduce the rate of colposcopy referrals for mild dyskaryosis.1

An accompanying editorial in the same issue of the Lancet points out that while Pap cytology screening has successfully cut the incidence of cervical cancer by about 75%, Pap testing has a sensitivity of only about 51% and a high false-negative rate. The author also explains that the concept of serial diagnostic testing (with first a highly sensitive test followed by a highly specific one to triage) has good precedent in other areas of medicine, such as testing for syphilis. And finally, he supports shifting the focus of screening from a morphology-based approach to one that searches for the sexually transmitted cause, remarking that placing "the emphasis of prevention not only on women but on their partners as well" is long overdue.2

1. Cuzick J, Szarewski A, Cubie H, et al. Management of women who test positive for high-risk types of human papillomavirus: the HART study. Lancet. 2003;362:1871-1876.

2. Franco EL. Are we ready for a paradigm change in cervical cancer screening? Lancet. 2003;362:1866-1867.

Mammography linked to smaller tumors

Women aged 40 years and older with breast cancer who have at least yearly mammograms before diagnosis are more likely to have smaller tumors and a diagnosis of ductal carcinoma in situ (DCIS) than those who receive less frequent or no mammograms. That means the former group are better candidates for breast-conserving treatments, according to a recent study from the Fox Chase Cancer Center in Philadelphia, Pa.

The study involved almost 1,600 women. Of those who had no previous mammography, 15% were diagnosed with DCIS, compared to 21% of the women who had mammograms less often than once a year and 26% of those who underwent yearly mammography.

While 32% of the women with no previous mammography had T1 tumors, 50% of those who received fewer than one mammogram per year and 56% of those who received yearly mammography did so. In fact, tumor size was less than 1 cm in only 8% of the first group versus 20% to 23% of the second and third groups.

As a result, breast conservation became an option for 61% of those who underwent mammography with some regularity versus 41% of the women who had never received a mammogram. Physicians recommended mastectomy to 41% of the women who never underwent the radiologic procedure and to 28% of those who did.

Freedman GM, Anderson PR, Goldstein LJ, et al. Routine mammography is associated with earlier stage disease and greater eligibility for breast conservation in breast carcinoma patients age 40 years and older. Cancer. 2003;98:918-925.

Pelvic arterial embolization for intractable postpartum hemorrhage

Pelvic arterial embolization is a safe, effective, fertility-preserving alternative to hysterectomy for the treatment of intractable postpartum hemorrhage, according to a study by radiologists at Yale University in New Haven, Conn.

The researchers reviewed data on 28 patients who underwent the procedure in the last 25 years. They found that the most common causes of hemorrhage were vaginal/cervical laceration, placenta accreta, and placenta previa, and that embolization was unsuccessful in only one of the cases.

All patients who wished to become pregnant were subsequently able to do so and experienced full-term, uncomplicated deliveries. The most commonly reported long-term side effects of the procedure were buttock numbness and urinary frequency.

Ornan D, White R, Pollak J, et al. Pelvic embolization for intractable postpartum hemorrhage: long-term follow-up and implications for fertility. Obstet Gynecol. 2003;102:904-910.

HT-associated breast cancer has better prognosis

The mortality rate of women between ages 50 and 79 who are diagnosed with invasive lobular carcinoma (ILC)—the type of breast cancer most closely associated with hormonal therapy (HT)—is 11% lower than that of women diagnosed with invasive ductal carcinoma (IDC), according to a recent retrospective cohort study spanning 24 years (1974–1998). The gap seems to be widening even further with time; from 1994 to 1998, the risk of death was 26% lower for women with ILC.

Researchers included in the study almost 165,000 women with one of seven types of invasive breast cancer. In addition to ILC, they calculated that the risk of mortality was 8% to 34% lower for women diagnosed with mucinous carcinoma, comedocarcinoma, or medullary, tubular, and papillary carcinomas, compared to women with IDC.

Li CI, Moe RE, Daling JR. Risk of mortality by histologic type of breast cancer among women aged 50 to 79 years. Arch Intern Med. 2003;163:2149-2153.

Experience says ICSI is safe

Intracytoplasmic sperm injection (ICSI) appears to be a safe alternative for couples otherwise unable to conceive, according to a review of the observational research.

In analyzing available studies from around the world involving thousands of ICSI pregnancies and births, investigators found no indications of increased rates of prematurity or perinatal mortality in ICSI pregnancies compared with in-vitro fertilization (IVF) pregnancies. They noted that while some studies suggest a higher incidence of low birthweight, the difference does not seem to be clinically significant. They concluded that while an increased rate of sex-chromosome abnormalities in offspring from ICSI pregnancies may exist, the procedure does not seem to increase the incidence of congenital malformations. Nor is there any evidence that the procedure has any effect on a child's psychomotor development.

The findings increase in importance as the procedure becomes more common. While in the past it was reserved for cases of severe male-factor infertility, its indications have expanded to include multiple failed IVF cycles, poor fertilization, and many others.

Retzloff MG, Hornstein MD. Is intracytoplasmic sperm injection safe? Fertil Steril. 2003;80:851-859.

New tool helps health-care providers ID domestic violence

A new presentation package, the second edition of the Universal Screening for Domestic Violence, will improve clinicians' ability to identify, treat, and assist battered women, according to its maker, the Association of Women's Health, Obstetric and Neonatal Nurses (AWHONN).

The package consists of CD-ROMs, a slide presentation with script, an abuse screening tool in English and Spanish, a danger assessment tool, and a list of resources. Topics include: types of abuse, the cycle of abuse, why women stay in abusive relationships, the physical and psychological effects of domestic violence, state mandatory reporting laws, creating the right environment for screening, and the impact of abuse on pregnant women and on children who witness it.

The package can be ordered online from AWHONN's Web site at www.awhonn.org in the continuing education section of the online store. The cost is $30 for AWHONN members and $40 for nonmembers.

C-sections double risk of stillbirth in subsequent pregnancies

Caesarean section delivery of a first pregnancy doubles the risk of unexplained antepartum stillbirth at or after 39 weeks' gestation in a second pregnancy, according to a study from the United Kingdom involving data on over 100,000 births.

Researchers analyzed pregnancy discharge data from the Scottish Morbidity Record between 1980 and 1998 and from the Scottish Stillbirth and Infant Death Enquiry for 1985 to 1998. They found that women who delivered their first pregnancy by C/S had a rate of antepartum stillbirth that was 2.39 per 10,000 women per week, while those who delivered their first pregnancy vaginally had a rate of 1.44. The absolute risk of unexplained stillbirth at or after 39 weeks' gestation was 1.1 per 1,000 women who had a previous C/S versus 0.5 per 1,000 for those who did not.

The researchers say the link between C/S and stillbirth is biologically plausible because intentional or inadvertent ligation of major uterine vessels during the first C/S can alter uterine blood flow in future pregnancies. Another possible explanation is that stillbirth results from abnormal placentation caused by uterine scarring.

A commentary in the same issue of the Lancet raises the question of whether, as a result of the findings, all women with a previous C/S should be booked for repeat C/S deliveries at 38 weeks or earlier. At the very least, the authors of the study say that all pregnant women considering C/S delivery for any reasons other than absolute medical necessity should be counseled about the risks of the procedure to current and future pregnancies.

Smith GC, Pell JP, Dobbie R. Caesarean section and risk of unexplained stillbirth in subsequent pregnancy. Lancet. 2003;362:1779-1784.

Lumley JM. Unexplained antepartum stillbirth in pregnancies after a cesarean delivery. Lancet. 2003;362:1774-1775.

PROFESSIONAL UPDATE

Meeting the test of character in the courtroom

With verdicts in medical liability lawsuits reaching the tens of millions of dollars, health-care providers should be aware of how the cards are stacked should they ever be brought to trial. The good news is that defendants win in more than 62% of all medical malpractice cases, Harvard Law School's Linda Crawford, JD, told Medical Liability Monitor (12/03). That's a better rate than any other type of tort, she added.

With that in mind, Crawford notes that, these days, jurors base their decisions on issues of character before conduct. She said that jurors first try to determine who they can trust—and the physician defendant who testifies on his own behalf tops the list of the trustworthy, above the plaintiff, the attorneys, and the expert witnesses.

Crawford added that jurors also consider the physician defendant's competency, placing more weight on experience and good judgment than academic credentials. They then determine whether the physician did the best he could under the circumstances and if he made the right medical decision.

Meeting the test of character in the jurors' eyes can benefit a defendant's case. "Juries want providers who exhibit character, whether it is in the examining room, operating room, deposition, or courtroom," Crawford said.

More physicians getting on-call pay

The percentage of hospitals and large medical groups that compensate physicians for call duty has been increasing over the last few years. According to the 2003 Physician Compensation and Productivity Survey, 40% of the 180 responding organizations paid physicians for call duty—up from 28% in early 2002 and 19% in early 2001.

The survey from Sullivan, Cotter, & Associates, which conducts annual compensation surveys for health care and general industry, found that there are two kinds of call duty compensation: restricted call duty, which requires on-call physicians to stay on the premises, and unrestricted call duty, which requires on-call physicians to be contacted and to go into their facilities if necessary. As you might expect, rates for restricted call duty are higher than that for unrestricted ones, reported the online newsletter MD Practice Alert (11/5/03).

When setting compensation rates for either restricted or unrestricted call duty, the survey found that 68% of respondents negotiate individually with the physician or group that will fill on-call slots. Another 23% base their rates on a percentage of the market rate for the physician's specialty, and the remaining 9% pay the same rate for all on-call physicians regardless of specialty.

The survey also found that the pay practices of hospitals and medical groups vary for physicians on unrestricted call duty: 41% negotiate their rates individually, 27% pay the market rate for the specialty, 23% grant the on-call physician or group the professional fees generated, and 9% pay a flat rate to the on-call physician or group regardless of specialty.

Survey says PDAs improve physician practice

Physicians who use personal digital assistants (PDAs) cite greater efficiencies in their practice and improved quality of care and safety, according to a survey of more than 800 physicians. Among the findings, which were reported in Modern Physician (12/15/03):

  • Nearly nine out of 10 physicians (88%) said their PDAs allowed them to provide better care in less time.

  • About four out of 10 physicians (41%) said that their PDAs enabled them to increase the number of patients they saw per day or per week.

  • Half reported that the devices helped reduce mistakes by 4% or more.

The survey also found that, in addition to personal information, most physicians have software references such as drug and clinical tools on their PDAs and 21% said they have integrated formulary information.

But the leap toward integrating their PDAs with other applications or hospital information technology systems has not yet been made: 62% said their PDAs are not integrated with electronic applications such as billing software and more than 80% "do not experience tighter integration with hospital IT infrastructure by virtue of their PDAs," according to the survey, which was conducted by Skyscape, a Massachusetts-based developer of mobile software for health care.

Case law: Informed consent for abortion does not include value judgment

A New Jersey Superior Court judge has ruled that an obstetrician/gynecologist was not required to provide more than impartial medical information regarding a pregnant woman's abortion to gain informed consent for the procedure, reported American Medical News (1/5/04). The judge found that the ob/gyn was not negligent in failing to tell the patient that the fetus or embryo was a living being before performing an abortion.

The case was brought against the ob/gyn by a patient who had her pregnancy terminated in the first trimester. She sued years later, claiming that the ob/gyn did not obtain her informed consent to perform the abortion because he failed to tell her that the fetus was a living being. The doctor claimed that he was not required to make a value judgment regarding the question of when life begins, but only to provide the medical facts.

The judge agreed with the defense. "When plaintiff insists that the doctor should have told her that she would be terminating the life of a living human being, she is asking for more than impartial medical information," the judge wrote in her decision.

A medical group that works to improve the 'patient service culture'

In response to low patient satisfaction surveys and patient attrition as high as 40% in a 2 year period, the Central Brooklyn Medical Group (CBMG) is seeking to revamp its "patient service culture," reports MD Practice Alert (12/3/03). To that end, the 180-physician multispecialty practice is implementing financial incentives for physicians and operational changes.

Discovering that lengthy waits for physician access contributed to patient attrition, CBMG is motivating physicians to cut wait times for appointments and increase face time with patients through compensation plans. Financial incentives include rewards for CBMG physicians who close down or avoid starting outside practices or jobs, or who obtain good patient satisfaction and clinical quality scores. For CBMG primary-care physicians, the group is implementing a "subcapitation" plan, which would pay the PCP a reduced rate whenever his or her patients visit other physicians or go to urgent care. Specialists are also offered a financial incentive, called "contact capitation" compensation, which rewards them for seeing new patients quickly.

In addition, CBMG is also installing an appointment tracking system, raising staff levels, and implementing an electronic medical records system.

CBMG leaders believe the initial outlay of costs will help retain patients and ultimately boost profits. It is estimated that an extra $6 million in revenues per year will be made by cutting patient attrition in half. Moreover, the improvements in patient service will likely bring in new patients—and the revenue that comes with them.

AMA to tackle claim denials based on specialty, audit equity

It's a problem: Some insurance companies are denying reimbursement based on a physician's specialty. An insurer, for example, may deny payment to a primary care physician who wrote a prescription for an antidepressant because that physician is not a psychiatrist.

To combat the problem, the American Medical Association approved a policy in December 2003 to discourage insurers from continuing the practice and to support "appropriate action" at the state and federal levels, according to American Medical News (1/5/04). The policy has the backing of many specialists, who believe that claim denials based on specialty restrict access to care. Moreover, some claim the denials put the practice of medicine in the hands of insurers, rather than physicians.

In addition, the AMA adopted a separate policy to push for legislation requiring insurers to refund for undercoding or balance it against any overcoding found during an audit. Just as insurers demand money back if overcoding is discovered, the AMA wants physicians to receive a refund for any excess due to undercoding.

 

Clinical Insights/Professional Update. Contemporary Ob/Gyn Mar. 1, 2004;49:15-24.