Clinical Insights/Professional Update





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Choose article section... Case law established: Medical boards must follow due process The latest stats on US abortion rates Residents seek more lucrative and desirable lifestyles FTC puts the squeeze on physicians negotiating health-plan contracts Groups show support for bill to protect pregnant women's rights Exclusive attention to policy issues draws in the cash for medical directors CLINICAL INSIGHTS Breast-conserving surgery as effective as mastectomy No problem taking OCs and fluoxetine together Walking helps prevent heart disease in postmenopausal women Single-agent chemo for ovarian cancer: just as effective and less toxic Can HPV testing replace Pap smears in primary care? Do young women need sexual assertiveness training? Pregnancy and immunosuppressive treatment for aplastic anemia Vaginal tape vs. colposuspension for stress incontinence

Case law established: Medical boards must follow due process

In Arizona, case law has been established that helps guarantee due process for physicians in their dealings with state medical boards. Taking the rare step of getting involved in the workings of the state medical board, the state appeals court ruled that the board cannot take action against a physician's license without due process. (American Medical News 10/7/02)

The case involved thoracic surgeon Dale Webb, MD, who was publicly censured by the Arizona Board of Medical Examiners for unprofessional conduct. In his appeal of the decision, Webb claimed that the board had notified him via letter to appear for an "informal hearing" pertaining to its investigation of a patient's complaint. While the letter informed Webb of his right to counsel and to submit material for the board's consideration, it did not advise him that he had the option to decline the informal hearing and to ask for a formal hearing instead.

At the hearing, Webb further claimed that "he was denied a meaningful opportunity to be heard at the interview conducted by the board," according to the appeals court opinion. Specifically, he was not given the opportunity to respond to an expert who testified against him.

In response, the board defended the "procedural adequacy" of the hearing. The appeals court, however, disagreed. It set aside the board's sanction "because (Webb) was denied the right to fully and fairly test the evidence against him before the board imposed a permanent and public sanction." The case was remanded back to the board to hold a hearing that satisfies the requirements of due process.

The case is Dale F. Webb, MD, v The State of Arizona, by the Arizona Board of Medical Examiners.

The latest stats on US abortion rates

The US abortion rate decreased by 11% between 1994 and 2000, from 24 to 21 abortions each year per 1,000 women aged 15 to 44, according to a study conducted by The Alan Guttmacher Institute. However, the rate among economically disadvantaged women—those living below 200% of the poverty level—increased.

The steepest decline in abortion rates occurred among adolescents, particularly those aged 15 to 17. The rate fell from 24 abortions per 1,000 women in 1994 to 14 abortions per 1,000 women in 2000—a decline of 39%. The authors of the study suggest that these numbers indicate that fewer teens are getting pregnant—an outcome that may be attributed to improved contraceptive use or delayed sexual activity.

Economically disadvantaged women accounted for 57% of all women who had abortions in 2000. The authors of the study found that abortion rates decreased as income rose: Among poor women, 44 per 1,000 had an abortion vs. 10 per 1,000 women among the highest-income women. The authors note that the high abortion rate among the former group is a reflection, in part, of their high pregnancy rates and their greater likelihood than the highest-income women to abort their pregnancies.

The study was based on a survey of more than 10,000 women who obtained abortions in 2000 and 2001.

Residents seek more lucrative and desirable lifestyles

The percentage of ob/gyn residency positions filled from 1998 to 2001 has declined, with a slight uptick in 2002, according to an article in the ob/gyn edition of Medical Economics (8/2002). While 93.8% of ob/gyn slots were filled in 2002, just 74.7% were US medical school graduates.

These numbers suggest that US medical school graduates are looking for more from their residencies. Not only do they seek more lucrative specialties, such as orthopedics or plastic surgery, they also seek specialties that offer a controllable lifestyle.

"The current generation is taking a hard look at length of training, number of hours on call, likelihood of litigation, amount of stress, and how much they'll be able to control or predict their work schedules," reported Barbara Weiss, news editor of Medical Economics, OB/GYN edition.

So where are the US medical students going? Preliminary data based on a survey of 358 residency directors indicate that some students are dismissed for poor performance, some switch out of their residencies for another program, and others leave medicine altogether. The residency directors surveyed cited a number of reasons for this trend. Among them: a lack of understanding of the demands of the specialty or graduate medical education, the desire to stay home or raise a family, and the need to pursue a lifestyle with less demand on self and time.

FTC puts the squeeze on physicians negotiating health-plan contracts

The Federal Trade Commission seems to be stepping up efforts to ensure that physicians are not violating federal labor laws when negotiating health-plan contracts.

In one case, reported in American Medical News (9/9/2002), the FTC advised the Clark County (Nev.) OB-GYN Society that they were investigating the 100-member group "to see if it violated antitrust laws by collectively negotiating health insurance contract prices or by collectively refusing to deal with plans."

The society's president, John Nowins, MD, denied any wrongdoing by its members, according to the report. Nowins told AMNews that physicians were calling health plans to ask for reimbursement increases to help offset the cost of increasing medical liability rates. These calls, he said, were made individually—not in collusion with one another.

The FTC has reached four settlements with physicians who used a "third-party messenger model" to negotiate contracts. Under federal law, independent, self-employed physicians are prohibited from jointly negotiating health-plan contracts. However, they can designate a third-party messenger to negotiate such a contract, as long as certain parameters to avoid anti-competitive conduct are followed.

The FTC had separately accused the physicians' groups of misusing the model, by not adhering to the guidelines that are in place to promote competition. The settlements were made to avoid lengthy legal efforts, and were not considered an admission of guilt.

Groups show support for bill to protect pregnant women's rights

Recognizing a gap in the care of pregnant women, the American College of Obstetricians and Gynecologists and the Center for Reproductive Law and Policy have thrown their support behind a Senate bill designed to ensure that low-income pregnant women receive both prenatal and postpartum services. S. 724, The Mothers and Newborns Insurance Act of 2001, would permit states to extend State Children's Health Insurance Program, or SCHIP, coverage to meet these pregnant women's needs.

The gap in coverage was created last year when the Department of Health and Human Services allowed states to classify a developing fetus as an "unborn child" eligible for government health care. This action allowed low-income women access to prenatal and delivery care—but not postpartum care—through SCHIP. The regulation took effect on Nov. 1, 2002.

S. 724 is "a necessary step to provide additional coverage beyond that available in the recently issued Bush Administration SCHIP regulation," according to Physicians for Women's Health, an ACOG group.

Exclusive attention to policy issues draws in the cash for medical directors

Group practice medical directors who focus full-time on policy issues earn $30,000 more in a year than medical directors who retain some clinical responsibilities, according to a survey reported in Managed Care (8/2002). The survey, conducted by Tampa, Fla.-based Physician Executive Management Center, found that the median total compensation for medical directors who perform clinical duties was $206,000 in 2001, while medical directors without clinical duties earned $236,000 in the same year.

The reasons for the difference: Experience is one factor; medical directors without clinical duties tend to be older with more experience in management. Another factor is the size of the group; larger practices can afford to hire medical directors who can devote all of their time to management.


Breast-conserving surgery as effective as mastectomy

Breast-conserving surgery is as effective as radical mastectomy for the treatment of many breast cancers, according to two recently published studies involving 20 years of patient follow-up.

The first study followed 701 women with cancerous tumors measuring no more than 2 cm in diameter who received either Halsted radical mastectomy or quadrantectomy. While a difference existed in the number of women experiencing a recurrence in the same breast—eight women receiving mastectomy versus 30 women receiving breast-conserving surgery—the study found no significant difference between the two groups in long-term survival, nor in rates of contralateral breast carcinomas, distant metastases, or second primary cancers.

The authors concluded that breast cancer prognosis depends on the presence or absence of occult distant foci of metastases—not on the extent of local breast tissue removal, and that breast-conserving surgery should be the treatment of choice for women with early breast cancers.

The second trial looked at 1,851 women with invasive breast cancer and tumors up to 4 cm in diameter who received either total mastectomy, lumpectomy alone, or lumpectomy and breast irradiation. Again, while a difference existed in the cumulative incidence of recurrent tumors in the ipsalateral breast in the lumpectomy/radiation group as compared to the lumpectomy alone group (14.3% vs. 39.2%, respectively), the researchers observed no significant differences between the three groups in terms of disease-free survival, distant disease–free survival, or overall survival.

The authors concluded that lumpectomy with subsequent radiation therapy is appropriate therapy for women with breast cancer, providing that the resected tissue can be obtained with cancer-free margins and the surgical result will be cosmetically acceptable to the patient.

Veronesi U, Cascinelli N, Mariani L, et al. Twenty-year follow-up of a randomized study comparing breast-conserving surgery with radical mastectomy for early breast cancer. N Engl J Med. 2002;347:1227-1232.

Fisher B, Anderson S, Bryant J, et al. Twenty-year follow-up of a randomized trial comparing total mastectomy, lumpectomy, and lumpectomy plus irradiation for the treatment of invasive breast cancer. N Engl J Med. 2002;347:1233-1241.

No problem taking OCs and fluoxetine together

Patients taking fluoxetine can also use oral contraceptives without worrying that the combination will affect the efficacy or safety of either agent, according to a review of the US fluoxetine clinical trial database.

Researchers looked at 17 double-blind, placebo-controlled fluoxetine trials, concentrating on subjects between the ages of 18 and 45 years. When they compared a subgroup of women taking OCs with a subgroup of women not taking them, they found no significant differences in the incidence of unplanned pregnancies or in changes from baseline in scores on the 17-item Hamilton Depression Scale (HAMDD-17).

The only significant differences between the two groups in adverse events involved headaches, asthenia, and pain, which were more common among OC users.

Koke SC, Brown EB, Miner CM. Safety and efficacy of fluoxetine in patients who receive oral contraceptive therapy. Am J Obstet Gynecol. 2002;187:551-555.

Walking helps prevent heart disease in postmenopausal women

Walking briskly or otherwise exercising vigorously for at least 2.5 hours per week reduces a postmenopausal woman's risk of a cardiovascular event by about 30%, according to a prospective study of 73,743 women between the ages of 50 and 79 years. On the flip side, prolonged sitting increases risk.

The study found an inverse association between increasing physical-activity score and the risk of coronary events and total cardiovascular events. The finding applied to black and white women, regardless of age or body mass index. The faster the walking and the fewer the number of hours spent sitting, the lower the risk of heart attacks and the like.

Because the relative risks derived from the analysis estimate the effects of exercise without considering its favorable influence on adiposity and related morbidity, the authors concluded that reductions in cardiovascular event risk may actually be closer to 50%.

Manson JE, Greenland P, LaCroix AZ, et al. Walking compared with vigorous exercise for the prevention of cardiovascular events in women. N Engl J Med. 2002;347:716-725.

Single-agent chemo for ovarian cancer: just as effective and less toxic

Single-agent therapy with carboplatin or standard chemotherapy with cyclophosphamide, doxorubicin, and cisplatin (CAP) are just as effective as paclitaxel plus carboplatin as first-line chemotherapy for ovarian cancer and seem to have a more favorable toxicity profile, according to The International Collaborative Ovarian Neoplasm (ICON)-3 randomized trial.

The trial followed about 2,000 women from 130 centers in eight countries for almost 5 years. Median overall survival of the women taking paclitaxel plus carboplatin was 36.1 months versus 35.4 months in the control group, who had received either only carboplatin or CAP. Median progression-free survival in the women on paclitaxel plus carboplatin was 17.3 months versus 16.1 months for the control group.

In the final analysis, the researchers deemed the three treatment options similarly safe and effective, but found paclitaxel plus carboplatin to cause more alopecia, fever, and sensory neuropathy than carboplatin alone, and more sensory neuropathy than cyclophosphamide, doxorubicin, and cisplatin (CAP). CAP, however, was associated with more fever than paclitaxel plus carboplatin.

The International Collaborative Ovarian Neoplasm (ICON) Group. Paclitaxel plus carboplatin versus standard chemotherapy with either single-agent carboplatin or cyclophosphamide, doxorubicin, and cisplatin in women with ovarian cancer: the ICON3 randomised trial. Lancet. 2002;360:505-515.

Can HPV testing replace Pap smears in primary care?

Human papillomavirus (HPV) testing is more sensitive, but less specific than thin-layer Papanicolaou screening at detecting cervical intraepithelial neoplasia (CIN) grade 3 or cancer, according to a recent study of over 4,000 women.

Researchers calculated the sensitivity of thin-layer Pap for identifying women with CIN 3 or higher to be 61.3% versus 88.2% for HPV testing by polymerase chain reaction (PCR) and 90.8% using a liquid-based RNA-DNA hybridization capture with signal amplification assay. In terms of specificity, thin-layer Pap scored 82.4% versus 78.8% for HPV PCR and 72.6% for signal amplification.

Rather than refer all women with abnormal smear results for colposcopy, researchers then looked at a strategy of referring only those women with a positive result on signal amplification testing. This strategy yielded a sensitivity of 61.3% and a specificity of 82.4%.

Lastly, investigators looked at a strategy of requiring two positive PCR tests for HPV DNA before referring for colposcopy. This approach had a sensitivity of 84.2% and a specificity of 86.2%. For all of the tests, specificity increased and sensitivity decreased in women 30 years of age or older, when compared to younger women.

The authors of the study concluded that screening for HPV DNA may be a reasonable alternative to Pap smear in women of reproductive age who are unreliable or inconsistent about regular screening.

Kulasingam SL, Hughes JP, Kiviat NB, et al. Evaluation of human papillomavirus testing in primary screening for cervical abnormalities. JAMA. 2002;288:1749-1757.

Do young women need sexual assertiveness training?

One in five young women are not aware of their sexual rights, according to a recent study. The investigation, which included 904 sexually active 14- to 26-year old women in Texas found that almost 20% believed they never had the right to:

  • stop foreplay at any time, including at the point of intercourse;

  • refuse to have intercourse, even if they had sex with a partner previously;

  • make their own decisions about contraception, regardless of partner preferences;

  • ask their partner to be examined for STDs; or

  • tell their partner about a desire to make love differently or that he is being too rough.

The study found that black, Hispanic, and younger women were less likely to be sexually assertive than white and older women were. A lack of sexual assertiveness may put women at greater risk for unwanted pregnancy, STDs, violence, rape, and even death.

Rickert VI, Sanghvi R, Wiemann CM. Is lack of sexual assertiveness among adolescent and young adult women a cause for concern? Perspect Sex Reprod Health. 2002;34:178-183.

Pregnancy and immunosuppressive treatment for aplastic anemia

Women treated with immunosuppression for aplastic anemia have about a 60% chance of a successful, uncomplicated pregnancy, according to a retrospective, multicenter study.

Researchers analyzed data from 36 women at 12 European centers who received immunosuppressive therapy for aplastic anemia. The 36 pregnancies resulted in 34 live births (including one set of twins), 22 of which were uncomplicated. A third of the patients became transfusion-dependent during pregnancy, and 19% experienced a relapse of aplastic anemia. Two women died.

While women whose disease is in remission before conception and those with normal platelet counts are more likely than those with persistent cytopenias to have uneventful pregnancies, such factors offer no guarantees, according to the report. In fact, two of the seven relapses in the study occurred in women who were in complete remission prior to pregnancy and one of these died of refractory disease.

Tichelli A, Socie G, Marsh J, et al. Outcome of pregnancy and disease course among women with aplastic anemia treated with immunosuppression. Ann Intern Med. 2002;137:164-172.

Vaginal tape vs. colposuspension for stress incontinence

Surgery with tension-free vaginal tape is as effective as colposuspension for the primary treatment of stress incontinence, but is associated with more instances of bladder injury. Colposuspension, on the other hand, is associated with longer operation, hospital, and recovery time and more delayed resumption of micturition, according to a recent multicenter randomized trial.

The trial, conducted in the United Kingdom and Ireland, involved 344 women with urodynamic stress incontinence. After 6 months of follow-up, the researchers found that approximately 66% of the women receiving the vaginal tape procedure were objectively cured, versus 57% in the colposuspension group. These numbers were lower than the cure rates quoted in a number of other studies, perhaps because the number of patients recruited fell short of the target.

In addition, the researchers caution that longer follow-up is needed to assess the long-term success of the two procedures, particularly with regard to prolapse and tape erosion.

Ward K, Hilton P. Prospective multicentre randomised trial of tension-free vaginal tape and colposuspension as primary treatment for stress incontinence. BMJ. 2002;325:67.



In Table 3 of "Cord blood banking: an ob's perspective " (November 2002, pg 35), we regret that incorrect information for Cryo-Cell was inadvertently listed. After the table was created, the company reported one successful transplant and its initial banking cost and storage fee should be $315 and $90, respectively. Also, the box on page 38, "Answering patients' questions about blood banking" should have read "In my opinion, a prospective customer of a private 'family' cord blood bank can feel more confident regarding their 'investment' if the company is well established (>5 years) [not 75 years].


Professional Update/Clinical Insights.

Contemporary Ob/Gyn


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